We're not being truthful with ourselves if we are pretending like this is not a huge problem, this is a huge problem. (upbeat music) Today we're gonna talk about addiction, substance addiction, of course, but also addiction more broadly. How as the world has kind of evolved from one of scarcity to one of over abundance, and we increasingly orient our lives around the pursuit of pleasure and the avoidance of pain. We are setting ourselves up for a myriad of unprecedented types of addiction and consequently, the pain we so desperately seek to avoid. My guest for this exploration is Dr. Anna Lembke. Anna is a professor of Psychiatry at Stanford University School of Medicine and Chief of the Stanford Addiction Medicine, Dual Diagnosis Clinic. A clinician, scholar, and authority on addiction medicine, the neuroscience of addiction and the opioid crisis. Anna appeared in the Netflix documentary, Social Dilemma, which has been widely discussed on this podcast. She's also widely published. She's testified before Congress and as authored two important books, "Drug Dealer MD", which the New York Times declared, one of the top five books to read to understand the opioid epidemic and her newest called "Dopamine Nation" right here, which is a powerful primer on how to moderate compulsive over-consumption in a world where unfortunately feeling good has become confused with the highest good. This is an important, and I think impactful conversation about the nature, the psychology and the neuroscience of addiction that I think among other things will reframe and broaden your sense of what addiction is and is not. And I suspect we'll hold great value for anyone currently struggling with addiction or close to someone who does, which let's face, it is almost everybody. So, please hit that subscribe button, hit that notification bell and enjoy my exchange with Dr. Anna Lembke. Anna so nice to meet you. Thank you so much for traveling down here to do this, I really appreciate it. Well, you're very welcome. I'm really excited to be here. Yeah. I'm excited to talk to you. We were introduced by our mutual friend, Andrew Huberman. Any recommendation from him is one worth noting. He's such a unbelievable mind. He's been a great guest and he's become a good friend. And, you know, upon his recommendation, the more I've dug into your story and your work, the more excited I got to do this with you. I think you're really the perfect person to have a really, I think, important, impactful conversation around the nature of addiction and kind of the current culture and our relationship to the dopamine induced world that we now find ourselves in. Well, first let me say, I agree with you 100% on Andrew Huberman. He is, you know, my colleague at Stanford, another professor, but I've seldom met a colleague who so generously was willing to promote someone else's work. And he's been just amazing about "Dopamine Nation" and trying to help me, you know, get the word out and get it read. And of course I'm really, really excited to be here and talk to you. It's a real, real privilege. Yeah, yeah, yeah. I mean so much to talk about. People who listen or watch the show know that I have a personal history with addiction and recovery and sobriety. It's a major theme or topic that recurs on this show. And, I think a good place to kind of start with this is to share a little bit, you know, from my personal perspective. When I think back on my emotional state of being when I was at the nadir of my using and facing the prospect of getting sober, I just remember such a deep sense of shame and embarrassment and this sense of just being irreparably broken and being scared of everybody scared of everything, of the world, and this sense that, you know, really getting honest with myself about the fact that I was an addict really equated to being a broken human being and this pathology that it evokes, you know, because my sense was that addicts were, you know, needle fiends and hopeless drunks, and that's kind of where the conversation begins and ends. But, as somebody who's been steeped in the recovery community and somebody who's been sober for a little while, I've become increasingly convinced over many years that that addiction is so misunderstood and so much more widely prevalent than I think we realize. And also that it exists on a spectrum that is so broad that it's not that much of a stretch to argue or contend that on some level we can all identify ourselves somewhere along that spectrum, whether it's a mild, unhealthy compulsion, all the way to some kind of full blown life implosion. And I'm interested in your sense of that because, I feel that your work and in particular this latest book, "Dopamine Nation" which we're gonna talk about, really, you know, is furthering that sensibility and providing that kind of perspective to a broad audience. I wanna first respond to your use of the word feeling broken. I think that is probably the single most powerful thing that has drawn me to people with addiction in recovery is that they've passed through that crucible of complete feelings of brokenness, humility, and they've come out the other side as these incredible humans with tremendous wisdom. And the book really is, you know, homage to people with addiction who have found recovery precisely because they have a profound humility having been through that experience. And although my addictions, which I talk about in the book are more minor than somebody with severe addiction- And somewhat comical. Somewhat comical, but, you know, for me, they were actually-
Real for you- Yeah, they were real- It's a subjective relationships. Right, it is, and because of the work that I do, I was at some point able to be aware of what was happening to me, that I don't think I would have been able to do had I not been in the line of work that I am. But I think most importantly, I've had other experiences in my life that have left me also feeling totally broken, a broken human, you know, full of shame, full of feeling like I wasn't good enough. And so I've really gravitated toward other people who have had that experience of brokenness and yet from it becomes stronger because of the profound humility that it engenders and a kind of surrender to the universe and a willingness to appreciate that. Like we have so little control. And all the other stuff, all the other good stuff that comes with that. Yeah. You share a quote near the beginning of the book that I love by this guy, Kent Dunnington, who says, "persons with severe addictions are among those contemporary profits that we ignore to our own demise for they show us who we truly are." Yes and that's why I'm meeting her for dinner. Oh, you are, cool. Who is Kent Dunnington? I don't know who he is.
Yeah, so he's a really interesting guy. He's a theologian and a philosopher. He works at Biola University. And I first came across a book he wrote called, "Addiction and Virtue." Which is this philosophical lens through to consider whether or not addiction really is a disease and whether or not people have a choice and what that choice looks like, and he uses Aristotle. And it's a fascinating look at that question because in the medical field now, I am really steeped in this idea that addiction is a disease. It's a chronic relapsing and remitting disease, there's, you know, verifiable brain chemistry changes that occurs, people become addicted, and yet, and yet, and I believe that that's true, and yet there is this element of choice, right? Somewhere along the way, people can choose to get help. Really that's the fundamental choice piece that's left. It's they can't necessarily choose to not drink or not use, but they can choose to say, I have, don't have the ability to choose or not choose to drink, but I do have the ability to hand it over to somebody else who might help me. Sure.
So anyway- But that element of choice is difficult. You know, often it's said that recovery is for people who want it, not those who need it and too often, the person who needs it is an is unable to make that choice. They're like the most unlikely person to make that choice. Yes, yes, I think that's right. That's right. I mean, and that's where this kind of mysterious thing happens where even people who really don't have the ability to make the choice can get into recovery, right? And we see that happen all the time. Right, and so, you know, in the context of this, we're gonna talk about neuroscience, we're gonna talk about psychology, we're gonna talk about environment, genetics, there's so many things that contribute to this. But in that context of choice, it never ceases to astound me that some people can just have an epiphany and say, this is a problem, and I'm gonna correct it, and they just do it. While others have to go to the gates of hell before they're ready to reckon with it. And too many just perish, you know, without ever having the courage to, you know, make that switch. Yes, that's right. It's so terrifying and sad in that regard, right? Yes. But my perspective is that in the typical case is the person who is kind of sliding down that scale with their addiction until they get to the point where the pain of perpetuating or continuing along that path exceeds the fear of letting go of it and trying something new. Yeah, that's right. That recognition that there's really no other option, but to embrace recovery. Mm-mmh. So why don't we define our terms here a little bit? Like, how do you define addiction? I define addiction as the continued compulsive use of a drug or behavior despite harm to self and or others. How do you define it? I mean, that's the standard definition. Yeah, right. And how does that, like, as I mentioned at the opening there's alcoholism, there's drug addiction, there are some qualitative differences between substance addiction and behavioral addictions. And now that we're in this world where everything has an addictive allure to it, do you qualify our relationship with our devices and online shopping and gambling in the same way, like with this idea of addiction being a spectrum, how does it differ in terms of like our relationship to Twitter versus our relationship to heroin? I don't really see all that much difference between those things. I think it's just a matter of degree. Obviously when we're talking about heroin, we're talking about the physiologic dependence and withdrawal as well, which I do think happens with behavioral addictions to things like Twitter. I believe we can have a true physiologic dependence and withdrawal to those behaviors, but not to the same degree as with something like an opioid, but in terms of the psychological aspect of the attachment, I think it's very, very similar. And I believe that because I've seen so many people come through my office who are addicted to things like gaming, gambling, pornography, shopping, and the natural history is exactly the same, and the manifestations are the same, the process of getting into recovery is the same. So to me, they're all one bucket. Mm-mmh. So is there a distinction between kind of an unhealthy recurring semi compulsive habit and what you would consider truly an addiction? Because both habits and addictive behaviors work through our dopamine reward pathway, I really think it's the same biology. It's just a matter of degree. Mm-mmh. And because I have seen people who can get severely addicted to behaviors like gambling, pornography, video games, to the point where they are suicidal so their life is threatened by that disease process or that behavior, I really think it's the same biochemistry. It's the same phenomenon in the brain. Yeah. It seems to me, we're in this weird time where on the one hand we use the word addiction very cavalierly, like, oh, I'm addicted to my TV show or chocolate, or what have you. And yet at the same time, we underappreciate the fact that, some of these things truly are addictions, right? Like these two things kind of cross each other in the night in a weird way. Which I think prevents us from really looking at them through the appropriate clinical lens. Yes. I think you're right. I think the way that we cavalierly refer to behaviors as addictions, oh, I am addicted to whatever my Netflix show does minimize the extent to which the brain biology is the same and also minimizes the impact on our lives. Because if we were to really scrutinize that behavior, I think people would begin to realize that it really truly does have an adverse impact on their lives,
Mm-hmm. and that, you know, we can't trivialize that. I mean, I've had, for example, you know, journalists writing for esteemed publications, call me to interview me about sex addiction and say to me, "well, that's not really an addiction, is it? I mean, it's really just about cultural morals around, you know, what's acceptable sexual behavior and what isn't." And I've had to correct that person say, no, you're you're wrong. This is really an addiction. It can devastate lives. People can lose their lives over these problems. And it's not just about, you know, oh, you know, polyamory should be socially accepted. That's not what we're talking about here. We're talking about a compulsive out of control phenomenon that has very serious consequences for people. Sure. If anybody questions that, I encourage you to read the first chapter of your book, because it's the most harrowing bone chilling story of a sex addict and the links that that guy goes to satisfy his need. Right. It's unbelievable. Yeah. And the fact that he's highly educated, that he's a good and kind person, that he has good social support, he has a great job. I mean, this is what I really want to drive home to people like, yeah, there are many risk factors for addiction, but you can have none of those risk factors in today's world and get really addicted. Mm-hmm. Do you feel like we're starting to understand that, in the sense that anybody can be an addict regardless of your social status or level of education, et cetera? I do think so. I mean, I do think we've moved beyond this moralizing around addiction as more and more people struggle with severe addiction and it crosses all demographics, all social classes, I think people, I mean, for example, in surveys of Americans asking whether or not they think addiction is a biologically based disease, the majority of Americans today will say, yes, it is. And that's different from 50 years ago. So I think we have shifted in that regard, but I think what's still new to people is the extent to which we've all become vulnerable to this problem. Yeah. That is a big difference. Yeah.
Right? And I do think, although we may recognize that that truth in that there is this biological component to it, we still are shocked when we hear the story of the upwardly mobile person who goes down some dark rabbit hole. Do you remember that, there was a New York Times article a couple of years ago about the guy, the lawyer in Silicon valley? Yes. That was like a huge profile of his second, you know, his other life.
Yes. And I just remember how, you know, people were so shocked by that story. Somebody who's been in recovery for a long time. I'm like, yeah, you know, I hear that story all the time. Right. I remember that being a big deal. Yeah. I think that there's still this kind of self-medication hypothesis thinking around addiction, which is only partially true. And the hypothesis goes like this, that addiction is the result of some other problem, either a willpower problem or a psychiatric illness problem, or, you know, a socio-cultural problem, but you can have none of those problems and still get addicted. And like I've spent a major part of my career reeducating in particular psychiatrists around this idea, because for so long, we've had this idea that addiction is a downstream consequence of some other problem, but addiction is its own problem. You can have a perfect life and get very, very addicted. Yeah. Yeah. That's a really important point. You know, I've had conversations with Gabor Maté and for him, it's all about childhood trauma, resolve that, you resolve the addiction. I had Johann Hari here. For him it's all about loss connections, your connectivity to your friends and your family and your community. And I think those are important pieces in this puzzle, but I'm reluctant to be reductionist about the role that those play in the broader context of addiction. Thank you so much for invoking those examples, because that shows me that you perfectly understand what I'm trying to communicate here, because yes, it's true that childhood trauma increases your risk for developing addiction. Yes, it's true that addiction leads to isolation and that the antidote to addiction is social connection in part. But what is so important to understand is you can have the perfect childhood, the perfect parents, the greatest social network, the best spouse, wonderful kids, and you can get really, really addicted. And that is so important for people to understand, and also healthcare providers, because everybody's sort of looking for the reason behind the addiction, but there doesn't have to be a reason behind addiction. Addiction just can be on its own. Yeah, I think that's a crucial point. I mean, I get asked very frequently, like, what do you think caused this? Like, what is the source of your addiction? And, you know, I'm heavily indoctrinated in 12 step and I'm sure I have some biases around that. But one of the things that you learn is that it's fine if you want a psychoanalysis and analyze that aspect of your origin story, but ultimately, it doesn't avail you with the tools for how to live today and how to move productively forward. And, you know, there is an argument to be made that it's sort of a fool's errand to spend too much time on that. Yes. Insight can be the booby prize. Yeah. Yeah, no, this is a really very, very important concept. And the other reason it's important is because I think we're natural storytellers and we want to rationalize irrational behavior. And so, the first thing that we try to do when we are doing something that's irrational and self and other destructive, is to tell ourselves a story or have someone else tell us a story about why we would do that crazy thing. But- And if we can solve that equation, then suddenly every everything makes sense- Right. And you can figure this out. But it doesn't work out that way. No, I mean, I have had over 20 plus years, countless patients come into my office and say, "Dr. Lembke, the reason that I'm addicted to alcohol or I'm addicted to cannabis, or I'm compulsive gambler is because I'm depressed and anxious. And if you would just fix that, then I wouldn't have that other problem." And what I have to do is say to them, you know what? I wish that were true, but here's the truth. Number one, even if I could magically wave my wand and make your depression and anxiety go away, once you're addicted, you're addicted, and if we don't focus on that problem, that's not gonna get better. The other thing is that, you know, that relationship between psychological symptoms and addiction, it's complicated and it's not necessarily that the depression comes first and then the addiction comes. Addiction can lead to depression and anxiety, which is why my first intervention so often is to have people abstain. But I'll never forget a patient of mine who said, "You know, Dr. Lembke, I realized I was an alcoholic when I got started on an antidepressant, wasn't depressed anymore, but kept drinking." That was his aha moment because he was like, oh, I thought I was drinking, 'cause I was depressed. But when I stopped being depressed, I was still drinking. Yeah. That's kind of the genius behind your dual-diagnosis clinic, right? It's almost a Trojan horse way of just treating addiction because the way you get them in the door in a non-threatening way is under the rubric of treating their anxiety or depression, et cetera. Right, yes.
Yeah. Although it's not without effort because people are resistant to that idea, right? They come in and they want help with depression and anxiety, they see the addiction as a secondary problem, and it takes all my powers of persuasion to get them on board. (both laughing) None too happy to be told that can't deal with your condition X until we deal with this substance or behavioral addiction that you have. And they storm out, leave a one star yelp review or something. Exactly. You you've got it exactly, you understand. (both laughing) Yeah. If people don't wanna hear that, you know, it's interesting that, that piece, I mean, as a psychiatrist though, you must have honed tools for how to communicate with people to kind of crack that core. Yes. And the key piece is to be empathic at the same time that you're telling people what they don't wanna hear. You know what I mean?
That's tough. That's a tight rope on. It is. It is. But I feel like I've gotten pretty good at it. Having teenagers also helps, you know, to sort of you breathe and you stay calm and you say, you know, I understand what you're saying, right? So the typical sort of validating first, but then you give them kind of the real deal. You know, what the science shows, what my clinical experience shows, what I'm asking them to experiment with, so that they can gather their own data and see if what I'm saying is right. But on the data piece, I mean, this doesn't operate, you know, in a logical framework, it's an emotional framework and timing is so important, right? Like I'm happy to talk sobriety with anyone who's suffering, but I've learned to detach or from any expectations of what they will or won't do. Like people get sober when they're ready to. Yeah. And one of the main things I have to teach my trainees, my fellows is that, an essential part of the work that we do is that, we have to actually really care about our patients, but there is a point at which you can care too much. And when we're trying harder than the patient is, or wanting it more than the patient wants it, we're not actually helping them. Then you gotta go to the Al-Anon meetings- That's right. (both laughing) Well, we have to conduct our own little Al-Anon session, you know?
Right. Right there at work. 'Cause I work with a bunch of young folks, which I can say is one of the most exciting things that's happened in the last 10 years. You know, 10 years ago, I couldn't find a medical student under a rock who wanted to learn about addiction. Now they're beating down my door, which is really awesome. Yeah. Well, let's talk about the neurochemistry of addiction. Walk me through what's happening in our brains and the role that dopamine plays in all of this. Yeah. So dopamine is a neurotransmitter, which means that it is the molecule that allows the electrical signal from the pre synaptic neuron to be communicated to the post synaptic neuron, because there's a little gap called the synapse between those two neurons. So neuro-transmitters allow fine tuning of those electrical signals. And dopamine is the most important neurotransmitter involved in motivation and reward. And the fundamental difference between things that are addictive and those that aren't is that things that are addictive release a lot more dopamine. So we have dopamine firing in our brain that occurs at a tonic baseline, and when we do something that's rewarding or pleasurable, we get a little rise in dopamine levels or a spike. So for example, chocolate increases dopamine levels about 50% above baseline. Sex is about 100%. Nicotine is about 150%. And things like methamphetamines are 1000% partially because of their specific mechanism. But the fundamental way that I explain to patients and medical students, and now in my book about the neuroscience of addiction so that they can really understand what's happening in the brain is, I say that really, you have to imagine that in your brain, there's a balance like a teeter-totter and a playground. When we experience pleasure the balance tips one way when we experience pain, it tips the other. But one of the fundamental rules governing that balance is that it wants to remain level. So with any deviation from neutrality, the brain will work very hard to restore a level of balance or what's called homeostasis. So for example, if I do something pleasurable, like eat a piece of chocolate, I get a little tip to the side of pleasure, a little release of dopamine, but no sooner that has that happened, than my brain adapts to that phenomenon by down-regulating my own dopamine receptors, down-regulating my own dopamine transmission. And I imagine that as these little gremlins hopping on the pain side of the balance to bring it level again. Mm-mmh. But the thing about the gremlins is, they like it on the balance. So they stay on until the balance is tipped an equal and opposite amount to the side of pain. And that's called the opponent process reaction, the hangover, the come down, the after effect. Now, and in my case, that's that moment of wanting another piece of chocolate. If I wait long enough the gremlin hops off and balance is restored. But if I continue to consume chocolate in ever larger amounts to overcome the tolerance or the number of gremlins on the pain side, then I end up with enough gremlins on the pain side of my balance to fill this whole room. And I'm essentially in a dopamine deficit state with a balanced tilted to the side of pain. Now I have to keep using not to feel good, but just to feel normal. And when I stop using my balance tips hard to the side of pain, I'm irritable, I'm depressed, I'm anxious, I can't sleep. Those are the universal symptoms of withdrawal from any addictive substance. And that can last a long time. Yeah. I think it brings up an important kind of broader point about culture in general and this idea that we live in a situation in which we are... There's this asymmetry in terms of how we approach our lives with respect to pleasure and pain. And we organize our lives completely around the pursuit of pleasure and the avoidance of pain. But as you kind of astutely put in the book, the more that we pursue that, ultimately the more pain that we reap, because these systems require a level of homeostasis that we're constantly trying to avoid. So, we're just delaying the inevitable onslaught of pain that, you know, we so fear. Yes, absolutely. We live in a world in which we are saturated with dopamine and we live in a culture which encourages us to pursue it. But the ultimate end result of pursuing dopamine is to feel worse than when you started. And this is really the central message. People are more depressed, more anxious, more suicidal, and more addicted than they were 30 years ago. And I contend that one of the main reasons is because of this relentless pursuit of pleasure that essentially adjusts the dopamine levels, changes the hedonic or seizure or pleasure set point to make people anhedonic meaning without joy. Yeah. And you can kind of calibrate this in lockstep with how we've progressed from a world of scarcity into a world of over abundance, right? And so, these addictive behaviors and substances are ubiquitous. It used to just be, hard drugs and alcohol and cigarettes, et cetera. But now it's literally everything from, you know, the billboards and the advertisements and the marketing messages crafted by Madison Avenue to of course, the devices that we all carry around with us that are specifically designed to lure us into this, you know, dopamine induced state and the food system, that's specifically designing foods with the right proportion of salt, sugar, and fat to make it impossible to just eat one potato chip. Yes, exactly. I mean, addiction can happen now in every realm of life, it's almost impossible to escape it. And the three factors that make anything more addictive are quantity, potency and novelty. And what our capitalist technologically innovative world has created is, an infinite quantity, incredible potency, and endless novelty and variety. Yeah. And ubiquitous availability. Yes, right.
Right? It's unavoidable. Yes, right.
Now. And now it's 24/7 and it's digital and it's right to your doorstep, exactly. Right. Everything's delivered as well. Yes, right. Including all the substances. Right.
(both laughing) Which we're going to get into. But, one curious thing for me back to the neurochemistry is, you know, why someone becomes, if this, you know, dopamine neurotransmitter pathway that you're speaking about, seems to be, you know, a general quality of all humans, why do some people get addicted and why some people don't? And, you know, for example, like, alcohol is my drug of choice, gambling, which debilitates a lot of people carries no charge for me at all. Like I just couldn't be less interested in it. Like, how does that work? Is that where genetics and nurturing and all kinds of other things come into play? Well, first let me speak to the concept of drug of choice, 'cause it's a fascinating one and there's actually very little science around it, but we know phenomenologically that it's true. What makes one person's balance tip to the side of pleasure, doesn't necessarily make another person's balance tip to the side of pleasure. So, for me personally, I thought that I was immune to the problem of addiction because the substances that are readily available and that most people get addicted to, do absolutely nothing for me. But look, what happened to me. I did find a substance that turned out to be incredibly reinforcing for me, essentially, romance novels. Right.
Right. I know you laugh, (Rich laughing)
you laugh, but I mean, it was- Did you really read the entire Twilight series four times? I did, that was my gateway drug. Are you kidding? I really did. And then I moved on from there. 'Cause I developed tolerance after the fourth time. It was no longer doing it for you. It wasn't, it wasn't good enough. And it was really mysterious 'cause I was like, you know, this is like a teenage romance novel about vampires and I was in my 40's. So I mean that in itself is slightly embarrassing, but it just led to this down this whole weird road for me. "Anna 50 Shades of Gray". Right, right. That'll do the trick. That was my bottom right there. No pun intended. So, I guess my point, you know, to answer your question is that, like, I think we're all gonna get addicted to something because now that special key that works for each of our individual locks, it's out there somewhere and the worldwide web will allow us to find it. Having said that, it is true that people bring different degrees of vulnerability to the process of addiction. We do know that about 50-60% of the risk of becoming addicted is genetic, that's based on family studies, showing that if you have a biological parent or grandparent addicted to alcohol, you are at increased risk of becoming an alcoholic yourself, even if you're raised outside of the alcoholic home, in a non using home. So, so that's powerful genetics. It's Polytechnic, it's complex, we don't fully understand it, it's thought to be related to things like impulse control, ability to delay gratification, emotional dysregulation. But, you know, we don't really know what it is. Other risk factors include, co-occurring psychiatric disorders. People with psychiatric disorders are more likely to develop an addiction, and also how you were raised. If you had a traumatic experience, as we've about, that puts you at risk. If you have parents who have explicitly or implicitly condoned substance use, either for recreation or as a coping strategy, that puts you at risk. Things like poverty, unemployment, that puts you at risk. So there are lots and lots of risk factors, but I think that the major risk factor in the modern world and one which is generally ignored, is simple access. If you have access to a drug, you are more likely to try it and more likely to get addicted to it. And now, as we've talked about, we live in a world of virtually infinite access. Yeah. You say there's a quote in the book, something along the lines of, whatever.... There is something that will addict you and it's coming to a website near you soon. Correct. Right.
(both laughing) Yeah. And it's never been more true, but that idea that, there is a drug out there that will be the key to your specific lock, I think is super interesting. And you've used the example in the book of this Stanford student who had all manner of problems and kept screwing his life up and tried all different kinds of drugs and would come back to Stanford and just go down some crazy drug rabbit hole and drop out. And they did this a number of times until he was prescribed Suboxone, and that really kind of balanced him out. And then the question becomes, is this something that he, you know, in his mind, he's like, I need to do this for the rest of my life. Like I can function as a normal human being right now, the question being, can he be, you know, titrated off of that and be normal, or is there truth to this idea that some people have a brain chemistry that's lacking in some regard that a substance can solve to make them productive and, you know, quote unquote kind of normally operative? Yes. I'm so glad that you have fundamentally understood that example of this very wonderful young man who is still my patient and he is doing so well in his life, it's just great to see, and he's a great guy. And as you describe I, so I don't know the answer, you know, I don't know whether he was born with something missing, whether his heroin use broke his brain, so that now he needs the opioids for the rest of his life, whether maybe it's really something with our culture and you know, our inability to create community, which he looked for at Stanford and couldn't find, and that somehow the opioid then becomes a way to adapt to a crazy world. And maybe that's okay. Like maybe we have to take drugs to like just exist in this really nutty world. You know, all those questions are things that I don't have the answers to, but that I think a lot about. Mm-mmh. Yeah, it's complicated. Yeah. We'll be back in a sec, but first, if you dig this podcast and I hope you dig this podcast, then I think you'll really enjoy my latest book, "Voicing Change." Featuring excerpts from poignant essays by and glorious photography of some 50 of my favorite guests over the last eight plus years, of doing this thing, this podcast, it's a gorgeous artful compendium of the show and copious wisdom shared there in all wrapped in a hardcover coffee table form that provides a great taste of what we do here at the RRP and serves as a beautiful keepsake or gift for the ardent fan. The book is only and exclusively available on our website, signed copies are available and we are shipping globally direct to any coffee table on planet earth. So to learn more and snag your copy today, visit rich roll.com/vc. That's rich roll.com/vc. All right, let's get back into it. I mean, the addict in me wants to believe that there's some drug out there that will solve my sense of discomfort and will allow me to just be functional without any kind of pathology attached to it. Well, here's what I've come to conclude and this is really a mantra for my own life that I'm never actually going to feel comfortable in the world or with living, that it's always gonna be painful and unpleasant, and that's just the way it is. Mm-mmh. Well, that's back to the pain pleasure kind of paradox, right? I mean, that's sort of a page out of Susan David's thesis of developing emotional resilience, like just being okay with the fact that, you know, in this happiness, obsessed world that we live in, acknowledging the truth that life is hard, and the more that we can kind of just be present with that, the more resilience we develop and the more kind of productive and fulfilled we ultimately can become, but people don't wanna hear that. You know, it's really fascinating. So as I've matured as a psychiatrist, and as I've just matured, I will say to patients, things like, they'll say, "you know what, life is really hard or I'm just anxious all the time." And I will say things like, yeah, I know what you mean, me too. (Rich chuckling) And you would be surprised, but people are kind of relieved. They're kind of relieved. They're sort of like, wow, if this Stanford doctor is like experiencing anxiety and dysphoria and discomfort, like maybe that's okay. I mean, maybe that's all right for me then too. So, by kind of having shared suffering, I think it makes the suffering more bearable, but also I really think we need to recalibrate our expectations. I know that that part of my role as a psychiatrist is to reeducate patients about, what they should really be expecting from their lives. Mm-hmm. Yeah. I feel like that that sort of burst the bubble. You know, every addict thinks that their interior experience is wholly unique and that nobody can relate to it and their problems are just so off the rails. Right. And that leads to the shame and the embarrassment and the inability to kind of connect with another human being and be honest about what that behavior is. Yeah. The terminology- I mean, the amount of courage that that sex addict guy had to summon to be so open with you about what he was actually doing is tremendous. I know. And that's why my patients are my heroes. Yeah. That's crazy. I mean, what he has had to overcome in his life and what the discipline required every single day for him to stay in to recovery, that's incredible. Right. It's superhuman. It is superhuman. Yeah. And also, you know, not for nothing like, the level of creativity and craftiness and resourcefulness, the links that the addict will go to to fill that need. I mean, in that guy's case, it's like, it's unbelievable, right? Like if you can just get that person healthy and find a healthy outlet for that level of concentrated energy, it's a powerful thing. Well kind of like what you did with your life, right? You took that energy and you channeled it into a whole new way of being, which is a really high standard in your life, right? You have to exert, I mean, maybe it's not, I shouldn't assume it requires discipline, but you know, you've chosen a path that is not easy in terms of your diet and your fitness and all of that. I don't know, you tell me, but it's- I guess, the way I would characterize it is, you know, I work hard in my recovery. I've plenty of character defects. My alcoholism manifests itself in all manner of, you know, errands behaviors, but I've made peace with the fact that my disposition is attracted to extremes. And I've tried to find healthy outlets for that. You know, people are always, "oh, you just transferred your alcoholism on the ultra endurance events, or you have an eating disorder because you have this restrictive diet." And, you know, I'll acknowledge that there's truth in all of those things. Whether those are addictive relationships, I'm not quite so sure because they have moved my life forward.
Right. Like they haven't created those negative consequences that my alcohol use did. Right. Yes. And, you know, your personality structure, I'm assuming, but this is sort of my job. You know, you have an intensity to you and your intensity has to find an outlet and you have to find a healthy and adaptive one and you have. And, and it's dopamine inducing. That's right.
You know, for sure. That's right. You know, and as somebody who makes their living online, like not immune from who, how many people listen to that, or what kind of response did this podcast get, or that Instagram post get. And I have to be really careful around. Yes, you do. And you have to like, probably do your inventory and be like, am I okay with this? And why what's driving this and what, you know, what kind of needs are coming up? Yeah. I mean, sometimes people ask me, well, I've seen people who get into recovery through 12 steps, alcoholics anonymous. It's like, it's a cult and they just get addicted to alcoholics anonymous. And I'm like, so- Fine.
(both chuckling) I mean, did you see their life before and their life after it's like pretty good now, right? So who cares? Yeah. Yeah it's interesting. On that piece of 12 step, you know, like I said at the beginning, I'm very indoctrinated in that it's saved my life, it continues to save my life. It's, you know, the priority of, you know, of my life to stay sober and how can I help another alcoholic achieve sobriety? You know, my friends and my community are all, you know, part of this. And I find myself, you know, kind of confronting the fact that every year there's somebody who comes up with some new homespun, you know, way of getting sober and staying sober and everything you thought you knew about AA is wrong. And now we have, interstage left, psychedelic protocols for treating addiction and other mental health disorders, et cetera. And, it's always, I'm constantly being... I always go back to AA and 12 step, and I have a challenged relationship with my openness to those other things, because I know what's worked for me. So I'm curious about how you think about the recovery context and the kind of protocols that are available to us. To me, AA is one of the most remarkable social movements of the past 100 years. When I have a patient who comes into my office, who's been in recovery through 12 steps, or is thinking about recovery through 12 steps, I'm like, hallelujah, because those patients are easier to manage and get better and stay better longer. So, I think it's a remarkable movement. There is so much wisdom there. As I write about in my book, I try to really elucidate what the neuroscience behind some of the things that AA has been teaching for 100 years. Like, I have a whole chapter on truth telling and why it's so important to tell the truth and what is the neuroscience possibly behind why truth telling allows us to be in recovery and to manage our compulsive over consumption. So, I think it's a remarkable organization, I think there's divine wisdom in it. And I think that a bunch of the AA that's happened in the last 10-15 years is just misinformed and misguided. You know, a Cochran review re recently came out that really looked at the scientific evidence behind AA, and there's also good science to support it. So it's not just that my clinical experience tells me that it works and your personal experience. But if you look at the data, I mean, people who actively engage in AA and other 12 steps do better, longer even than people who get some kind of professional therapy. Yeah. I feel like it's sort of lazy and easy to just take shots at it and say, well, it was, I tried, it, it wasn't for me. Well, did you try it? Like, what did you actually do? You know? Well, and I think it's important to acknowledge that it's not the path for everyone, right? It's not the path for everyone. But that doesn't mean that it's like not a good path, right? That doesn't mean that somehow, you know, you throw the whole thing out the window just because it didn't work for you or you had a bad experience. And then of course, I absolutely agree with you. I mean, when people say they've tried it in the past and didn't work, I'm always like, well, try it again. You know, this might be the time that it really takes. And for my most severely addicted patients, it's almost universally, the best option. And the data support that for the more severely addicted, 12 steps may actually work better than anything else. People get tripped up on the God part. Yes they do. Yeah. So, I'm interested in as a neuroscientist, as a psychiatrist, how do you conceptualize the role of spirituality in all of this? Because it is such a core precept tenant of 12 step. And I think that gets back to how we started, where you talked about just feeling totally broken. To me that is the fundamental spiritual pivot. When we acknowledge our brokenness, that is when we can give it over to something outside of ourselves, and that can take many different forms. But the key piece there is acknowledging that we are not in control and that when we ask the universe such as it were, you know, to guide us or help us, that simple reorientation totally changes, like decision-making, it changes so many things about how we proceed in our lives, the sort of, you know, cognitive math of decision-making, or what to do next. And, and I know I've experienced that, for other reasons, not related to addiction. And I know that's the fundamental pivot that my patients experience that kind of feeling utterly broken, and then looking outside themselves, something larger than themselves in order to pick those pieces up again and move on. Yeah. That idea of surrender and the kind of humility that inculcates with that, is a tall mountain to climb for a lot of people, and it was, it was difficult for me, but that's really where things kind of open up and you are able to reframe your relationship with how you're living. Yes. Right. It's a total game changer really, when you make that pivot. And it's amazing the good things that come from doing that. Yeah. Let's talk about withdrawal a little bit, back to the biochemistry of everything. Obviously, you know, every substance has a different half-life and the withdrawal from whatever you're doing is gonna be different, but what's going on in your brain, you talked about the kind of seesaw and the way that dopamine operates when somebody is withdrawing from a substance and they're kind of experiencing the pain that comes with that. What is going on and what does it take to kind of get past that to the other side? So there's a distinction between acute withdrawal and protracted withdrawal. Acute withdrawal is essentially where the body manifests the opposite of whatever the drug does. So if you have been using a stimulant, then an acute withdrawal you will be sedated. If you've been using a sedative, then an acute withdrawal you will have physiologic restlessness. And that can last anywhere between a few days to a few weeks, depending upon the substance and its half-life as you point out. But once you get through the acute physiologic withdrawal, I think what's underappreciated generally is that there can be this sustained protracted withdrawal that can go on for months, and in some cases, even years, which is primarily psychological symptoms, again, irritability, anxiety, depression, and insomnia, as well as craving. So this is like ruminative obsessive thinking about wanting to use, and that can even be accompanied by sudden physiologic feelings, sweating, stomach cramps. But that's the piece that in my mind I visualize the pleasure pain balance, chronically weighted to the side of pain because those neuro adaptation gremlins have essentially camped out there. They like it there and they're not getting off. And that is what drives relapse even after people's lives have gotten objectively better, right? They've gotten their spouse back, their job back, and then people see them relapsed and they say, well, why would they do that? Everything was going so well. But if you put yourself in the mind of that person, what you would see is that, every day they get up, they are anxious, they are irritable, they are craving. And that is what drives relapse. It's sort of that, that intense physiologic and psychologic suffering really. Yeah. After the acute withdrawal, that protracted period where everything just feels gray. Yes. Because you're so used to those dopamine hits. Yes. And even though your life is getting better in the back of your mind, you're just like, if I just do this one thing, like I'll be able to write that paper or get through this uncomfortable experience. And I'm just gonna do it once. Mm-hmm. And that's the cunning baffling and powerful component here that mystifies the non-addicts because it leaves them just utterly confused as to why somebody would make that choice. But it's almost impossible to avoid depending upon- Yes. The behavior and the substance, obviously some are more powerful- And what I've come to appreciate is that something strange happens to our perception of time when we're in that state. So we're in that state of craving and dysphoria, it really feels like it will never end. I mean, it will, you know, in most cases we know with sustained abstinence, the gremlins hop off, homeostasis is restored, but when we are in that state, it feels as if it will go on forever. Plus, as you said, we have a way to fix it, right? It's right there within reach. If we use again, we can relieve those feelings. So I think that's the combination of those things that the distorted time perception, that those awful feelings will never end, even though they will. And knowing that we can make ourselves feel better if we just- Yeah. And if you're telling the patient they're facing the prospect of possibly years of this. Right. I mean, if they're coming off benzos or something like that, they're in for a very long, hard road. Yes, that's right. Fortunately in my experience, most people who abstain for one month begin to notice improvements in mood, hopefulness, you know, sleep. They might not be where they wanna be, but they begin to see a little bit of light at the end of the tunnel. Not always, but that's the piece that then I really have to remind them of. And I say, remember how you felt when, you know, and if you can just hang in there with recovery and with abstinence, you know, incrementally in small ways, you will get better. And I think that's an important function that I serve. Kind of a cheerleader and a reminder because the hippocampus is tricky. I also think that's a major function of AA, right? That we, we go, I use the we pronoun. So I'm, I'm not a member of AA, but in my clinical work, I use the we pronoun because again, I think we're all broken and humbled in the face of this problem. So I'll say to patients, you know, remember how you felt then, remember how you felt a little bit better, you've done this before, you have the data from recovery, hold that close and tincture of time alone will get you there. Are there cases where that dopamine balance never again, reaches some level of homeostasis? Yeah. So unfortunately I think that that can happen. So for example, in the book that I think the case of Chris possibly one of the things that happened to him was after so many years of opioids, heroin- Suboxone. Yeah. That his balance was essentially broken, it was stuck tilted to the side of pain. And the only way for him to feel normal is to be on what's called replacement therapy or opioid agonist therapy in the form of Suboxone, which has sustained him feeling well now going on almost a decade and I've been talking very, you know, he's doing great. Its not like he's just kinda like tragic long, he's doing great. And he's been able to maintain that level of Suboxone at a base rate, like he's not asking for more? No. And I do see that. I do have patients for whom, for reasons we don't understand, they do to develop tolerance, but not him. It worked immediately, it worked well, it restored homeostasis, he's re-engaged with life, and he's interesting to at least somebody who never went to 12 step. And never really got physychotherapy beyond what we do, but that's what works for him. Yeah. So interesting. I'm always amazed by people who just figure out how to get sober and stay sober without AA. And, you know, I've often thought, what happens if someone like yourself develop some kind of pill that resolves, you know, alcoholism addiction on a biochemical level, like what I take it and I wouldn't trade my experiences or the richness of my life experience and what I get out of this program in this community for that option. Yeah. That's so cool. And I've heard that from so many of my patients that, they get to a point in their recovery where they actually regard their disease of addiction as a gift. Yeah. I remember when I first came in and you would hear it, you know, there's always the guy who says, I'm a grateful alcoholic. Yeah, right. What kind of fucking asshole is that? (both laughing) Like how? What? You know, I didn't understand it. Now of course, I completely understand that. And that goes back to this idea of embracing the painful parts of life and understanding that those are our greatest teachers. And if you can really learn about yourself through those experiences, you can create meaning around them. That can be helpful for other people as well. Yeah. I mean, as a physician, you know, one of the things that attracted me to addiction medicine in addition to the patients themselves, was the docs in recovery who practice addiction medicine. Because they're not like any other types of doctors. You know, when I go to medical meetings that are not addiction focused, everybody's like trying to show off how much they know more than the other guy, and then you go to, you know, an addiction medicine conference and people are like, yeah, you know I'm X number of years in recovery and oh man, I'm struggling with this character defect and that character defect and I'm so embarrassed by this or that, or another thing I did, it's just such a cool culture. Yeah. And it's empowering. Yeah. I never get tired of hearing the stories. And I'm sure when people read your book, they're gonna be so shocked. Yes. To read these but, I'm so inculcated in that. Like I'm so used to hearing the craziest stories and I love it. I love the honesty and the vulnerability of all of it. And it's so empowering. And it's such a beautiful expression of our shared humanity. Yes, wonderfully put. You know, when I first wrote the book and I gave it to, you know, my agent and the editor, they were like, you know, this story of sex addiction, like maybe you could put it toward the middle or, you know, at the back. You're just blasting people from page one. (Rich laughing)
Like, they were really worried that just people would just be so freaked out. It would be so other that it just, that nobody would read it. And I'm like, you know what? I'm not gonna do that because this is exactly the point that I'm trying to make, like pornography and sex addiction, it is everywhere. I mean, we're not being truthful with ourselves if we are pretending like this is not a huge problem, this is a huge problem and we need to put it up front and center. Now the book is not just about sex addiction, it's about all kinds of addictions, but like you, I hear these stories every day. So to me, they're not freaky and other, and in the book, I really relate my patient to my own kind of sex addiction that I developed. And I wanted to do that, you know? As you said, I wanted to make sure that people understand, like, this is all of us, right? I mean, this is our shared humanity as you said. Yeah. I mean, a lot of people will remember you from the social dilemma. Right. You appeared in that documentary and that's a beautiful, you know, starting point to have this conversation about the universality of all of this, whether it's sex addiction or online shopping or porn or gambling, or, you know, Twitch streaming, it doesn't matter. Like it's so ubiquitous and on some level we're all addicts or we're all addicts in waiting. Right.
Right? And so, you know, I thought it was interesting that in this book, you know, the word addiction is not used on the cover. Like this is not a book for addicts to read, this is a book for everybody to read, because I think it's important that we reframe how we think about addiction and all of the levers and pulleys and buttons that are out there right now, just waiting to trigger us and lure us into unhealthy relationships with substances and things and behaviors and everything. All of it out there. Yes. Yep. You get it. Exactly. So elaborate, I guess. I don't know that wasn't really a question, but you know, this idea that we are all addicts, I think is regulatory for it. And I think people that may ruffle some feathers. Like I'm not that, like, I just know, even when I was in the depths of alcoholism, I would always look at people who were worse than me to say that I'm not this, as opposed to looking for ways to identify or find similarities. Yeah. I mean, if you look at the basic wiring of the brain, we're all wired to approach pleasure and avoid pain. And that is what has kept us alive in a world of scarcity for, you know, gazillions of years. And the fundamental problem now is that we are not living in that world of scarcity. We live in this world of overwhelming abundance, but our brain chemistry and our wiring hasn't changed. So when you are basically wired to seek out pleasure and avoid pain, and you live in a world surrounded by pleasure goods, infinitely available at the tap of a finger, and you're encouraged to avoid pain at all costs, you know, how could we not get addicted? Of course we are, and we will. And I do think people are beginning to relate to that, especially as regards smartphones and things that we're doing online, because people are now observing their own behavior, getting, you know, losing time, getting caught up, spending way more time than they planned. Having it interfere with their parenting or their work, or so I do think that there, I hope that there is sort of this dawning awareness that this is a universal phenomenon, and that yes, we're variably vulnerable, which is to say, we're not all equally gonna, you know, become addicted, but that we are all vulnerable to the fundamental problem now. And that were essentially outgunned and outmatched. Yes. You know, that was a big point in the documentary that, you think that you have some agency here. Well, think again, because you have no idea how much money and science has gone into removing that agency when it comes to your relationship with your devices. Yes, exactly. And also importantly, and this is, again, something I learned from my patients, when we are in our addictions, we cannot see the true consequences of those behaviors. I mean, you know, in the world of addiction, it's called denial, but I mean, it's really a fascinating phenomenon, how we cannot objectively observe ourselves or the consequences of these compulsive behaviors until we get some distance from it and look back and then kind of go, wow, that was surreal that I did that much of that thing for that long. Like, that was really bizarre. And I also lied about it and like, you know, did all these like fancy maneuvers to do it more. And now I look back and it's like, I've had so many of my patients say, "it's like another person, it's like that was another person," you know, which is very interesting. Yeah. Why did I sit on the toilet for an hour staring at my phone, (all laughing)
you know? There are a lot of teenagers out there spending a lot of time in the bathrooms these days, I can tell you that. Listen, I've done it. Like, I'll call myself out right now on that. When you were talking about the doctors that are your colleagues that are in recovery, it reminded me of my experience in treatment. I went to a treatment center where, there was a lot of professionals there on diversion. So a lot of doctors, and a lot of pilots, like the two people that you literally give all of your agency over to, it's very horrifying to realize that surgeons and anesthesiologists and commercial airline pilots were in treatment. And I wanted to share anonymously, some of those stories when I was writing, "Finding Ultra" and my publisher said the same thing. They're like, it's too crazy, you can't do that. (Anna laughing) But to hear these, you know, tales from anesthesiologists like stealing fentanyl and how it made them more productive leads to ketamine and jumping off roofs and all kinds of crazy stuff. Like there was a doctor who was taking just handfuls of Vicodin every day there was another neurosurgeon who was a IV morphine addict, like, you know, it's wild. You know, being smart and being highly educated is not any protection against addiction and might even make you more vulnerable because you think that you'll know. You're superman. Yeah, or that you'll know when you've crossed the line. I mean, you know, I've treated many docs in addiction over the years, but the one that comes to mind now as an anesthesiologist, you know, who had just a big stash of pills, that he would take them in all different combinations and permutations. And he just thought, well, I'm an anesthesiologist, you know, so I know how to dose this stuff until he didn't, you know what I mean? There's gotta be a higher percentage of anesthesiologists that become addicts versus other doctors. Yes, the higher percentage of anesthesiologists and psychiatry. Mm-mmh. Why psychiatrist? Ah, you know, we're kind of stuck in our heads. Is it the brokenness that allures you into the profession to begin with? I think it's the kind of, I mean, I wouldn't wanna speak for all psychiatrists, but I don't know. I don't know what it is. I mean, many people who go into psychiatry have family members with mental illness and so there's kind of a mission driven purpose wanting to help others. Sometimes it's being broken and wanting to help yourself, but I think that's become less and less true as the field has attracted a lot of very high-powered students who are really into neuroscience and such. I don't know, I don't know what it is. I mean, with anesthesiologists, you know, the assumption is it because of increased access, increased access to things like opioids and Benzos. But I think there's probably a self-selection process where you've got people who are already maybe addicted or vulnerable or almost addicted who then subconsciously choose anesthesia 'cause maybe because of the access, I don't know. Yeah. Yeah. And you're in anesthesiology, you're just dealing with those all the time. And I hear these crazy, like you get these tiny little vials of fentanyl and they would like take a little bit of it and fill the rest of it with water and the lengths that they would go to be undetected and tapping into the pharma closet. But, you know, I mean, doctors are just regular people with all the same regular problems. I mean, in some ways what's so tragic about doctors and addiction and the problems of getting into recovery when you're in that profession is because, I think the shame is more pronounced because you're supposed to be this healer, who's got it all together. One of the things that was kind of scary for me in writing "Dopamine Nation" was that obviously I disclose, you know, ways that I'm kinda messed up. So, I mean, that has brought up a lot of shame for me and kind of worrying what other people will think, it is fascinating how afraid we are to do that. I think everybody's afraid to do that, but I wonder if physicians are maybe a little more afraid. Yeah, yeah. I would suspect that that's true. But there has to be a cathartic aspect to that for you as well, right? A freeing. Yes, absolutely. I mean, I really try to live a transparent life where everything I say and do, if it were published on the front page of a major newspaper, I would be okay with it. And so it's not really, maybe as much of a leap for me to disclose those things as it would be for somebody, you know, somebody in another field of medicine or somebody with a different path than I've had. But, you know, I mean, I've never read a doctor authored book where they're nothing but the most wonderful healer. Do you know what I mean?
Right, right. And that leaves you distrustful. Yeah. There's something about leading with vulnerability and the honesty, you know, incumbent in that, that leads me to, you know, feel like this person has more integrity. It works counter-intuitively to the way you think it might. Yes. Well, I'm glad to hear that and I agree with you. And in my own psychiatric practice I've really changed the way that I viewed disclosure. So we are trained to not disclose anything about ourselves to be sort of that removed Freudian type of person who, you know, listens empathically and strategizes with the patient about how to get well, but doesn't actually disclose our own thing, but I'm not sure I believe that anymore. First of all, I mean, our patients can see through us, we bring ourselves to the practice, but also I think that it's helpful for patients to know that like we're all broken, you know, and we all struggle. And so I try to do it thoughtfully. I'm not like airing my dirty laundry with my patients, you know, going and on about my problems, but I do strategically talk about my own anxiety, you know, my own depression, my own insomnia, my own sense of life being, you know, kind of drudgery at times. That is interesting, yeah. Because you think of the therapeutic context as you're this blank slate, right. Who never wants, gives any clue as to what you think or who you are. Right. Right. And so funny because the expressions on my patients' faces, like when I do that, initially there's sorta like this raised eyebrow, like, get me out of here, get me out of here. This lady is crazy. Or like, this is about me, not you. I don't get that so much because I don't go on and on, but there's a sort of like, there's this initial, this alarm is like, I don't wanna be treated by a crazy psychiatrist, but then I think on some core level, they recognize that, well, maybe she's, you know, not that crazy and maybe there's a reason that she's telling me that. Although I did have this one patient who was telling me about his flying phobia and I'm like, oh yeah, I get that. And then he goes, "what? I like to sit to the next to the window 'cause I feel like if I can see the ground somehow, that makes it less likely that we're actually gonna fall." And I'm like, I'm right with you there. I always get the window seat. And that's when he was like, "crazy." (both laughing) But he came back, he came back and he managed to get off his benzodiazepine. So, it was a success story. Where are we in terms of the number of people that qualify as being addicted maybe specifically to substances right now, like it's on the rise, right? There's a crazy spike in the percentage of people that are dealing with some form of substance addiction. Yeah. So, I mean, here's a crazy statistic. 50% of the world's deaths attributable to addiction occur in those under age 50. So, I mean, that's a whole lot of people, right? If we've got more than half of the world's deaths due to addiction in people under 50, that's kind of scary. Wow. And then if you look at specifically things like alcohol, so, rates of alcohol have gone up in the last 20 years, including in groups that were previously immune to alcohol addiction, rates of alcohol use disorder, alcohol addiction have gone up 50% in people over age 65. From when to when? Between the late 1990s and today. And they've gone up 80% in women, which is a really fascinating change. Wow, so what do you make of that? Well, it's complicated. First of all, for older people, what I make of it is that we are living longer, right? And that as people age and their brains age, a lot of folks who have been able to kind of moderate their use for most of their middle years, are finding in their latter years that something changes biochemically, psychologically, and all of a sudden they pop off into addiction. I see these people all the time. People, you know, basically like baby boomers, right? It was like, I have smoked pot every day, since I was 25, I never had a problem. All of a sudden I'm dabbing, right? And it's unmanageable. And in some ways harder because now you have, you know, 65 years of habit and learned experience around using every day, you're gonna give that up when you're 65, 70, you have less brain plasticity to form new habits. So I think the older people phenomenon is both a function of just living longer, having more time, maybe more boredom. And then also the more potent drugs that we have now, the more variety people slipping into addiction in older age. For women, it's really fascinating because, I mean, I see that all the time where, you know, traditionally the rates of addiction of men to women, the ratio has been like 5:1, five men to every one woman with addiction. Now it's one to one in millennials. I mean, it's like equal amounts. Wow. And I mean, I could speculate on why that is. I guess I will speculate. I think that, you know, with the women's movement and you know, more opportunity and more equality, I think there are trade offs, right? That the burden that comes with with burdens that may be leading women into more addictive tendencies, plus you've got more potency and more variety. Right, yeah. That's what came to mind for me immediately. Like that just the proliferation of so many different drugs now and the potency of that. Yes, right. Compared to what it was decades. That's a big part of it. But I also think part of is, you know, culturally, like women weren't really supposed to imbibe and now, like that's not really... That was cultural morals aren't really there anymore. You know, for better and for worse. Yeah. That's interesting. And how does that break down in terms of opioid addiction? Like what percentage of that can be attributed to opioids? In terms of addiction to opioids, I don't know if we have consistent science on that. You know, some studies show that women are more likely to be addicted to opioids, other studies show men. One thing we know for sure is that men are more likely to die from opioids. And that's sort of interesting and not entirely clear why that is. But I think in general, the rates break down to about 50/50. Right. And then in just in terms of addiction at large, like in this spike that we're seeing in the rates of addiction, how much of that overall, what portion of that is opioid related? Well, if you look at the current drug overdose deaths, the majority involve some kind of opioid. Polypharmacy is the norm in drug overdose deaths and in fact, what confers a lot of the risk is polypharmacy. So mixing a bunch of drugs together as a lot more dangerous than monotherapy, but a lot of times people are taking a mixture of drugs and don't know it, right? Because a counterfeit pill that they think is a Xanax bar actually has Flualprazolam, benzodiazepine, designer drug, plus a little bit of fentanyl in it. And they don't know that that's what they're taking. Mm-hmm. Wow. So, what did you ask me? Sorry.
(Anne chuckling) I'm just trying to get at, I wanna kind of segue into the whole opioid crisis 'cause this is obviously an area of expertise for you and as a foundational to that, like just getting a sense of how big the opioid problem is and then what percentage of addiction overall it kind of commandeers. Okay. So there's somewhere between two and 15 million Americans today addicted to opioids. Why is the range so large? Because the way that we do those surveys varies a lot. According to the National Survey on Drug Use and Health it's about 2 million Americans addicted to opioids with about 11 to 12 million Americans, misusing prescription opioids. So, slightly different misuse is not necessarily addiction. Addiction is crossing into kind of a crossing a threshold there, so, but on the outer range, you know, some studies have included, for example, homeless populations or incarcerated populations have gotten up to as high as 15 million Americans addicted to opioids. So, it's, by any count, millions of Americans either addicted to and, or misusing opioids. And then if you look at opioid related overdose deaths, what you see is that they've essentially been rising steadily since the late 1990s. They seem to go down and plateau a little bit in 2018, but in 2020 they rose the biggest percentage they have in the last 20 years. Is that pandemic related? Yeah. We think it's pandemic related. A combination of an ongoing potent drug supply especially, including fentanyl, which is 50-100 times more potent than morphine or heroin combined with increased isolation and decreased access to treatment. Right. So wild. Yeah. So let's talk about how we got here. I mean, you wrote this other book, "Drug Dealer MD," it's a pretty fascinating dissection of the origins of the opioid crisis, how we got here and the multiple contributing factors to it. Talk a little bit about that, the idea of big pharma and big medicine being in cahoots to, you know, create this problem that we're having such difficulty figuring out. Yeah. So in the early 2000's, I started seeing more and more patients coming in addicted to the opioids that their doctors were prescribing. And that was really at the beginning of my own personal reeducation around addiction and how to help people with addiction. And I learned so much from my patients and my colleagues about addiction medicine, and really it transformed the way that I practice. So I assumed that if I just educated my colleagues about addiction, they would all also see the light and stop prescribing in that way. And what I discovered was that, even with re-education, even when, for example, I consulted on a patient and let them know, oh, by the way, this person went to 10 other doctors in the same month to get Vicodin, you should stop prescribing for them, they didn't stop prescribing. And that was really the moment where I thought, what is going on here? This is really bizarre. This is a really good person, this is a highly educated person, why on earth are they continuing to prescribe in this way? And what I then discovered through my research is all of the invisible incentives inside of medicine that keep doctors prescribing in ways that are orthogonal to patients actually getting better. And the most shocking discovery for me was the extent to which the opioid pharmaceutical industry had essentially infiltrated every aspect of medicine to promote opioid prescribing and their influence was so enormous and so powerful that essentially doctors were not able to not prescribe. And the vehicles that pressured them into it were, shame, basically saying pain is undertreated and the reason it's undertreated is because you are opioid phobic, afraid of opioids. So you need to prescribe more. It was things like the joint commission, creating guidelines and quality measures that said, every doctor has to ask every patient about pain, whether or not they look like they're in pain and use this pain scale from one to 10 and prescribe opioids if they endorse pain. It was things like the Federation of State Medical Boards saying, "if you don't treat pain using opioids effectively, you're gonna get sued. You're opening yourself up to a lawsuit." And behind all of those regulatory bodies and all of those professional medical societies were millions of pharmaceutical dollars. Yeah. And in order to really understand this, you have to understand the history of how the medical establishment has thought about pain and what it means and how to treat it. Yeah, I mean, so for example, the whole concept of chronic pain, pain that lasts every day for more than three months, three months being the time that we consider normal tissue healing should occur, that concept of chronic pain didn't even exist until like the middle of, you know, the 1900's. Prior to that pain had been considered to be, a downstream effect of a disease or an injury. The whole phenomenon of more and more people developing these chronic pain conditions, as well as the industry that goes along to treat it, is about 50 years old. And that industry in effect, of course, in a way, has generated the pharmaceutical companies that now serve that cause, you know, to the extent that we have the opioid epidemic. Right. So originally pain was construed as something that potentially had benefits in terms of accelerating healing or helping you to develop some kind of physical or emotional resiliency. At a certain point, the thinking shifted to, no, all pain is bad, it creates all kinds of trauma and it should be ameliorated at all costs. Enter the pharmaceutical industry and a whole infrastructure around making sure that nobody ever feels pain ever and demonizing any doctors who are not going to ensure that that patient walks out of the office, armed with everything they need to never experience pain. And that early idea proved to be untrue, right? And we're seeing the kind of waste byproduct of wrong headedness. Yes, exactly. I mean, not only did it turn out to be untrue, but it turns out that taking opioids every day for long periods of time can actually make pain worse through this process of opioid induced hyperalgesia, which is basically the pleasure pain balance, neuro adaptation, and changing set points around pain, such that pain will get worse if you take an opioid every day to treat pain. And you're absolutely right when you know, in the middle 1800s, when general anesthesia was first invented, the leading surgeons in this country actually were resistant to using it because they felt like experiencing some amount of pain, you know, boosted the cardiovascular response, boosted the immune response, and it was good for tissue healing. Now, I don't know of any objective science showing that that's true, that it pain actually expedites healing, but there are studies now showing that opioids can slow healing down. Right. That's a shocking thing to realize, right? Yeah. And much like the cigarette industry, the pharmaceutical industry put a lot of time, money and effort into creating a narrative here. I think I read some something about, there was a guy, what was his name? Who was propagating this narrative that only 1% of people who were on opioids would some kind of addiction. And that became kind of like the trope that doctors would think, it became an entrenched kind of talking point. Yeah. So that basically started with produced promotion of Oxycontin. In 1980, there was a letter to the editor, which doesn't count as a study, it's just like the equivalent of a medical journal tweet by two individuals called Porter and Jick saying that in a cohort of 11,000 hospitalized patients, they only had four people who manifested signs and symptoms of opioid addiction. So in 11,000 patients who got opioids to treat their pain, only four of them got addicted, which comes out to less than 1% in that population. And that one tiny little data point, which is not really a study, was then used by Purdue Pharma in their promotion of Oxycontin to say, hey, if you're a doctor using opioids to treat a patient with pain, less than 1% of those individuals will get addicted to opioids. It turns out that is totally untrue. A meta-analysis by vols at all, which came out around 2015, shows that one in four patients prescribed an opioid for a bonafide pain condition will develop an opioid use problem. And one in 10 will get severely addicted. Wow. But those kinds of messages that addiction is rare, or uncommon, or few will get addicted as long as you're a doctor and they're a patient in pain was really believed by most of the medical establishment through the first part of this century. And almost on like a magical biological level. Like there must be something magically protective, biologically, if a person has pain, when you give them an opioid, like somehow that's gonna erase the addictive part. But it's not true. It doesn't work like that. Right. So, you know, the conspiracy minded person inside of me, pictures, the mustache twirling guy at the board meeting at pharmaceutical company X, getting on the phone with, I don't know, somebody at the FDA, like how does this all break down? Like what's conspiracy and what's reality in terms of how the tectonic plates of medicine and pharmacy and government kind of created this situation that has produced the crisis that we're in? Well, I mean, I'm not sure I would use the word conspiracy to describe it, but what we definitely have is misleading promotion on the part of opioid manufacturers that represented as science. What in fact was untrue messages about what opioids can and can't do essentially overstating the benefit and understating the risk, in a very fertile ground of health care providers who wanted to believe it. Why did they wanna believe it? Because medicine has transformed in the past 30 years into basically assembly line production, quota incentives. We have to get patients in and out, we have to do it quickly, we have to make sure that they're satisfied customers, when their insurance changes, we may never see them again, they'll see another doctor, there's a different doctor for every different body part. So, the misleading messages were also delivered to a population and institutions for which those were very convenient myths. And I think it's that combination, the intense lobbying, the intense promotion, the millions of dollars given to the FDA, the DEA, other regulatory bodies, you know, promoting these messages. And then you've got healthcare providers who frankly really wanna believe them 'cause they're seeing more and more patients with terrible and debilitating pain for which they don't have the time or the energy or the resources to provide something like, you know, a plant-based diet as a way to get well, or even physical therapy, right? They've got to get them in and out the door. Yeah. And then layer on top of that, the prospect of malpractice, if you don't treat that pain, right? So you have this misalignment of incentives that create this problem. Yes, exactly. Yeah. And the pernicious thing is that, this becomes the entry point for so many people who otherwise might have never experienced any form of addiction, right? And I know so many people in the program who ended up relapsing because they go in for a knee surgery or they have a back problem or they've been sober for 20 years and it takes them out. Yeah, no, it's terrible. So in the 1960s, if you asked somebody who was addicted to heroin, what their first exposure to opioids was, 80% would say that it was heroin, right? They started with heroin as their first opioid. In the early part of this century, or today, if you ask people who use heroin, what was their first exposure? 80% of them will say it was a prescription opiod. Yeah, that's crazy. So this spike in heroin use that we're seeing is really a function of opioid addiction. Prescription opioid addiction. And when you've exploited all the doctors who will tolerate you and you've got nowhere else to go, you're gonna find the heroin dealer. That's exactly right. That's exactly right. And when that heroin supply is spiked with fentanyl, then you've got people who are, you know, who are dying because fentanyl is so much more potent. I know that you've testified on the Hill, you've spoken at the White House, you're involved in policy on some level. What's your sense of where we're at now with redressing this crisis? Well, I mean, just last week, I was in New York testifying in the first jury trial of this opioid litigation. And as you probably read in the paper today, there's a $26 billion settlement in the offing. I didn't know that. Tell me about that. I was in New York, I would have come to the trial. It was open to the public, you could have come. Seven grueling days. Yeah, tell me about this. Well, it was, it was fascinating. So, I mean, first of all, the opioid litigation is understandably confusing to people because people think that the settlement with Purdue that happened, you know, some already, I think last year, even though it's still evolving is sort of the whole deal and the done deal, what they don't realize is that there's something called the multi-district litigation, which is essentially thousands of states and counties coming together to sue, not just Purdue and other opioid manufacturers, but also the distributors that truck the opioids from the manufacturer to the pharmacies and the pharmacies who have dispensed these opioids to the public, thereby creating what the lawyers call, a public nuisance. And the idea of a public nuisance has just that the actions on the part of the opioid pharmaceutical industry led to and cause the opioid epidemic. So there've been a series of bellwether trials for the multi-district litigation that I've been involved in as a medical expert witness. I wrote a report, I've testified, but the trial in New York last week is the first jury trial that is trying this. And it started out with I think, 11 defendants and Johnson Johnson settled, the distributors settled, so what's remaining is just a smattering of, opioid manufacturers, not including Purdue, for example, which has declared bankruptcy. You can't sue somebody who's in bankruptcy. So it's a very- Is Purdue's behind behind Oxycontin? Yes, so Purdue is behind Oxycontin. And they were sort of like the genius so to speak, like the sort of malevolent genius behind marketing opioids in a way that would be extremely palatable to prescribers and would overstate the benefits and understate the risks and then others, you know, copied them, you know, in suit. So, this what would be great is if there could be some kind of global settlement so that all these different county and state trials would come together and be a part of that global sediment so that the litigation could end. Because we can't keep trying this over and over again. And the good news is that it looks like a global settlement, $26 plus billion may actually be in the offing. It's not a done deal that all the different states and counties in the multi-district litigation have to agree to it, but you know, hopefully the details we'll be able to work down. Sure. Yeah, because it's a settlement, it doesn't create some kind of case law precedent, but certainly a chilling effect, right? So what is the of implications of that settlement and how does that impact how pharma kind of, thinks about this and moves forward? Oh, yes, I'm remembering that you have a law degree. Yeah, sorry.
(Anne chuckling) It's been a while.
No, no, it's good. Since I flexed that muscle. Well, so what's interesting settlements are, and again, I'm not a lawyer, but this is what I've learned through this, this experience. So settlements can take many different forms. This settlement that's in the offing, importantly, the defendants are not admitting to wrongdoing, right? But they're providing money to abate the harms of the opioid epidemic. And one of the things that looks like will come out of it in terms of monitoring diversion, or basically pills going to people other than who was intended is a, some external agency, which I think is really good, so to monitor diversion, because essentially what's what we have now is that the opioid pharmaceutical industry is supposed to police itself. And that has not worked out very well. (both laughing) It never does. No. It never does. Just like big tech. I mean, the parallels here are unbelievable. Yes, yes, that's right. So, one of the major things that looks like may come out of this settlement is a better policing system that is not the industry itself policing itself, but then also importantly, billions of dollars going to states and counties to do things like help treat opioid addiction. You know, in the tobacco settlement that was also what the money was intended for. Most of the money went to balancing state and county budgets and didn't end up going to people who had been harmed. So one of the things that people are trying to be very thoughtful about with this settlement is making sure that the money actually goes to the people that have been harmed. Importantly, this settlement does not include monies going to affect it individuals and their families. It's a public nuisance claim, so it's going to states and counties to address the community, not on an individual claim. Hmm. That's interesting. So where does that money get spent ultimately? Yeah. Great question. I mean, I think it's gonna be budgeted at the state and county levels. Right. Which means it's probably not gonna get spent in an effective way. I hope that's not true. I hope that's not true. I'm trying to be optimistic. There are so many good and well-intentioned people, you know, involved in this process and I really do hope that the money is put to good effect. I mean, I think it will be, I mean, not all of it, but I think much of it, you know, which brings up another point, one of the main ways that we as a society currently pay for addiction treatment is through grants from the federal government. And the reason that that's problematic is because by relying on these temporary grants, we never build an infrastructure inside of medicine to target and treat addiction. Like the way we have excellence, like centers for cancer treatment, right? Or centers for diabetes treatment. What we need is addiction treatment centers like right at Stanford University, right? Or whatever the hospital is, there should be a unit and there should be, you know, a specialized clinic building and inpatient beds, we don't have that. And so, I do hope that this money will be put toward actually building the infrastructure that can be a part of, you know, the weft and weave of medical practice and not siloed outside of that. Yeah. 100% we need better rehabilitation across the board. And that should be, especially with the opioid crisis and all the attention it's receiving, it should be something that would, marshal the political will to create something that could be of greater benefit to those that suffer. I mean, it's such a, on one level, kind of a no brainer, right? This is what we should be doing. We shouldn't be putting these people in jail, we should be treating these people and rehabilitating them. At the same time, kind of big rehab. You know, if there is such a phrase, is rife with all kinds of crazy corruption and problems. There's a lot of predatory behavior, especially in the kind of sober living ecosystem right now. Yeah. This is such a tough thing because, I as a treatment provider am very grateful for the good residential facilities and the good sober living environments out there, without which, you know, some of my patients wouldn't have a hope, but you're absolutely right. We don't have adequate oversight, we don't have quality measures, we don't have good outcome data. I mean, we know treatment works and we know people get into recovery with, or without treatment. So, I mean, there's a lot of reason for hope and optimism, but you're absolutely right. It's been siloed and marginalized in medicine. And so we have not gathered the data to really be able to guide building this infrastructure going forward. And we need to do that. Yeah. One of the things that that is unique to our time is the proliferation of certain types of pharmacology that have now been mainstreamed and legalized. So we have pot essentially being legal now, it's ubiquitous, it's everywhere, you walk down the street in New York or Los Angeles, you can't help, but smell it. There's dispensaries everywhere that look like the Apple Store, billboards all over the place. At the same time, we have a lot of interesting science going into, clinical applications for psychedelic compounds and I think what's going on there is super interesting. But for me as somebody who's been in recovery for a long time, these are like trigger points for me. It's like, oh, pot should be part of your wellness routine or what ails you can be found in doing this mushroom trip under supervision. And I find this tension because on the one hand, it's like, no, I'm clean and sober and this is what I do, versus, you know, people who I respect telling me, like, actually, you might find some benefit in exploring these things. And when you tell an addict that the solution to what ails them can be found in a mind altering substance that ends up renting a lot of space in my head. So, walk me through how you think about this, you know, kind of cultural development that we're seeing right now. I have to admit that I am equally ambivalent, you know, as somebody who has been treating people with addiction, getting into recovery for going on more than 20 years, it is very hard for me to believe that a chronic relapsing and remitting illness is going to be effectively treated by, you know, three doses of LSD or psilocybin or whatever it is. I just am very skeptical of that. On top of that, you know, I wanna try to have an open mind about the potential utility of these agents in certain very rarefied conditions, but I think that overall, the messaging is very dangerous. Because exactly as you described, I have many patients who have been in recovery and are doing well, who all of a sudden, you know, read a book that says that they can have some kind of spiritual awakening if they take ecstasy or they take psilocybin. And then that, as you say, they actually ruminate on it. And to begin, they think more and more, and then everybody else is doing it, and, you know, someone famous said that they did it and it was so great. Then I've got a really big job, you know, there. First of all, I don't have a crystal ball, you know, I don't know what's gonna happen to them, but my instinct, my experience and my knowledge of the science tells me that would not be a good thing. That would not be a good thing for somebody with the disease of addiction. And so, you know how then I have to like pull back from that and sort of say, well, you know, I hear you, but gee whiz, like, look at, look at the potential risks. And, you know, sometimes they listen and sometimes they don't and the ones who don't almost universally end up in a very, very bad place. I had a patient who was in great recovery from his opioid use disorder who got it into his head because of things that he had read, that he could treat his depression with ketamine. He ended up getting ketamine on the dark web, dosing it like every nine minutes for three days ending up in the ICU with like, irreversible neurological damage, irreversible in this PhD, brilliant PhD student who completely relied on his brain for, you know, his profession. And, you know, he's better now, but geez, like- So was that person an addict in recovery at the time? Yeah. So you have a brain that is addicted. Like you can't solve a problem with the brain that created it, right? So the lack of objectivity that you have, because what part of that brain is truly seeking, you know, life improving solutions and what part of that brain is the addict saying, oh, we can find an excuse to go on this exploration? Right. Yeah. Especially when like brilliant, famous people are saying, oh, it opened my eyes and I realized-
Justify it. Yeah, I had a oneness so when I realized everything was so much better and it's medicine. So, you know, medicine it's good. I mean, yeah, right, right. (Anne chuckling) You know, if you call it medicine- Right. That's, what's crazy. And it really does. Like, it's weird. I mean, I had, you know, I love Gabor Maté. He told me after we did a podcast that he would personally, you know, supervise me in an Ayahuasca experience, you know? I've got another friend who is a hardcore, you know, 12 step guy been sober a really long time, leads meetings, helps lots of guys, did a supervised, Psilocybin experience. I think he did it at Johns Hopkins and just said it was regulatory. And I said, well, how does that impact how you think about your sobriety? And he's like, "I'm not sure right now." Oh, God.
So it's confusing, it's de-stabilizing, you know, you hear one thing, you hear another thing, all I know is that I've stayed sober in a certain way for a long time and I'm very reluctant to screw with that, but I can't help thinking like, well, maybe I could have some kind of, you know, epiphany or psychological breakthrough that is unavailable to me, that could be helpful. Is that a rationalization? Is that a justification, or is there some truth to that? So here's the thing. You already had a spiritual awakening and you did it by hitting bottom and crawling your way back out again. That took time, it took an incredible amount of tolerating pain and it led to really good things. I do not believe that there is a pill that you can take or a substance that you can imbibe one time or two times or three times that can buy you that, it can maybe give you a shadow version of that, but in the deeply embedded neurological way, that is necessary for sustain wellness and recovery. What people want is the spiritual awakening without doing the hard work to get there. You know, one of my patients once said to me, "one of the things that I've learned about addiction recovery is, the hard way is usually the right way." And to me, these psychedelic interventions, they're like taking the gondola to the top of the mountain instead of walking up. Now you could argue that, okay, you know, both people got to the top of the mountain, but I contend that there's something more enduring and better about walking up to that top of the mountain, then taking the gondola now. And again, I admit I'm probably biased from 20 plus years of, you know, treating people in recovery and, you know, maybe there are aspects of my personality that I also bring to the table that will always kind of favor, let's say a more aesthetic approach to life. But I find it hard to believe, you know, that there's not a cost to pay on the other side. Yeah. I appreciate that. I mean, I don't know a lot of people who are walking the earth enlightened as a result of this, if it was really delivering on the promise. And I think, you know, it's just interesting to see the kind of cultural embrace of this and the vernacular that goes into it, whether it's, you know, pot, or Ayahuasca the plant medicine, or, this is life enhancing as opposed to detrimental, like particularly with pot and as a parent of teenagers, you know, the way in which it's messaged, you would think that this is innocuous and that everybody's life would be better with a little bit of this. Right. But for every, you know, Seth Rogen, there's a lot of damage that I think is underappreciated and not talked enough about. Like I know plenty of people in recovery whose drug of choice is marijuana. And it's far from a innocuous. Yeah. And again, I think what I try to communicate to people because I think it's under appreciated is, you might be fine smoking pot every day for 10 years, 20 years, maybe even 30 years, but eventually it will come and bite you in the butt and then it's gonna be really, really ugly. So why not stop now? Why not stop now?
Right. But that's tough. My mind is like, well, I'll deal with that in 30 years. If I can do this for 30 years without a problem, like, sign me up for that. Really, because in 30 years, I mean, it's really, really bad do you know? I know, so I think it's even in those 30 years, it's deceptive because basically you develop tolerance, your brain adapts, and then you're using to stave off withdrawal from the last dose. You're not really feeling better anymore. I mean, that's that deceptive piece- Where it needed to feel normal. Right, and you're not really seeing the impact 'cause you're in it. And I suspect that somebody who's been a chronic daily pot smoker for 30 years when they do decide enough's enough and they try to stop, that period of acclimating your neurochemistry to some level of normal is gonna be brutal and very long. Brutal, long and in some cases not possible, right? I especially have a cohort of older adults who've been smoking pot their whole lives, who actually, they've lost the brain plasticity to adapt to not using. And yet not only is the pot not working for them anymore, it's actually turned on them, gives them panic attacks, makes them paranoid. So here's this thing that they have to keep using every day in order to stave off withdrawal, but it makes them feel absolutely awful. So that's what I mean about the cost. Mmh. What about vaping? Vaping nicotine, vaping cannabis? I guess you can vape anything now, right? You can really vape anything, right? I mean, I know very little about this other than the fact that I'm a parent of teenagers and this is like a huge thing. The fact that not only are powerful substances more readily available, they've suddenly become essentially undetectable. Right. They're like the little kid chargers- In the classroom, they know how to do it while they're sitting in class and not be detected by the teacher. Right. It's odorless. It does create a kind of a smoke, but you know, it's not the kind of smoke that you would get with cigarettes. It looks like a little battery charger, you can just plug it into your computer. So it's essentially undetectable. And the scary thing, especially in the nicotine pods is that they deliver so much nicotine, that kids are ending up with very high blood levels of nicotine, much higher than they would with normal cigarettes. So these kids aren't sleeping, you know, they're jittery. Yeah. I mean, the technology has made these things so potent and so accessible that it's really scary. Are you seeing this show up in your patients in your clinic? We are seeing a lot of that. It's funny in the bay area, parents and other advocacy groups mobilized very early to raise awareness about vape pens and you know, nicotine levels. So we've done a lot of community education around this, such that we were initially seeing a ton of vaping, and I feel like it's dropped off a little bit, what we really struggle with frankly, most in young people is cannabis. MM-hmm, yeah. I wanna spend the last section of this talking about how to identify somebody who is potentially addicted or is moving in that direction. Like, what are some of the warning signs, whether you're a parent or a friend or a brother or a colleague given the ubiquitous nature with which we're all becoming addicted and in this diversity of ways, like what are some of the warning signs? I think one of the most important warning signs is the double life, which is when we're behaving one way with the people in our lives, and then have this separate life that they're not aware of, and that we lie about. To me that's a really important early sentinel signal that indicates a whole host of different types of compulsive over consumption edging toward addiction. So, believe it or not, I actually prescribe truth-telling to my patients no matter what stage of their addiction they are in. And even people with little minor addictions, I say, try to go this whole month and don't lie about what you're using, but also don't worry about anything at all. Just turns out to be really, really hard for all of us. Yeah. And terrifying. Yeah. And terrifying, 'cause, we're all, you know, liars, it's a sort of part of human nature. So I think that's a piece of it. You know, often you'll hear people who are in my field tell parents that, you should look for changes in function. But unfortunately there are a lot of kids who can be using a lot of drugs and get straight A's and appear to function just fine. It may improve their function. In many cases, it does. Well that's right, right? Yeah. It solves a problem. Whether that's anxiety or social phobia, you know, wanting to be comfortable in groups or manage anger, existential, you know, uncomfortableness or whatever it is. So I don't really think that function per say, is necessarily gonna allow us to detect that in our loved ones. I really think that this, this kind of, obfuscation, I can't even say the word. Obfuscation. Thank you, obfuscation, you know, the sort of smoke and mirrors. Even little things like saying, oh, you know, I was over there, but then you weren't there, you were somewhere else. You know, that should be a worry. That should be a worry. Yeah. I guess that's, I mean, I don't like to say like, oh, look for this because the truth is that, people are really good at covering up addictive behaviors. Yeah. That's what I was thinking. Like you can say, well, you know, look for the double life, but the addict is very diligent and crafty and protecting that second life to be undetectable. That's exactly right. So when they come into your clinic and are at some of being ready to be honest, that doesn't mean that they're gonna be ready to be honest outside of your office? That's for damn sure. Yeah. Boy, I just had a patient last week and we even role played about how she was gonna tell her girlfriend that she relapsed. And I said, okay, call me tonight, let me know how it went. No phone call.
No phone call. No phone call. But you've been doing this long enough to know that on some level, perhaps you weren't expecting a phone call. Oh, I always hope for it, I always hope for it. Because sometimes you know, it works and I get the phone call. So I always expect it, hope for it, but, and yet I'm not surprised when I don't get it. And I'll just have to reach out to her again, and keep holding her in that space till she's ready, keep encouraging her to make that step. But yeah, I mean, it's hard. And I, you know, I really feel for parents because many times when serious addictions come to light parents blame themselves and say, how could I not have seen that? How could I not have known? And I just feel like saying like easily, you could not have known very easily because, you know, people are really good at hiding these behaviors and come up with all sorts of really advanced strategies for doing it. So, you know, don't blame yourself. I mean, I don't know what my kids are doing online. I mean, you know, now that they're older, I did when they were younger. Now I have no idea and I'm kind of neurotic about it too. But what I try to do is, educate them about the pleasure pain balance and really demand honesty. I say, you know, I can't control what you do, but don't lie to me. It's a hard balance to strike as a parent. You don't wanna be the overly intrusive, overly helicoptering parent who's into their business too much, but you also can't be checked out either. And you know, where that sweet spot is very difficult. You know, it's interesting data show that parents who are more involved in their kids' lives know where their kids are, know their friends, check their backpacks, go through their rooms, that those kids are actually at decreased risk of developing addictions. Yes, not surprising. Now I agree with you. There is a quality to that that if it's intrusive and overly controlling can completely backfire. Yeah, that will create the opposite reaction once they get a little freedom. Yes. And Lord knows I've been guilty of that in my own parenting. (both laughing) So your parenting story too? No, it's my childhood story, you know? Oh interesting. Okay, interesting. Yeah, okay, so how did that go? So I can not make that mistake. Well, I, I just, I grew up in a, I mean, you read my book, I grew up in a very achievement oriented household and there was a lot of attention on me, and a lot of expectations and I was very academically and athletically motivated, but I lived a very structured life. Like I never got into trouble, I never, you know, broke the rules or any of that kind of stuff. And when I moved 3000 miles, like, no wonder I moved 3000 miles away to college. When I was able to put that kind of distance between, my upbringing and my current situation, I found myself, you know, spinning out of control or just, you know, sowing my wild oats in a way that was unhealthy. Because I think there wasn't enough freedom that I had, and it was, you know, not to overly blame my parents, like a lot of it was self-imposed. Yeah. So I hear you on that, but I'm wondering what could your parents have done differently that might have protected you? Hmm. That's a good question. Maybe nothing, or maybe just creating a little bit more leeway to kind of get in trouble a couple of times, you know? 'Cause I was so afraid of getting in trouble. So that I could have gotten a little bit of that out of my system or just have that experience younger. Yeah. Well, I'm gonna think about that. So addiction runs in my family and know, I am worried about our kids, particularly our sons. And, you know, I've tried to be real thoughtful as a parent around this to try and give them the best chance, knowing that there are no guarantees. And I don't know that I've thread the needle. I mean, I know times when I have done it wrong and being sort of overly intrusive and that kind of letting go is something that I'm working hard on now. I try to give them knowledge of the science, knowledge of people's life experiences, and also some metacognitive strategies along the lines of tell the truth. You know, that shame can be both a force for good and a force for evil. Think about quantity, frequency, potency, I mean, all the things I write about in my book. But still, I think that what you're saying about your childhood is probably true for my kids, you know, in an achievement oriented, so achievement can be its own addiction, and that's the other thing, right? Certainly, for me. Yeah. Well, and I think for many of us, so, and so like, I wonder if our kids, you know, if they developed a problem, I hope that they would come to me and to us, but I do worry that they might not because the shame would be so great. So anyway. Right. And you being an expert in the field- Well exactly. You know, multiply that possibly. I think one of the things I've tried hard to do as a parent, and I am curious about you, is that I've tried to be very open with my kids about my character defects and my mistakes so that they know that I'm not perfect. Of course they don't think I'm perfect at all. In fact, there's almost nothing good about me these days. Yeah. But I know what that's like. Right. But what I'm trying to say is from very early on, I talked a lot about my mistakes and my regrets and my shame and the bad things that I've done and tried to own up, even in our interpersonal relationships, in the ways that I'm highly flawed and broken. I hope that will be helpful to my kids to give them room to feel like, you know, we all make mistakes. Yeah. I think that that's true. I think that's powerful. I mean, that's something that we've definitely practiced as parents, you know, and I've taken my kids to AA meetings and they know my story and we're pretty transparent almost to a fault- Yeah, right. When it comes to that kind of thing. 'Cause that's how I'm inculcated in that. Like, that's my nature. Like I don't carry shame around it anymore. I'm fine talking about it. But what's interesting, at least with respect to our younger kids, we have one who is very extroverted and honest to a fault. Like the great thing is, is like, she'll just tell you everything. And sometimes it's shocking. Right.
(both laughing) And even when she does lie, like she's a terrible liar, but she really is honest, and that's great, so there's an open channel there. The younger one is very internalized and so it's harder to know what's going on. Yeah. And that's just their natural disposition. That's right. So it's also an individual thing with respect to what works for what kid. Yes. That's right. Which makes it harder, I guess. Yes. Just when you think you've figured it out- Right. What works for one- Doesn't work for the other one. That's right.
I know, I know. But it sounds like you've done everything that you can do. You're the psychotic, you're the expert. I know, I know. That's all we can do-
That's the scary part- And if something were to happen, you know, the job for you then as you know, is like, it's not your fault. Well, yeah. And I think this is something, you know, a lot of parents, like I know my parents, like when I ended up in treatment, like they blame themselves, they were devastated. Yeah. And they kept running this, you know, narrative in their head. Like what did we do? And how did we cause this and all of that? And a lot of my work with them has been, trying to alleviate that in them. Right. Yeah. I mean, I think it's perfectly possible that I'm doing something terribly wrong right now in my parenting that I will not realize until 20 years later. Well, I feel like it's rigged that way. Like no matter what you do it turns out to be the wrong thing. Right. I mean, one of the mantras that I've just sort of, I mean, I could almost get a tattoo for it is the AA mantra "one day at a time," which I think is just such a healthy way to be a parent. Because, all I can do is just try my best today, to be honest and thoughtful, to listen, to really listen and to try to be helpful, to be a guide. Knowing I'm probably gonna make a lot of mistakes, but I'm trying, you know, I haven't given up, I'm in it, I'm trying. And I think the kids can feel that, you know, that, like I want to be a good parent. I may not always be a good parent, but I'm trying to be a good parent. And I think that might carry me over, and like, you know, help through some of the messed up stuff that I am sure that I'm doing. But in the event that one of them develops some kind of addiction situation, you know, sort of having a healthy relationship with how you contributed or didn't contribute to that, while maintaining an open channel of communication, right? Isn't that the key? Yes. I think that's right. You don't wanna take on too much responsibility and this is where like the let it go, let God is really useful. It's like, you know, I've done what I can do and now these are your choices, right? And kind of just saying like this is your life like- Yeah. I think that that's important. And the genetic piece is interesting. Like, is it true or not like, there's this trope that it jumps generations. Like my parents weren't alcoholics, my grandparents weren't either. But so you have it's in your family, it's not in your generation, but is there this thing where it jumps generations? Is that a truism or is that not backed up by science? I don't think there's data to support that. The data are, you know, looking at family studies and twin studies, you know, an identical twin with an alcohol use problem will, or an identical twin, if their twin has an alcohol problem, they're at higher risk. If you have a biological parent or grandparents, so it can skip the generations, but the biological parent, you know, is gonna make a difference too. But that's what the studies show. But I also just think, you know, again, addiction is endemic in the population. It's part of how we're wired. We are wired to seek out pleasure. We wouldn't be here if that weren't true. And so, you know, it can pop up anywhere. Like you don't have to have it in your family for your kid to develop a serious addiction problem. And it doesn't mean that you did anything wrong or that there was trauma that needs to be uncovered. Yeah.
Right? It's like wiring. Yeah. What about the epigenetic piece? This stuff is fascinating, right? The idea that your great, great grandparents suffered some trauma in childhood and the emotional experience of that trauma gets passed down genetically and can manifest in some kind of unhealthy addiction related behavior. Yeah. And I know there are animal studies showing that, you know, these non inherited base pairs that get modulated through an experience, literally that DNA then gets passed to, you know, the offspring and their offspring. So I guess all of that is plausible in humans as well. But, you know, I also wonder how much of it is just the culture. I mean, we inherit and elaborate on our culture as much as we do on our DNA. So I think it's gonna be really hard scientifically to separate out what is like protein expression and what is, oh, this is how we do it in our family. You know, we talk about X, but we don't talk about Y or, you know, this is how you tolerate hard things that come along. Yeah. How can you parse those two things? It's almost impossible. I think almost impossible, yeah. Well, finding ourselves mired in a culture that is driving us all towards some addiction in one form or another, maybe a good way to end this is to share, you know, a little bit of wisdom or some thoughts for the person who's listening. Who's never thought of themselves in any kind of addictive context, but is like, yeah, maybe I spent a little bit too much time shopping online, or, you know, I am sitting on the toilet a little bit too long scrolling through Instagram, or like, why is TikTok, why can't I stop scrolling up on these TikTok videos or whatever it is? You know, my first intervention with most of my patients in my clinic, whether they come in specifically for a problem related to addiction, or whether they come in for something else like depression, anxiety, but are simultaneously consuming a lot of high dopamine substances or behaviors, is to recommend a dopamine fast. And that is a period of time abstaining from that drug or that behavior that is causing the problem or related to the problem. And over, you know, the last 20 years I've essentially evolved an intervention, which is a month long dopamine first, then the month is somewhat informed by the science, and there are some interesting studies that I talk about in my book, but essentially I tell people, you know, you're gonna go into withdrawal in the first two weeks, and by week four, you'll probably be feeling better as the gremlins hop off the pain side and homeostasis is restore restored, and you've generated more of your own dopamine. You're not as fixated on that drug and you're able to kind of get pleasure from more modest rewards. A lot of times patients will ask, well, why can't I just reduce the amount? And the reason I don't recommend that is 'cause, it just usually doesn't work. We really need to reset reward pathways, and then if we decide to go back to using our drug and moderation, put barriers in place so that we can maintain moderation. And by the way, most of my patients who come in with even serious addictions after a month of abstaining and feeling better when I asked them, wow, things are so much better. Do you wanna do another month? Or do you wanna go back to using your drug? In the vast majority of cases they wanna go back to using, but they want to use less. So then we talk about barriers and you know, how they can engage in what I call self binding strategies and other metacognitive strategies to moderate use. And then it really is an experiment. Some people are able to moderate their use and others are not, and it's just like data gathering. Sometimes people can moderate their use and then decide it's just not worth it. Like it's so exhausting to moderate use that it's just easier to abstain. Yeah. For me, abstinence is easier than moderating use. Yes, exactly. You just remove it completely. And eventually you acclimate, but moderating use ends up occupying a lot of emotional and mental energy, but that's me, right? So, that idea of abstinence followed by an experiment of what re reframing your use looks like will be information that will tell you how big of a problem this really is for you. That's exactly right. It's informative in many different ways. And because it resets dopamine, it's also restorative because people tend to feel better after a month of that. And it gives you some guidance for, you know, what the next step might be, whether it's moderation or abstinence. I think talking about moderation, which has kind of been taboo in addiction medicine for many years is also really important. Not only because for some people, moderation is actually the right choice, but because now there are so many drugs that like, we can't eliminate entirely like our smartphones. I mean, people, you basically can't function without a smartphone-
Or food. Or food, right? So then people have to figure out ways to moderate consumption of those substances or those goods. So it's an important discussion that we have to have. And my main message about self binding strategies is that you have to think of them and put them in place before you're exposed to the substance. If you wait until you're offered, you know, a use, it's not gonna work,- Forget it. Yeah. Forget it. You have to anticipate it, have that barrier in place, have a plan. And, you know, as I talk about it again in the book, there are pharmacologic strategies now that can create barriers for people, which are very interesting things like naltrexone on that binds and blocks the opioid receptor, that for some people is really a miracle drug when it comes to things like alcohol and moderating alcohol use. So there's an interesting, you know, science that's opening up there around ways to do. Yeah. The self binding thing is interesting. I mean, basically it's about prophylaxis, like creating space, like temporal, you know, geographic space, like all these different ways of, you know, putting distance between you and whatever the trigger is. But in the kind of vernacular of recovery, the idea being like, if you haven't done that, when you're met with that triggering substance, it's gonna be impossible to refuse it because, the train pulled out of the station a long time ago. Like that relapse was a long time in the making and all it needed was an opportunity to express itself. And I think that that's underappreciated in thinking about recovery, like they always say, you know, in the rooms like the, every decision or, you know, everything that you do is either moving you towards the drug or away from the drug. And relapse often requires a very long runway, you know? Yes. And so being aware of that, like it's, you know, what I'm doing now today to take care of my sobriety has an impact on, you know, some situation that I'll find myself in a month ago. Right.
A month later. Right, yes. I mean, in the throws of desire there's no choosing. And the other important part of what you just said is that, you know, wellness is usually not one sledge hammer that's gonna fix everything. It's the slow accumulation of a lot of small behaviors over many days. And that's something that I have to remind patients of, you know, again and again. Yeah. In the book, you lay it out with this dopamine acronym where every letter in the word dopamine, you know, is kind of, you know, one step along this pathway of, you know, thinking more intelligently about how all of this operates. Yes. Yeah. Cool. Well, it was awesome talking to you. Really awesome to talk to you. Thank you so much.
How do you feel? Did we do it? You know what? I'm like- Is there anything we didn't talk about? I am not worthy because I'm not blowing sunshine, I'm telling you the truth. Like, you read my book, you thought about it, you got it, you asked great questions. Like this has been the most satisfying interaction I've had around the books, since I wrote it. As an author, you know, like the primary desire is to be understood. Like we want to be understood. And I'm so grateful because you get it, you totally get it. You got it, you get it. And it's been really rewarding talking to you because that. Well, I appreciate that. I wanna come and have a therapeutic session in your office next time I'm in the Bay Area. Anytime. Free of charge. Yeah. And I'd love to have you back on, like this is obviously, as I said, at the outset. This subject is near and dear to me and I think, you know, we can't do it justice in a couple hours. So, I'd love to continue the conversation. Oh thank you, I'd love to. You know, especially, like, it's so funny that you mentioned like Johann Hari and Gabor Mate, you know, two wonderful people, they written wonderful books, but you drill down to something. One of the reasons that I wanted to write this book was exactly that it's like, yes, trauma's important, yes, social connection is important, but like, even without those problems, like addiction is, you know, happens, you know? Yeah, it's still there. It's still there and it can happen to any of us. And this problem of, you know, be living in an addicted genic universe is really core now. Like we have to realize that 'cause otherwise we keep looking for the trauma, you know, or keep trying to like, well, maybe I'm not connected. If we just understand that trauma. Right. If we just understand that trauma. Or if I just had a more intimate relationship with my spouse and it's like, no, no, you could have, the best relationship on the planet. That's an emotional geographic. Right. Right.
Right, yes, that's good. I've not heard that before, that's a good one. All right, well, to be continued. In the meantime, everybody pick up "Dopamine Nation." I love this book, I think it's gonna help a lot of people. So, thank you for the work that you do. Yeah, thank you. And I'm at your service, peace. And plants. Sobriety. (Anna laughing) Awesome. (Rich laughing)
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