00:00:00
the amount of alcohol it takes to begin to cause health rellated problems is much lower than you think. Okay. So, if I have this glass of wine every day,
00:00:07
you'd be in what we call moderate risk, which is associated with pretty much every form of cancer. So, say that I'm drinking If you're drinking two of those
00:00:13
glasses, we're talking like a 40% increase. But even drinking that amount, your risk of breast cancer would increase by about 5%. This amount. Mhm.
00:00:20
Which for many people is very normal. So, there's a lot of misinformation out there about how much should you drink,
00:00:25
which I think people don't know, but I can take you through everything. So, Dr. Sarah Wakeakeman is a Harvard professor
00:00:31
and addiction expert leading the charge against one of the biggest public health crises of our time, addiction. Bringing
00:00:36
facts, empathy, and hard-earned truth. One in three people may have a problem with alcohol at some point in their lives. And globally, 2.6 million people
00:00:43
every year die from alcohol-related causes because pretty much every organ in the body is impacted by it. You can
00:00:49
see here, this is a 43year-old person where their brain looks the way a 90-year-old with dementia would look
00:00:54
because of that brain damage over time from alcohol use. But what drives people to use substances? It's probably the
00:00:59
most important question and if we look at studies, one is about 40 to 60% genetics. And the other half of the
00:01:05
equation is trauma. And so we hear someone talk about alcohol gives them pain relief, whether that's emotional or
00:01:10
physical. That's a very real thing. That's because your sort of natural painkiller system is activated by drinking. It's an anti-anxiety and a
00:01:17
pain medication sort of allin-one. So when you think about how we treat addiction, where are we going wrong? The
00:01:22
biggest problem is that people haven't been given the evidence and tools to understand addiction. But also many
00:01:27
rehabs don't offer the things that we know are actually effective. And what is it that people need? Great question. One
00:01:32
of the most effective tools we teach people is something called and they found that people drink much less after
00:01:38
it. Yeah. Wow. This has always blown my mind a little bit. 53% of you that listen to this show
00:01:45
regularly haven't yet subscribed to the show. So, could I ask you for a favor before we start? If you like the show
00:01:50
and you like what we do here and you want to support us, the free simple way that you can do just that is by hitting the subscribe button. And my commitment
00:01:56
to you is if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen
00:02:03
to your feedback. We'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so
00:02:09
[Music] much, Dr. Sarah Wakeakeman. With all the work that you do, what is the mission that you are on?
00:02:20
My mission is really to change the way people think about and understand alcohol and drug problems and also to
00:02:25
give people the evidence and the facts both to understand addiction, which are sort of problems related to alcohol and drug use, but also to just understand
00:02:32
the science around, for example, how much should you drink? Is drinking healthy? Is it not healthy? There's a
00:02:37
lot of misinformation out there, and I want to give people the tools to make the right decision for them in their lives. And who who are you and what what
00:02:44
is your sort of body of experience education? So I'm a medicine doctor by training. So I still do some
00:02:50
general medicine like in the hospital take care of pneumonia and heart failure and in the outpatient setting take care
00:02:55
of people's diabetes and um depression but I train especially in addiction medicine. So I'm board certified in
00:03:01
addiction medicine and that's been kind of my life's work. I work in a big academic medical center in Boston,
00:03:07
Massachusetts, where I would say my kind of focus professionally has been thinking about how do we bring addiction
00:03:12
care back into the medical system so that it's not this separate and unequal and often very poorly done sort of
00:03:20
siloed system, but actually just a part of the health care that people get. And then I train people so I'm um program
00:03:25
director of our fellowship program. So I train doctors who want to be specialists in addiction medicine. When you think about how we treat addiction in the
00:03:32
modern world, what are some of your gripes? Where are we going wrong? Oh, how much time do we have?
00:03:39
Where do we begin? I mean, I think at its core, the biggest problem is that we've all been taught and sort of
00:03:45
infused in this idea that addiction is an issue of behaving badly, that it's an issue of morality, that people really
00:03:52
need to kind of knock it off and pull themselves up by their bootstraps, and that this is like a criminal legal
00:03:57
issue, that um it's an issue of willpower. And so, if you believe those things, then why would you think that
00:04:02
someone should get medical care or why would you treat them with compassion and kindness if you think that they're doing something wrong? And so really reframing
00:04:10
how we think about addiction based on all of the science we have and what effective treatment looks like, which
00:04:15
often is very different than what people may have experienced if they were trying to access care for themselves or a loved one. And what is an addiction? What what
00:04:23
falls into the the bucket of addiction? You know, because I'm I use my iPad a lot. I use my phone a lot. Um is that is
00:04:31
that an addiction? Yeah, it's a great question because we use that term colloially a lot. You know, I'm addicted to Netflix or whatever. Um, so addiction
00:04:39
is really defined by use despite consequences. So continuing to do something in your life despite bad
00:04:44
things happening to you because of it. So we talk of addiction, we talk of the four C's is a way to remember it. So one
00:04:50
C is loss of control, meaning like you've tried to change and you haven't been able to. So you've tried to cut back or you've tried to stop and you
00:04:56
couldn't. The other is compulsive use. So your use is like spiraling out of control that you're kind of using in a
00:05:02
way that isn't really attached to your rational thinking. The next is consequence. So continued use despite
00:05:07
negative consequences either in your life, your job, your relationships, your health. And then the last C is craving,
00:05:14
which is this sort of strong psychological urge to want to use. Like you can't get the idea of having a drink out of your mind. And so it's really
00:05:20
those four C's that we think about. And then we make the definition based on how many criteria people meet out of this 11
00:05:26
list of different criteria. And then based on that, people can have a mild, use disorder, moderate, or severe. And
00:05:32
so moderate, severe is really what we think of as addiction. But it's that use despite bad things happening to you. And
00:05:37
what things are capable of being addictive? Yeah, lots of things. I mean, um, I focus mostly on alcohol and drugs.
00:05:44
So, alcohol obviously probably most common. I think we'll talk about that a lot today, which I'm excited about. And
00:05:50
certainly when we look worldwide, 400 million people have an alcohol use disorder, meaning addiction alcohol.
00:05:56
It's a lot of people. The other are drugs. So, that can be, you know, opioids like heroin or pain pills or
00:06:03
fentanyl. can be cocaine or stimulants like methamphetamine or prescription stimulants, sedatives that people may
00:06:09
take for anxiety like bzzoazipines, cannabis. And so there's a whole sort of range of substances that can be
00:06:15
addictive and how addictive a substance is um is really related to sort of how much dopamine is released in the brain.
00:06:21
I know you've had a wonderful episode with Dr. Lumpkkey about dopamine, so you've talked about that a bit. Um and
00:06:26
there are different sort of addictive indices of different substances. So cannabis is less addictive than
00:06:32
methamphetamine for example, but all of those substances can cause addiction in people. Even beyond that, I wonder
00:06:37
sometimes in my life if I'm addicted to other things like I mean I drink coffee every day. Certainly get a craving to
00:06:42
drink it now. Yeah. Well, there's, you know, a couple important pieces there. Is your coffee drinking causing harm in
00:06:48
your life in any way? No. I think it's I think it helps. It may be helping you, right? Okay. So, it's not Yeah. So, it's not addiction. So, there's a difference
00:06:54
between physiologic dependence, meaning like if you don't drink your cup of coffee, you're going to get a headache,
00:06:59
and addiction, meaning that you're spending all your day and all your money buying more and more coffee. We don't really see this, but um buying more and
00:07:06
more coffee despite, you know, your girlfriend nagging you about it and you you're late to work cuz you're purchasing coffee. We don't really see
00:07:12
that so much with coffee, but that would be sort of addiction. And how big is the problem? So, if you were to frame like
00:07:18
why should we care? Why should the person listening to this care? Because I imagine it's the case that many people
00:07:23
here don't have an addiction that fits into the category of having severe consequence for their life. I also
00:07:29
imagine some people are under the impression that addiction is something that happens to other people. Yeah. So c
00:07:35
can you frame the situation for me and explain to me why we should all care about this and the I guess the scale of
00:07:41
the impact it's having? Well, I guarantee that many people listening have been touched by addiction either
00:07:46
personally or in their lives. Because of stigma, we tend not to talk about that. But the scale is huge. So globally 2.6
00:07:53
million people every year die from alcohol-related causes. So that's 7,000 people today will die from an
00:07:58
alcohol-related death. Another 600,000 people die from drugrelated deaths annually. So that's like 1,600 deaths
00:08:06
today from drugrelated causes. And then when we look at the criteria of sort of meeting criteria for a substance use
00:08:12
disorder or addiction, it's about 400 million people worldwide for alcohol and 80 million people for drug use. So it's
00:08:18
incredibly common. If you think about alcohol, some studies estimate that the lifetime prevalence, meaning in over the
00:08:24
course of your life, how likely are you to at some point develop alcohol addiction? Somewhere between 15 and 30%
00:08:30
in some studies. So one in three people may have a problem with alcohol at some point in their life. So this touches all
00:08:36
of us. We just don't talk about it because of stigma and because of these mental images of kind of othering that
00:08:41
you know it's only those people who are injecting heroin who have addiction or that person who you know has the shakes every morning and is drinking as soon as
00:08:47
they wake up who has a problem with alcohol. In which direction are we going in as a society? Are we getting better
00:08:53
or are we getting more addicted? Yeah, great question. Um the pandemic was not kind to addiction. So we saw rates of
00:09:00
alcohol and drug use and deaths related to those increase significantly after the onset of the COVID pandemic. Um that
00:09:07
has started to level out. So for drug use related deaths, we're now back at the prepandemic levels. But there was a
00:09:14
very significant increase during the time of the pandemic. And that's really not surprising when we think about what are the things that drive people to use
00:09:20
alcohol or drugs in a problematic way. I was looking at some of the some of the life expectancy graphs and um this one
00:09:26
in particular I found quite shocking. I'll throw it up on the screen but it shows that obviously you know we would
00:09:33
expect that there was a drop in life expectancy during the pandemic but even when you compare it to other countries it's not as significant. So I'm wondering why in your view there was such a significant decline in life
00:09:46
expectancy during the pandemic. Yeah. So um obviously COVID was one driver. One of the main other drivers was substance related deaths. So actually immediately following the onset of the pandemic, so
00:09:56
beginning March, April of 2020, we saw a 23% increase in alcohol-related mortality and we saw the highest rates
00:10:03
ever we've seen of drugrelated overdose deaths. And that actually impacted US life expectancy up until this year. This
00:10:09
is the first year that we've seen that change. at the essence of what's actually going on there because you know
00:10:16
addiction is downstream from something else. Yeah. What is actually going on? Yeah. So that's a really great question like what drives people to use substances. It's actually probably the
00:10:26
most important question even in my work. You know if you don't understand what someone's substance use is about or
00:10:32
related to how are you ever going to address it or help them address it? Um so trauma is probably the single biggest
00:10:38
driver. So, you know, you often hear things like cannabis is a gateway drug. I would say trauma is the gateway drug.
00:10:43
If we look at many, many studies, they're kind of two different things that drive someone's risk of addiction.
00:10:49
One is genetics. It's about 40 to 60% genetics, similar to diabetes in terms of someone's risk. That's not a done
00:10:56
deal. Obviously, there are people with strong genetic risks who never develop addiction and people without that who do. The other half of the equation is
00:11:02
based on kind of your exposures and your experiences. And one of the number one drivers is what we call adverse
00:11:08
childhood experiences. So there are this famous study called the ACES study which is stands for adverse childhood
00:11:13
experience and it's been replicated. There's a recent one done actually in Europe as well that looks at the number
00:11:19
of adverse childhood experiences you have and it's a linear track increase in terms of your risk of substance use
00:11:24
disorder. So if you think about what's happening in the brain with substances, you know, when we use alcohol or drugs,
00:11:31
all sorts of feel-good hormones are released, right? dopamine, your indogenous opioid system, which is literally your natural pain reliever.
00:11:38
And if you take someone who's experienced trauma, there's great relief that people can find in substance use.
00:11:43
And so we saw that in the pandemic, like what was going on in the pandemic, people were scared, they were bored, they were lonely, they were stuck at
00:11:50
home, they didn't have their usual routine, some people were losing people that they loved. And so we saw all of
00:11:56
this escalating substance use. And it was actually most pronounced in people who are frontline workers. So that could be a healthcare provider. It could also
00:12:02
be someone working in a grocery store or a convenience store who had to work through the scariest times of the pandemic. And also people who are
00:12:08
caregivers. So those are kind of the two groups that had the biggest increase in their substance use during the pandemic.
00:12:13
What is going on in the brain? You referenced it a little bit there. You referenced that dopamine makes you feel
00:12:19
good. Um so you know very naively I would assume a case if you feel bad dopamine makes you feel good. You want
00:12:24
more dopamine. But is it is it more complic complicated and nuanced than that? Yeah. Yeah. Well, alcohol is a
00:12:29
really complicated one because alcohol has lots of different effects on the brain. Um, so any drug that can or
00:12:35
substance that can cause addiction is going to release dopamine. That's sort of a primary driver of many things that we find rewarding whether it's sex or
00:12:41
food or alcohol or drugs. But alcohol also so it binds to the part of our brain um a system called GABA which is
00:12:48
sort of our anti-anxiety system. So it's the same system that anxiety medications like people may have heard of Adavan or
00:12:54
larazzipam or Xanax. These medications that are kind of sedatives and anxiety meds, alcohol acts on that part of the
00:13:00
brain and it actually then causes a release of your indogenous opioids in your brain. So like your brain's natural
00:13:05
painkillers. So that's actually why one of the medications that's effective in helping people stop drink actually just
00:13:11
blocks the opioid response in the brain, which doesn't make sense when you first hear about it until you understand these neural mechanisms that actually your
00:13:19
sort of natural painkiller system is activated by drinking. So when you hear someone talk about alcohol gives them
00:13:24
pain relief, whether that's emotional or physical, that's a very real thing. That's a powerful system in our brain um
00:13:30
that gets activated when you're drinking. Ah okay. So, if I'm having a stressful time at work and work is
00:13:35
making me anxious and um is crippling me, then I'm more likely to want to have a big blowout on the weekend because that's effectively a a pain medication.
00:13:46
Totally. It's an anti-anxiety and a pain medication sort of allin-one, you know, and I think often this is part of the
00:13:52
area where I think just getting more awareness and and education about alcohol is so important because we see
00:13:57
that as a way of like treating ourselves, right? And and it's very easy to have that get out of control. And I
00:14:03
think especially if in your head you think as long as I'm not like drinking in the morning or missing work because of drinking or you know having problems
00:14:10
in my relationships I'm fine. But actually there's so many health problems and even life problems related to alcohol that people may make different
00:14:16
decisions for themselves if they had that awareness earlier on. You know I was thinking about a friend of mine who
00:14:23
is fairly well known um passed away from issues related to his addiction. Yeah. He had a lot of pressure on him when he was fairly young. He wasn't
00:14:38
necessarily a a young child when he had a lot of pressure put on him, but he was
00:14:43
young. And I was wondering as you said childhood experiences, what age that is? Yeah. Is there like a certain age where those experiences become, you know, if you
00:14:54
experience a certain level of trauma at a certain age, it's harder um to recover from that and you're more likely to be
00:15:00
addicted. Yeah. So, it's a great question. Trauma at any time can put you at risk for addiction. The earlier that
00:15:06
happens, the more sort of long-lasting the impact can be. Um, so when we think about the brain, you know, your brain doesn't really fully form until early to mid20s. And so both in terms of trauma,
00:15:18
but also in terms of early substance exposure, you're at much greater risk when you're younger, but that doesn't
00:15:23
mean that trauma in later life doesn't um put you at risk for developing substance use as well. So I've seen
00:15:28
people who, you know, their first trauma was in their 20s or 30s or 40s and they can still develop a substance use
00:15:33
disorder. It's just the risk is even greater when you experience those adversities as a child. And the
00:15:39
interesting thing is, you know, trauma is not so much about the experience. It's about often being left alone to
00:15:45
grapple with that experience by yourself. And so what's traumatizing to one person may not be traumatizing to
00:15:50
someone else. And you know, take the pandemic for example. I've talked to people who like being stuck at home and
00:15:56
alone and bored was deeply traumatic. Other people were fine. They like were in their living room, you know, doing
00:16:02
whatever and found ways to connect and to live their lives and did okay. It was the same experience, but it was experienced very differently by
00:16:08
different people. So, it's less about the actual experience and more about the impact on that human, how they're left
00:16:13
feeling. And often it's about feeling disconnected. Um, we often talk about the opposite of addiction is not
00:16:19
sobriety, it's actually connection. It's how do you build that connection with other people again? My friend um that I
00:16:25
was referencing is is Liam Payne who's from One Direction, the the boy band who passed away. and he was on my podcast
00:16:30
and uh a few years before he passed away and on the show he said that much of what made his early life so
00:16:38
difficult as a teenager was he was obviously thrust onto this big show and then the way it worked was you know got all this public spotlight and then
00:16:45
they'd like put him up on a stage and he'd be in front of 100,000 people in Dubai and then they after that
00:16:52
experience he was then like driven back to a hotel room and like locked in the hotel room because obviously you can't go out because you're you're that famous
00:16:57
that if you walk out on the street the crowds are going emerge. So he was then locked in that hotel room and on the show he said I was locked in there with
00:17:04
the mini bar which is full of alcohol. Yeah. So I would drink and that cycle would repeat itself and he'd be like
00:17:09
stage you know car hotel locked drink stage car and that cycle repeat itself. So when you were talking about isolation
00:17:15
and loneliness as well I never really considered the fact that connection and social
00:17:21
um relationships could play a role in help in creating an addiction in someone but it it tracks totally. I mean, it
00:17:28
makes me think of a patient I saw this week who really wants to stop drinking and is able to go for a few weeks, but
00:17:33
his life is pretty empty. Like, he's not working right now. He doesn't have a lot of relationships. So, when he's not drinking, he's sitting at home like
00:17:39
watching TV by himself. And it doesn't take very long for him to think that like, you know, the thing that's going to give me relief is having a drink. And
00:17:46
so, then the question becomes less about the molecule of alcohol and more about like how do we fill up people's lives?
00:17:51
How do we form connection and build community and build a sense of identity and purpose and engagement outside of
00:17:57
the relief of substance use? You're you're clearly extremely smart and when I meet people like you, I always think
00:18:02
to myself, you could have committed your life to anything. You could have you could have worked in pretty much any field and you would have been a success
00:18:08
because you have what it takes to be successful. So, why do you care so much about this? Yeah. Um, I think like many
00:18:16
people, I had kind of a personal thread. I um had a family member who was impacted by addiction who actually died
00:18:21
when I was in medical school. And so that was a sort of a pivotal moment I think that coming at the same time that
00:18:27
I was learning all of this science, I was realizing like, wow, I wish I'd known this when I was younger and
00:18:33
dealing with family members and friends who were affected by this and that we've gotten it so wrong and most people don't
00:18:38
have the kind of tools and knowledge to do things differently. And so, you know, you sort of there's that saying when you
00:18:43
know better, you do better. And I think I kind of wanted to put out into the world what I wished was there for other people. An immediate family member. Mhm.
00:18:50
And what age were you when you lost that person? Probably 24 or so from addiction. Yep.
00:18:58
When you're dealing with a family member or someone close to you that has an addiction. So many people listening will be able to relate to that feeling. Yeah. Can you can you describe that what they
00:19:10
feel to in I guess in attempt to make them feel seen because sometimes especially in hindsight if you end up
00:19:16
losing that person you can be filled with lots of feelings of guilt or misunderstanding and especially thinking
00:19:21
about how society's moved on. So how do you put into words how it feels to be a family member with someone dealing with
00:19:27
addiction? Yeah, I think you feel powerless. You feel like you want to do something and you either don't know what
00:19:33
to do or feel like everything you've tried hasn't worked. Um, I think again because people have been exposed to this
00:19:38
idea that it's an issue of willpower or choice, which really implies that if people wanted it bad enough, they could just stop. And so if you're a family
00:19:45
member, then that's easy to feel like, oh, they don't love me enough, you know, that they're not choosing me over this
00:19:51
substance. And so I think often people feel deeply hurt and they've, you know, been through experiences that have
00:19:56
created trauma for themselves. There's a lot of trauma within families who are experiencing this. And then they're sometimes given really bad advice, you
00:20:03
know, that you have to like kick someone out or this whole concept of kind of tough love and that people need to hit
00:20:08
bottom. And so sometimes people, you know, either do that and then wrestle with the guilt of was that the right
00:20:14
thing or not or they feel bad even like being kind or loving to their family member. So I think there's a whole mix
00:20:20
of feelings and of course if you lose someone you always wonder what if like could I have done something differently? Could something else have changed? And I
00:20:27
think people can feel angry and sad and guilty and be left with that. What did those people in your life need that you
00:20:33
lost that they didn't get? I think they needed science-based treatment and compassion and empathy and um and I think they needed a world where addiction was not seen as something to
00:20:46
be ashamed of or something that we judge but rather something that is a problem.
00:20:51
You know, the shift from like you are the problem to like you have a problem and we can help you with this. And I
00:20:56
think too often we have approached it as if like you the person are the problem. Do you sometimes think back and think
00:21:01
you know if if id done something differently whether it was you or someone else around you or the system around that individual they would still be here today. Cuz I think
00:21:12
that was the first thing that sprung to mind. I played back all the decisions that I made and I thought okay maybe
00:21:18
that was bad advice that I was given. Maybe I should have been you know maybe I could have called more. Maybe I could have intervened here. Maybe, you know,
00:21:25
maybe there's something else I could have done. Absolutely. I mean, I think about that all the time. And um, you
00:21:31
know, I think I think of a friend, I lost overdose. I think of the family member, I lost alcohol. And not only
00:21:36
things that I could have done differently, but also, you know, those people, they they saw their doctor, they
00:21:41
were in the hospital, they had all these touch points, all of these like reachable moments where someone could have engaged with them and offered them
00:21:48
kindness and actual effective care that's backed by science. And and they weren't. And so there are all of these
00:21:54
like missed moments and missed opportunities. But the other thing I think about is like how much time I lost
00:21:59
with them because I think often in this model of like tough love and kicking people out or thinking like I'm not
00:22:06
going to see you until you stop using or stop drinking because I think that's going to help make them make that
00:22:11
change. You lose out on like all of these moments of time with people that you love and you you can't get those
00:22:16
back. And so there is this problem I think in that binary model of like you're either like sober in recovery or you're actively using and this is good and that is bad is that we lose the fact
00:22:29
that like people who are struggling with addiction are amazing funny loving people who have a problem that they're
00:22:34
dealing with. But if someone was dealing with cancer, you wouldn't like not want to spend time with them. You know, you
00:22:39
miss all of that time. And you know, the both cases that I'm thinking about it, like I'll never get that back. You know,
00:22:47
there's a phrase I had many years ago which I'm now reconsidering, which is um change happens when the pain of staying
00:22:52
the same becomes greater than the pain of making a change. And that kind of dovetales into this idea that someone
00:22:59
needs to hit their own rock bottom for them to change. I think the part the reason why that idea prevails is because
00:23:04
we hear so many stories. I hear them on this podcast of someone's family rejecting them, throwing them out on the
00:23:09
street and then them having that Eureka moment that [ __ ] I need to change my life. And people always reference that
00:23:15
like rock bottom moment where they took action because you know they were at the very bottom of the well. And um how does
00:23:22
that phrase sit with you? Change happens when the pain of making a change becomes greater than the pain of making a change. I think that there are those
00:23:29
times for sure. It's not to discount that and I hear those stories too. But I think there are um from evidence what we
00:23:37
know there are probably more times where people just endure the pain again and again again until they never change. And
00:23:43
I think the part that we don't see are are the folks who change happens when they begin to get enough hope that
00:23:50
things could be better for them. That you know someone loves them someone cares enough that they're reaching out a
00:23:55
hand in the darkness that there actually is a path forward. I think people stay stuck when they feel hopeless, when they
00:24:00
feel like nothing could ever, that they're never going to get this, they're never going to be able to change, their life would never get better. And so, you
00:24:07
know, take the example I'll often hear from family members when their loved one is in jail that they're like, "Thank
00:24:13
heavens." You know, they're they're in a safe place at least like there's actually this sense of relief. There's even a term for it called a rescued that
00:24:19
people feel. I think it just goes to the desperation that families are dealing with, but this idea that like that's a
00:24:25
safe intervention. And you hear these stories, right, of someone who they get locked up and like that's their Eureka moment. And yet, if imprisonment were an
00:24:33
effective intervention for addiction, for example, we wouldn't see that actually the time after getting released
00:24:39
from prison, there's 130 times increased risk of dying from a drugrelated cause after people leave prison. And that your risk of dying ever from addiction is much much higher if you've ever been
00:24:49
imprisoned. And so I think there are those stories, but we tend to elevate those like amazing narratives and we
00:24:54
miss the fact that so many other people are going to die in pain and alone and isolated because they have no hope. And
00:25:00
so it's not to discount those moments. And some people are incredibly resilient and against all odds even with the most
00:25:07
trauma they can, you know, make it through and that's incredible. But that doesn't mean that we should like create
00:25:13
a system that makes it as hard as possible on people. So would you say that if we are trying to help someone
00:25:19
change really it's about hope it's about the strength of their why and it's about love and empathy and connection
00:25:25
absolutely is there anything else missing and it's about effective treatment and treatment
00:25:31
okay which is subjective right which could be depending on the situation they're in it depends on the type of
00:25:36
addiction and their situation but in most cases is some combination of psychotherapy medication
00:25:43
so alcohol yes there's I I mean, alcohol's been on a journey. Yes. It's been on a journey in terms of society's opinion about it. Mhm. Can you take me on that journey and tell me where we are
00:25:54
now and and in ter when I'm saying that, I'm talking about society's opinion on its health benefits and what it is and
00:26:00
and then and then also what we're getting wrong now about alcohol. Yeah. Yeah. Um, so I mean the journey of
00:26:06
alcohol is fascinating. So, first I think we think of this as a relatively modern thing, but you know, archaeologists have discovered like beer
00:26:12
making equipment in hunter gatherers cave dwellings from 13,000 years ago. That's wild. Like 13,000 years of people figuring out how to make beer. You know, you look at China 9,000 years ago, it
00:26:24
was really about like a spiritual journey or a social thing. It was never really about health. At some point, we
00:26:29
started talking about this as something that is good for your health. Like drink red wine. It's going to improve your health. And that's where I think we got
00:26:36
wrong. And the reason why was actually from how we were looking at the data. So first if you look at only one health
00:26:42
condition, there are some health conditions where a moderate amount of alcohol actually improves your health. But it was also how people were
00:26:48
conducting the studies. So in most of those studies, what people do is they take like a massive population, tens of
00:26:53
thousands of people, where we have some data where they're reporting how much alcohol they used. And then we look at health risks over time. And scientists
00:26:59
would lump people into sort of non-drinkers versus light drinkers, moderate drinkers, or heavy drinkers.
00:27:05
And what they were finding is that people who were drinking in the even up to the moderate level were actually doing better than the people who weren't
00:27:10
drinking at all. And so that was where that um concept that drinking is good for your health came from. And so people
00:27:16
talk about this like J-shaped curve, meaning that moderate drinkers actually have lower risks of health problems. And
00:27:22
then it's really only when you start drinking very high levels that you start having more risk of health problems than people who don't drink at all. What they
00:27:28
realize is wrong with that is that in the people who don't drink at all, many of those people are not drinking because they're actually really unhealthy for
00:27:34
another reason. Like they might have heart failure and they like don't want to drink because they don't want it to mix with their medication or they might
00:27:40
have had a history of alcohol use disorder and they're actually in recovery. So they've already had some damage from alcohol and they're not
00:27:46
drinking because of that. And so when you change the reference group, you actually make the the sort of group that
00:27:51
you compare people to to people who very rarely drink. So, it's not that they're not drinkers at all, but they drink, you
00:27:56
know, very very light levels. Then you start to see that those like health benefits of alcohol go away, especially
00:28:03
if you look across all conditions. Are you telling me that there's no healthy level of alcohol consumption? Yes. I
00:28:10
would never say drinking alcohol is good for your health. That doesn't mean that drinking at what we call low-risk levels
00:28:17
can't be a part of a healthy lifestyle. So, it's a slight slight shift that like don't fool yourself into thinking that
00:28:23
drinking that glass of wine is like going to exercise for 30 minutes. Like, it's not something that's going to promote your health. I think of it more
00:28:29
like having dessert, eating bacon, going out in the sun. There are risks associated with all those activities. It
00:28:34
doesn't mean that I would say you can never do any of that, but you need to understand what the risks are and then make choices for yourself. Say look at
00:28:41
this glass of wine here and this pint of beer. Yep. If I drank one of these a day, not a huge amount, um I think what people tend to think is they think, well, it's only one, so my body will
00:28:53
just flush it out and there'll be no adverse health consequences. Yep. I Is that true? Well, so part of
00:29:01
the challenge is what we think of as one drink. So I think um much like, you know, if you learn to re read the
00:29:06
serving size on a food, you realize that like, oh, a serving of ice cream is like a half a scoop. It's not like a giant
00:29:12
ice cream sundae. The same is true with alcohol. So um in the UK the kind of low-risisk drinking limits talk about units of alcohol which is the equivalent of 8 grams of alcohol. So how much of a
00:29:23
drink has eight grams of alcohol and to be in that lowrisk category you have to be below 14 units. The problem is that
00:29:29
glass of wine just eyeballing it has several units of alcohol. So it is not a even though we think of it as a single
00:29:36
drink it's probably I mean I have to guess but it's probably like three units of alcohol. So, if I have a glass of
00:29:43
wine every day, I'd be over that limit. Then you'd be right at that limit. The problem is most people don't drink just
00:29:49
one glass. If you um you know, you have two glasses one day and then one glass one day and then three glasses one day
00:29:55
cuz you're at a social function. All of a sudden, you're actually quite a lot over that limit. So, if you said that this this is roughly three units roughly
00:30:02
and you get 14 a week. You get 14 a week. Mhm. So, 3 * 7. Mhm. 21. Yep. So, yes, you're over if you're drinking that size. Yep. Okay. Okay. So, if I have this glass of wine every day, then I'd
00:30:14
be over the UK limit of lower risk drinking. Lower risk drinking. So, I'd be medium risk drinking. You'd be in
00:30:20
what we call moderate risk, which is associated with pretty much every form of cancer, which I think people don't
00:30:26
know. Okay. Cuz I was wondering why cancer has been increasing. Yes. A variety of different forms of cancer increasing. You know, breast cancer is one of the
00:30:36
ones we always hear about that's increasing. So you're saying what is the data in terms of low or moderate risk of
00:30:43
drinking and cancer? Yeah. So the data is um growing and really worrisome. So for breast cancer so there's really there's a few cancers that even at low risk limits you see the risk begin to
00:30:56
increase. So where we would say there's kind of no healthy or there's no even like low risk amount. So breast and
00:31:01
esophageal cancer are two examples of that. So breast cancer if you were to drink um below those low risk limits. So
00:31:07
in the US that would be fewer than seven drinks but a drink in the US is 5 ounces of wine which is smaller than that or in
00:31:14
the UK is below that 14 units. So it would be you know fewer than seven of that that size glass of wine. We still
00:31:20
see a slight increase in the risk of breast cancer. It's about a 5% increase. So that means your risk of breast cancer
00:31:25
would increase by about 5%. Now that's not huge. So I think you know percent increase is kind of hard to do the math
00:31:31
on but if you think in the US for example the average woman has a 13% likelihood of getting breast cancer in
00:31:36
their lifespan. 13% likelihood. Really? Yeah. Wow. Really high. So 5% increase would increase that to like 13.6 or so. So that means that if there's nine women
00:31:48
in this room Yeah. one of them has is going to get breast cancer probabilistically in their life. Yep.
00:31:56
Damn. Yeah. Why is it is it and it's increasing. Yeah. And so the reasons for that are likely environmental because
00:32:02
your genes don't change over that time period. So the risk factors, you know, if you think about breast cancer, it's alcohol, it's obesity, um it's, you
00:32:10
know, age when you have children or don't have children because it's a really hormonally driven cancer. Same
00:32:15
thing if you think about colon cancer, that's a really scary one where we're seeing more and more cases in younger people. Some of the drivers of that
00:32:22
eating meat. So processed meats increase your risk of colon cancer. So, you know, these very sort of normal behaviors.
00:32:28
There's probably other environmental things honestly that we're not yet measuring or able to measure just given
00:32:34
the rate of acceleration. When I talk to my colleagues who are oncologists, you know, things like plastics or other
00:32:40
things that we don't yet know, there's um it's clearly something in the environment that is driving these increased cancer risks. So, even at even
00:32:47
at this sort of level, if I'm drinking that might be one unit, right? Yes. So, that would be one unit. So, that would be fewer than 14 of that. So you could see like an, you know, if you had double
00:32:58
that, it would be a decent pour of wine. You could not have more than seven of those in a week to be in low risk. But
00:33:03
even drinking that amount, your risk of breast cancer would go up a little bit. Even this amount. Mhm. There's really
00:33:08
sort of no safe amount of alcohol when when it comes to breast cancer. Is it just breast cancer? So that lowrisk
00:33:17
category. So when we these big cancer studies categorize people as sort of low risk or light drinkers, moderate or
00:33:23
heavy. And for pretty much every cancer, once you get to the moderate category, we start seeing increases. And there's
00:33:29
what we call a dose response relationship. So the more you drink, the higher your risk of cancer. There's only a few cancers that the risk seems to
00:33:35
increase even at that very low level. And breast cancer is one of those. And then esophageal cancer is one of those.
00:33:41
So there are certain cancers where even a small amount of alcohol will increase your risk. Does it have an impact on
00:33:47
thinking about cancers that are prominent in men? Yeah. Um, so colon cancer, we're seeing that in a lot of
00:33:53
young men. Um, liver cancer, yeah, prostate cancer, which is obviously a male cancer, we don't think of as much
00:33:59
as being sort of an alcohol sensitive cancer, but most cancers, because the way alcohol impacts your risk of cancer,
00:34:05
is not really on a specific organ outside of the liver. It's really about how it changes our DNA. So, it's about
00:34:11
inflammation and what are called reactive oxygen um species that sort of change our cells and increase the risk
00:34:18
over time of the mutations that lead to cancer. So yeah, can you drill down on that? So if I if I'm a heavy drinker, so
00:34:23
say that I'm drinking uh let's say I'm drinking two glasses of wine a day consistently, which I guess
00:34:29
would cons like if I was drinking if you drink two of those glasses. Yeah, you'd be in the heavy category. So two of those a day puts me in the heavy drink
00:34:35
category, which would surprise most people, right? Like that for many people is very normal. It is very normal. Yeah,
00:34:43
I think it's some somewhat more difficult for younger people to understand because younger people drink less. But if I think about the
00:34:49
generation above me, having two glasses of wine a day is quite normal after work on the weekends with with every meal
00:34:55
that you have. So that would make me a heavy drinker. And then what are my what are the stats saying in terms of my
00:35:02
cancer uh risk profile? Yeah. So it varies by cancer, but roughly we're talking like a 40% increase in cancer
00:35:09
depending on the cancer type. And the more you drink, the more that's going to go up. So you know these are scientific studies where it's not precise to you as
00:35:16
an individual. They're based on large populations, but definitely the more you drink, the greater the risk. And then if
00:35:21
I have other sort of do they call them comorbidities? Yeah, exactly. So other illnesses, other diseases in my body, my
00:35:28
probability is going to go up further from obese some if I'm overweight. Exactly. If you smoke. So one of the main drivers of alcohol too and cancer
00:35:35
is that it actually makes you more susceptible to the cancer-causing effects of tobacco. So if you drink and
00:35:40
smoke, your risk of cancer is going to be even higher. How does that work? The thought is like
00:35:46
if you take esophageal cancer at like the cellular level, it makes you um more susceptible of the carcinogens which are
00:35:52
kind of the cancer-causing compounds in tobacco. And so rather than just seeing like an additive risk, you actually
00:35:58
almost get a multiplied risk in terms of the risk of cancer. So smoking and then obesity is the other big one. So a lot
00:36:04
of um cancers your risk goes up if you're if you're you know have an increase in your body mass. What's going
00:36:09
on in the body then? If I drink alcohol, how is that leading to cancer? You referenced it slightly there, but I'm
00:36:15
trying to I want to make sure I'm super clear of my brain as to like what the the the knock-on effects are and how
00:36:20
that ends up as cancer. Yeah. I mean, there's lots of different mechanisms. So, I mean, maybe starting just with
00:36:25
like what does alcohol do in your body? So, you ingest alcohol. The like fancy name for that is ethanol. It's a
00:36:31
molecule and it basically gets absorbed pretty quickly from your stomach. And so, you know, it hits your bloodstream
00:36:36
usually within 10 minutes or so of having a drink. Um, how much it hits your bloodstream depends on how much
00:36:41
water you have in your body. So alcohol doesn't penetrate into your fat. It just kind of diffuses into the water parts of
00:36:47
your body. So that's actually why for many women, they will get more sort of drunk or more of an effect from alcohol
00:36:52
at a lower level than men because women have more body fat than men. But that's going to depend on you as an individual. If you have more body fat, you're going
00:36:58
to have a different impact. So alcohol gets in your bloodstream. Alcohol can instantly cross across what we call your
00:37:04
bloodb brain barrier. So it impacts your brain instantly and that's where you feel the initially pleasurable effects
00:37:09
for many people of feeling a little relaxed, feeling more social, feeling a little bit, you know, less anxiety. If
00:37:16
you keep drinking and that level keeps going up, then you start having impaired judgment. You might have motor lack of
00:37:22
motor coordination. So we've all seen this and many people have probably experienced it. You know, you may be stumbling, not able to drive safely.
00:37:29
You're not going to make the same decisions you would make if you weren't drinking. And then if you keep drinking then you get you can actually lose
00:37:35
consciousness so pass out and people have experienced that your body is going to try to break down alcohol as quickly as it's able to like anything we want to
00:37:42
kind of excrete any abnormality and get back to our normal functioning and so that process happens mostly in your
00:37:47
liver which is why the liver is so sensitive to alcohol because your body sees ethanol as poison. Yes. I mean you
00:37:54
know I know you talked about this Dr. Lumpy but your body always wants to restore what's called homeostasis. You're always your body's always going
00:37:59
to fight to get back to what it feels its normal is. And so ethanol is not something that belongs in your bloodstream. Your body's going to try to
00:38:05
excrete it as fast as it can and then it converts it into something called acetate and then you can pee that out
00:38:10
and breathe that out and get rid of it. So to eliminate the alcohol in your body, you have to go through this
00:38:16
process and part of that process includes this toxic molecule that's going to be floating around and causing
00:38:21
damage to your cells. So that's one way that alcohol can cause cancer. The other is um just general sort of inflammation.
00:38:28
People have probably heard that inflammation is just not good for the body and increases the risk of cancer and o um alcohol generates a lot of that
00:38:36
inflammation in the process of getting eliminated and so it can actually change your cells that over time that can lead
00:38:41
to cancer. So I also found this graph which shows for anyone that can't see what we're describing at the moment. It shows the acceleration in liver disease uh death rates and general li liver
00:38:52
disease compared to other parts of the body. Yeah. Other organs in the body. I believe it shows y what impact does
00:38:58
alcohol have on the liver and we have our little mannequin here of the human body. Where is the liver? Yeah, great
00:39:04
question. So here's um our little mannequin. So just to orient people to the body. So we're looking at the inside
00:39:10
of the body. So like the ribs are gone, the outside of the skin is gone. These two pink things are the lungs. They kind
00:39:15
of encase the heart. You can see the hearts behind the lungs pumping your blood. The liver is this brownish organ.
00:39:21
It's on the right side of your body, right under your ribs. It's quite large and it's big. An amazing organ. It is
00:39:26
quite big. It processes much of what any kind of toxins that we take in, things that we eat, your glucose, alcohol, 90% of it's metabolized by the liver. So the
00:39:39
liver is sort of the clearing house, getting rid of byproducts in your body. The other are the kidneys, but the liver
00:39:45
plays a huge role, especially in alcohol. So, it sits right here. It almost looks like it's as big as the lung as one lung. Yeah. Yeah, it is.
00:39:51
Yeah. Really? Yeah. It's a giant organ and it's an amazing organ. So, you could actually cut out 80% of the liver and it
00:39:58
would regrow itself. So, kind of like you know those lizards that you cut off their tail and they regenerate a tail.
00:40:03
The liver is fascinating. It's why we can do living liver um transplant. So, I could take half of your liver and give
00:40:09
it to someone who needed a liver. you would still be able to live and they would get a second chance at life from that part of your liver. So, it's this
00:40:16
really cool organ that can regenerate, but it can only regenerate up to a point. So, once you get to a level where
00:40:22
you have a lot of scar tissue in your liver, we call that cerosis. Um, you sort of reach a point of no return where
00:40:28
at that point the liver can't heal itself. So, I sort of think of it like to use a baking analogy. If you're
00:40:33
making muffins or a cake, you're going along, you're mixing all your ingredients, and you realize before you
00:40:39
put things in the oven like, "Oh, I forgot the eggs." You can still add the eggs in and like whisk it all together and it's going to be okay. If the
00:40:44
muffins are baking in the oven and you forgot the eggs, you can't like pour the eggs on top and make the batter the same. And the liver is sort of like that
00:40:50
that up to a certain degree, you can actually completely repair the effects of things like alcohol or obesity, other
00:40:58
things. But once you pass that point into scar tissue, the liver can't regenerate anymore. And so when you
00:41:04
think about that graph or just the rising rates of liver disease, um the the main drivers of liver disease are
00:41:10
obesity and two is alcohol. And so those are the leading causes of of liver transplant. And the thing that is, you
00:41:17
know, so sad is I mean I see this all the time working in the hospital is first of all, we're seeing younger and
00:41:23
younger people coming in in liver failure. So people in their 20s coming in in fulminant liver failure from
00:41:29
alcohol and then dying in the hospital. And the terrible thing is that they often didn't even know that this was
00:41:35
causing a problem in their health. And by the time they get to the hospital, they're so sick it's too late. And yet all of that could have been prevented or
00:41:41
even repaired if it was caught sooner. And so that's where I think this education of understanding like what
00:41:47
really are the health harms of alcohol and that we have normalized binge drinking in many occasions, especially
00:41:52
in young people, as being totally normal. and yet there are very serious health consequences.
00:41:57
So, I've got a bunch of questions around around the liver. Um, does that mean that my liver can take a bit of a
00:42:03
beating before there's any real problems? Should I, you know, some someone like me, I don't drink alcohol,
00:42:08
I'm not engaging in anything too bad, but sometimes I do wonder if I could have like a blowout weekend and then my
00:42:14
liver would just recover to normal again and I'd be fine. Yeah. I mean, so first, every person is different. One blowout
00:42:20
weekend, you probably would be fine. Anyone would probably be fine. The challenge is one blowout weekend then leads to like multiple blowout weekends
00:42:26
and then over time that can actually accelerate the damage to your liver. The up you said that my my liver regenerates
00:42:33
though. So I'm thinking this thing will just pop back to normal again. As long as you haven't gotten to that scarring phase. So once you get too far down that
00:42:39
path even if you were to stop drinking your liver won't recover. The hard thing is that that we don't totally understand
00:42:46
who and why that happened so young to. So, this is an active area investigation because there are people who've been drinking for 60 years and their livers
00:42:54
don't show signs of scarring. And then we're seeing these young people at 25 who come in and die in the hospital. And
00:42:59
so, there are individual factors that you don't have any way of knowing that are going to impact your risk of developing liver inflammation and scar
00:43:06
tissue. And so, the safest way to prevent that is to not drink in these really high ways that we know are going to lead to harm. The other way is to get
00:43:13
medical care because often we do detect these things through blood tests and we can do ultrasounds and when we see those
00:43:19
early phases. So what happens first is you actually get fat deposition in your liver. That's the first step and then we
00:43:26
see inflammation and fatty liver and if you don't stop the thing that's driving those changes over time we see the
00:43:32
development of what's called fibrosis which is like scar tissue. And then that scar tissue gets more and more advanced
00:43:38
to the point that your liver stops functioning and you either die or you need a liver transplant. What activities
00:43:43
outside of alcohol cause great stress on our liver that we might not see as obvious? Yeah. Um so obesity. Um so food
00:43:51
does. Yeah. Food. So your liver is very involved in glucose metabolism. Um so so
00:43:57
our diet and our body weight impact our liver health. Um the other medications. So um acetaminophen or Tylenol, which is
00:44:04
a very common over-the-counter pain reliever, um above a certain threshold can cause serious liver damage. So
00:44:11
sometimes you'll see cases where someone didn't realize that like their cold medicine plus the Tylenol they were taking both had that ingredient and then
00:44:17
they go out and drink heavily and that kind of combination effect can cause liver damage. How
00:44:23
much do you think this might be a bit of a strange bit of an an unclear question
00:44:28
but how much alcohol is going to cause liver damage? So again it varies person to person for liver damage it does tend
00:44:34
to be the moderate to higher amounts that cause damage. Um, one thing is that you know that having these big surges, like these massive binge episodes, is probably more harmful than drinking like
00:44:45
at a moderate level for a long period of time. Those like big surges cause a big buildup of that toxic byproduct that
00:44:52
your body has to clear. And so, you know, if you have several years of binge drinking heavily, that actually probably is going to cause more damage than a longer period of time of just drinking above the risk limits. So really trying
00:45:05
to minimize and avoid those very heavy drinking episodes is incredibly important and then keeping it to those
00:45:10
low-risisk guidelines which we just learned are kind of eye opening and and how low risk they are is going to reduce
00:45:15
the risk of liver damage. And does alcohol just impact the liver? No. I mean alcohol has effects across our
00:45:22
body. So many parts of the body can be affected by alcohol. So kind of starting from the top your brain and we can look
00:45:28
at this with pictures like an MRI. Oh, I've got one actually. Yeah. I think this is, by the way, shocking. Yes. To
00:45:35
me. So, when we do an MRI of someone's brain, um, we basically, this is like a cross slice. So, it's almost like you're you're facing me and I'm cutting your face off and looking at your brain onwards. Um, healthy brain tissue is the
00:45:47
gray and white matter. And you want it to be as plump and like taking up as much space as possible because that's where all of your brain activity is.
00:45:54
When people get really old or have dementia, one thing we see is more and more the black space is essentially
00:46:00
water. So we see the brain starts shrinking and shrinking and there's more water and less active healthy brain tissue. That process is accelerated with
00:46:07
heavy alcohol use. And so you can see here, this is a 43-year-old person with severe alcohol use disorder where their
00:46:13
brain looks the way, you know, a 90-year-old with dementia would look because of that um brain damage over
00:46:18
time from alcohol use. And so we can actually a form of dementia is related to alcohol use. And so your brain can be
00:46:24
hugely impacted with alcohol. What is going on there? like what's causing the brain to deteriorate in such a way
00:46:31
because of alcohol. Yeah. Well, um remember I said um ethanol which is the molecule crosses the bloodb brain
00:46:36
barrier and so especially when you're having these high levels of blood alcohol that ethanol is sort of bathing
00:46:42
your brain and if you think about what we talked about inflammation and changes to cells and to DNA and proteins that is
00:46:49
happening at the brain level. The other thing that can cause accelerate the brain damage we see with alcohol is actually nutritional deficiencies. So
00:46:56
people may be drinking a lot and they're actually not getting really crucial nutrients in their diet and that can
00:47:01
accelerate the process of brain damage. We can even see a very like sudden onset amnesia from heavy alcohol use in the in
00:47:09
the setting of not getting enough nutrients in your diet. Okay, so that's the brain. That's the
00:47:14
brain. So the brain for sure. The next is the mouth and your esophagus. So obviously you're drinking alcohol. It's
00:47:20
bathing your mouth. It's bathing your esophagus and your stomach. So we do see an increase in cancer like we talked
00:47:25
about and that's accelerated by smoking. But we also see like benign but annoying and problematic health conditions most
00:47:32
notably acid reflux. So heartburn. So if you notice like I'm like always having heartburn. I'm having to pop all these
00:47:37
like ant acids and take this medicine. You might want to think like how much am I drinking? Is that contributing to my
00:47:43
heartburn? So that's a very common thing. Um the heart is affected by alcohol. So you know the heart is an
00:47:48
organ where at low risk levels there doesn't seem to be harm from alcohol. But once you get into the moderate and
00:47:53
high, we see harms. And the harms can be a couple fold. One is um something called atrial fibrillation, which is basically where your heart starts beating really irregularly. Yeah. So um
00:48:05
in your heart, there's four chambers. The two chambers at the top. So this is really showing the ventricles and the atrium. So there's two chambers that
00:48:11
blood flows through. And in a normal heart, your electrical activity comes from the top of your heart, goes down to
00:48:17
the bottom of your heart, and tells the heart to pump. Mhm. And so you get a single impulse that goes to the bottom of the heart, says pump. And that pumps
00:48:23
blood out to your brain and your body and your organs and your liver. In atrial fibrillation, the top of the
00:48:28
heart is just kind of quivering with this abnormal electrical activity. And so the heart can't pump in a normal way.
00:48:33
We actually there's a a term in medicine called holiday heart because we see sometimes people drink a ton over the
00:48:39
holidays and we'll end up in this abnormal rhythm just from that binge drinking pattern. And then over time, if
00:48:44
you're drinking at high levels, your heart actually dilates and you can end up with congestive heart failure from a
00:48:49
cardiammyopathy, which means the heart muscle gets kind of weak and thin and floppy and can't pump the way that it
00:48:55
needs to. Oh, damn. Sometimes we think that if we're good at handling our beer or our alcohol, then it's having less
00:49:02
harm on us. So, I'm for whatever reason, I've always been good at drinking quite a lot when I used to drink. drink
00:49:08
anymore, but when I used to drink and being less affected than my friend who was a little bit bigger than me, had a
00:49:14
little bit more body fat, which is really interesting because you pointed out an association there that I was never aware of. Just to pause on that
00:49:19
for a second, you're saying that if someone has more body fat, they're more likely to get drunk. Yeah. Because they have less body water and alcohol doesn't
00:49:26
go into your body fat. So, you're essentially it's like if you took, you know, a glass of water and you dropped red dye in it, you're going to diffuse
00:49:32
into that water. So the more water you have, the more diffuse it'll be and the lower your blood alcohol content. So if
00:49:38
you have very low body fat, you probably have more body water. And so, you know, two drinks for you is going to diffuse
00:49:43
into a larger amount of water. Ah, that explains a lot cuz I always wondered, he was he was so much bigger than me at the time. He was um he had much more body
00:49:51
fat. And he would get drunk very very quickly. And you always think, oh, a big guy, they can handle their beer or whatever, but he would get drunk very
00:49:57
quickly. So I used to wonder I used to think well alcohol isn't harming me as much because I'm not having I'm not as
00:50:02
drunk as he is. But but that's not true. No. I mean so first of all I think the interesting story there one is not just
00:50:08
the body fat but also that people metabolize alcohol at different rates. You probably I don't know if you found
00:50:14
this to be true. You probably had fewer hangovers than your friend because it hangover does seem to be related to the amount how high that your blood alcohol
00:50:20
level gets. So people who don't metabolize alcohol as quickly tend to have worse hangovers. So that may have
00:50:26
been something you experienced but it doesn't protect you from the other health harms of alcohol like liver damage like cancer like overtime you
00:50:33
know heart problems or esophageal problems. What is a hangover? Yeah hangover is a fascinating thing that
00:50:39
people are you know there's a lot of emerging evidence about it and trying to understand what happens. It seems to be
00:50:44
most related to how high the ethanol concentration in your brain gets because they've actually done a ton of studies
00:50:49
with mice and with people. It was initially thought to be due to the byproducts of alcohol like that acetal
00:50:55
aldahhide molecule we talked about but it doesn't seem to be related to that. that seems to be related to ethanol, but
00:51:00
essentially it's this syndrome where after you drink, once your blood alcohol content comes down to zero. You feel
00:51:06
sort of apathetic, you're tired, you have a headache, you often feel nauseous. And so it's sort of that
00:51:11
squelli of your brain essentially being bathed in this ethanol and then as it leaves you just feel totally crappy
00:51:18
because people think of it sometimes as just being dehydrated. Yeah, it it is not just being dehydrated. There's actual sort of
00:51:24
effects of ethanol on your brain that lead to the hangover. Okay. I think if you are drinking at an amount that
00:51:30
you're getting a hangover, it is a good sign that you're drinking above a limit that would be considered okay for your
00:51:35
body. Cuz sometimes I remember back in the day if I had a big glass of water before I went to bed, if I had been
00:51:42
drinking, I felt better in the morning. There is some element of dehydration, don't get me wrong. And that's partly
00:51:48
because, right, if you think again, alcohol is diffused in water. So if your total body water is contracted because
00:51:53
you're dehydrated, your ethanol level is going to be higher. So drinking is going to help you sort of flush it out and
00:51:59
feel better. I'm drinking water, but it's not only because of dehydration. There'll be people listening to this
00:52:05
now. I doubt they would have got this far, but um because if they if they did, they probably wouldn't think this, but
00:52:10
there'll be some people who would have gotten this far in the conversation and be thinking, "Yes, but Mhm.
00:52:15
Alcohol helps me socialize and socializing is really important and I can't socialize very easily because of
00:52:22
the design of the modern world without having a drink or I have great times when I drink so I don't want to quit my
00:52:29
alcohol use and you know in some cases that they will be high and medium consumption alcohol drinkers. What do you say to those people? Well, first like there's no judgment here. So a
00:52:41
molecule of ethanol is not more moral or immoral than a molecule of glucose. So you could say the same thing about diet.
00:52:46
We have lots of awareness now about processed foods and white flour and white sugar. That doesn't mean that
00:52:51
everyone's going to live this like aesthetic lifestyle where they never eat dessert. So I think it really is like an
00:52:56
you need to go in with eyes wide open and understand what are the risks, what matters to you, and how do you make that
00:53:02
calculus. So if you decide it's a choice you want to make, you want to set yourself up for success. So, if you
00:53:07
decide like I want to cut back on how much I'm drinking, but I'm going to go to happy hour every night with my friends and just try to like not drink
00:53:12
while I'm there, you're probably not going to be very successful because you're going to be in a situation that's constantly like reminding you of alcohol
00:53:18
use and everyone around you is using alcohol. So, try to make some different sort of structural changes and how you
00:53:24
set up your life and your week and your day. Um, and you may find that actually you don't miss it that much. That you could cut out three or four days of
00:53:30
drinking and still get that social pleasure two days out of the week and your overall health risk is going to go down significantly. In terms of treating
00:53:38
someone with alcohol uh abuse disorder, rehab is often the most widely known form of treatment. Um, one of my friends who struggled with addiction really, really badly with alcohol addiction, but
00:53:50
also drug addiction said to me multiple times, he said, "I've been to rehab three or four times now, and it's just not working." Yeah. And I think when the
00:53:57
most popular or the most well-known treatment doesn't work for you, you kind of develop an even greater sense of hopelessness. Are you a fan of rehab?
00:54:04
Generally, no. Um, so you know, rehab is this idea that you go away somewhere for a week, a couple weeks, and then you're
00:54:11
kind of cured, right? It's almost like people have thought of addiction as an infection where you need like two weeks of antibiotics and then you're done.
00:54:17
Mhm. What we really understand is that for many people addiction is more like a chronic illness or even like cancer
00:54:22
where you need a lot of treatment upfront for the first few years and then over time you get into stability and
00:54:27
remission and you're almost like a a cancer survivor. You're in long-term recovery. And so this idea that you go
00:54:33
somewhere for a couple weeks and then you come out and you're all better really doesn't match what we know of addiction. The other problem is that
00:54:39
much of what happens in rehab is not all that therapeutic most of the time. So the things that we know are most
00:54:44
effective for addiction, one are medications, which there's a lot of stigma, misunderstanding about, and then
00:54:50
two are like evidence-based psychotherapy. So things like cognitive behavioral therapy, motivational enhancement therapy, you know, working
00:54:57
on your underlying trauma. Often in rehabs, the model is really built around this idea of like you remove yourself
00:55:02
from this environment. You do some groups while you're there. Sometimes often they're based on more of like a
00:55:09
peer support model. Sometimes the therapies that are offered are frankly not very evidence-based. Like we actually did this study, it was a secret
00:55:15
shopper study where we called rehab programs across the country to like ask about what they offered. And many of them offer things like, you know, horse
00:55:22
therapy or like dolphin assisted therapy, which like I'm sure it's very nice to swim with dolphins and to work
00:55:28
with horses, but it's not something that's been like studied and effective. And many places don't offer the things that we know are actually effective,
00:55:34
which are, you know, trained clinicians doing evidence-based treatments or medication treatments. So, it's a
00:55:40
combination of like this short-term fix for a long-term problem and not actually getting the treatment that you need. So,
00:55:46
what does work like for alcohol use disorder, most people don't know we have very effective medications that can help you even if you just want to not drink
00:55:53
as much. So, there's this medication I mentioned at the beginning that actually blocks your opioid receptors. Yeah.
00:55:59
which seems kind of funny that it works on alcohol, but the reason it does is that that for people who part of the thing that drives them to drink is that
00:56:06
they drink, they feel this like pain relief pleasure sensation from the release of opioids in their brain and
00:56:11
that makes them want to drink more. That if you block that, people don't get sick if they drink, but they just don't find it as rewarding. And so, someone named
00:56:18
Sinclair actually in Europe did some fascinating experiments of even just using it as needed. So rather than taking it as an everyday medication, if
00:56:24
you know that when you go to like a holiday event, you're going to drink way more than you want to drink, you take it
00:56:30
like 30 minutes before you go, and then what people find is they have like one drink and they're like, "Ah, I'm good. I don't have that same urge to want to
00:56:35
drink more and more because I didn't get the same sort of tickle of feeling better and feeling relief." What do you
00:56:41
think about psychedelics as a way to counteract addictive behaviors like the ones we've described? Yeah, one of the
00:56:47
most like groundbreaking trials in the last couple years for alcohol use disorder was psilocybin. So there's a
00:56:52
big study of psilocybin assisted psychotherapy for alcohol use disorder which showed really remarkable effects.
00:56:58
So people took psilocybin they actually compared it. Folks came in and they either got a big dose of benadryil or
00:57:03
psilocybin and then they sat with a therapist for like eight hours for this guided um psilocybin journey and they
00:57:10
found that people drink much less after it. So it does seem to have some effect and the thought is that part of the way psychedelics work is they imp increase
00:57:17
neuroplasticity meaning the ability for the brain to form new pathways and kind of retrain itself and so it does seem to
00:57:24
be a potential therapeutic for alcohol use disorder. Psilocybin is the active compound in magic mushrooms. Yes,
00:57:29
exactly. Have you heard of iberane? I have. Yeah. Which is often associated which is another psychedelic often
00:57:35
associated with addiction. Yes. People have looked at ibagane for um opioid use disorder. um those studies have been less promising than psilocybin although it hasn't been tested in the same kind
00:57:47
of rigorous ways recently partly for opioid use disorder we have really effective medications that have been shown to improve recovery and reduce
00:57:54
death and so it's sort of hard to be better than that one really interesting like new whole class of medications for
00:57:59
alcohol is um medications that are being used for weight loss that people have probably heard of so like WGOI ompic
00:58:05
that whole class of GLP-1 um medication seems to also reduce alcohol use which is kind of interesting
00:58:11
Really? Yeah. Have they studied that? Yeah. So, they Well, first of all, there's I mean, there's whole like Reddit threads and online communities
00:58:17
about this where people were prescribed it for diabetes or for weight loss and they all of a sudden were like, I don't really want to smoke or drink. Like that
00:58:24
kind of urge has gone away entirely. And for some people, they really describe it as being like miraculous. They've been
00:58:30
trying to stop drinking for, you know, years and years and for the first time, they don't feel that sense of like craving and urge. Um, and there recently
00:58:36
have been some actual clinical trials where they've done, you know, placeboc controlled blinded studies and have
00:58:42
shown that it does reduce drinking. And so it's a really interesting area where it seems like those medications kind of
00:58:48
reset craving and appetite more globally and not just for food. What the hell is this? I'm going to tell you. All of you will probably know that I spend a huge amount of year
00:59:00
about 50 weeks a year traveling around the world. And one of the great tips that I've always offered for traveling is to pack as light as you possibly can.
00:59:07
Because if you do, I found that I can save hours by not having to check in my bags and then having to wait for them on
00:59:12
the other side. So, I always travel with a small, tiny bag that can be stowed above me in the plane everywhere I go, even for trips that take weeks and weeks. It is a massive travel hack. And
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day trial. That's extra.com with code DOAC. One of the ways that many of us understand addiction if we haven't experienced it directly in our own lives is we look up at role models on TV and
00:59:55
in sort of celebrity pop culture and we see these role models who you know we see on stages start to deteriorate and
01:00:01
deteriorate in the public eye and ultimately it seems often like it's inevitable that someday the TMZ
01:00:06
headlines going to ring out and say that this person has passed away and that happens all too often. We think about
01:00:11
you know Whitney Houston or um I guess Michael Jackson's even been associated with dying from an addiction to I think
01:00:18
it was painkillers or something. Prince Elvis Presley Mac Miller who a lot of people will know as well and a Nicole
01:00:25
Smith and even now in the public eye there are certain individuals where we're starting to see this sort of
01:00:30
erratic behavior. They're posting on their Instagrams. They're they're showing up in society in a slightly
01:00:36
different way. When you see that in the line of work that you operate in, what is your natural reaction? How
01:00:43
does it make you feel when you know because there's a couple of people I'm thinking about at the moment who the world are talking about that you know we
01:00:49
think they have an addiction, we think they need help. What is your natural reaction to to that and what what is it
01:00:55
that those people need? Yeah. Well, when I when I read the headlines of someone dying, I mean, to me, it's gutting and
01:01:02
heartbreaking. One, because obviously it's a human life that was someone's mother and sister or brother and people
01:01:08
cared about, a public figure that people looked up to and cared about, but mostly that it was a totally preventable death.
01:01:13
Like really, no one should die from a substance related death. We have tools to treat addiction. We know how to
01:01:18
prevent the harms of, you know, drug overdose, for example. And so the fact that someone can die, especially someone
01:01:24
that everyone has watched for so long, is I think just like a tragic example of how what the mismatch is between what we
01:01:31
do around addiction and what science does is actually helpful. Um I think you know when I see someone who actively is
01:01:38
showing signs, like it's just sad to see that happen so publicly without people being able to support that person. And
01:01:45
it's not a magic fix. not going to be like a you know you have an intervention the person goes to treatment gets better
01:01:50
forever that I think is often in people's minds it is a process a journey like any change and so really it is
01:01:58
around where we began that idea of how do you begin to understand with this person how is their substance use
01:02:03
getting in the way of what they want for themselves and how might their life be better for them based on whatever they
01:02:09
believe better is if they were to make changes to their substance use I am I remember I had this one particular
01:02:14
friend who had an addiction and um I remember always the life of the party. And I remember this one day he came up
01:02:20
to me at at an event and he'd sat down in front of me and said to me um he said he like whispered to me, "I'm in so much pain." Mhm. And he told me
01:02:32
about rehab and how it had failed him, etc. But it it just it almost sounded unbelievable that someone with such a big smile on their face would whisper to me, especially a man because men don't
01:02:44
really talk much about their emotions. I'm in so much pain. Mhm. And then funnily, I I then see how the world
01:02:50
treats that individual, him having whispered that to me one day and the world how the world responds to his
01:02:56
behavior and attacks him and criticizes him. But I was privy to the whisper. Yeah. Yeah. And that that one whisper
01:03:03
helped me to kind of reframe how to how to treat that person, but also really what was at the heart of what was going
01:03:08
on and probably gave you so much empathy, you know, a huge amount of empathy cuz I would have been like the rest of the world. I would have just thought what an idiot, what a [ __ ]
01:03:14
Like what's he doing that? That's strange behavior. Y, you know, and you said something really important that was a slight shift in words. You didn't say
01:03:21
he failed treatment. You said the treatment failed him. And that matters so much because I think too often we've
01:03:26
made it seem as if people are failing. like if they go to rehab and they don't get well h it's their problem you know
01:03:32
and actually the treatment wasn't right for them. If someone had cancer and their cancer came back or didn't get
01:03:37
treated by chemotherapy we wouldn't say like they failed you know we would say well what's the next treatment how do we get them to the right doctor and so
01:03:43
there is this like personal blaming and that gets it stigma which is one of the main reasons that people don't share
01:03:49
that they're struggling with substances that they don't seek treatment and so we have tremendous stigma towards drug and
01:03:54
alcohol addiction. It's one of the most stigmatized kind of social conditions globally. And so, of course, then if you're a person who starts to think
01:04:00
like, "Oh, maybe I do have a problem." Like, maybe my alcohol use is getting in the way of things. It's really hard to then say anything because you worry that
01:04:06
you're going to be judged. You're going to be labeled. You're going to be misunderstood. In some cases, terrible things could happen to you. You might
01:04:12
get your children taken away by, you know, child welfare. You could lose your housing or lose your job. And so, that
01:04:17
stigma has like played into this terrible cycle where people, you know, have to whisper it to someone. shows how much he trusted you to even be able to
01:04:24
say honestly what he was going through because there's so much stigma about the condition itself. You must have had many
01:04:29
cases that broke your heart. Yeah. Can you tell me about one that changed you? Oh goodness. So many um you know so one gentleman in particular he was um
01:04:44
struggled with heroin addiction for a long time and had been like we talked about it had been kind of a chronic
01:04:50
illness for him. He'd had periods where he'd done really well. He'd had periods where he had struggled and had always
01:04:56
stayed safe through all of that. And he actually his like one really meaningful relationship in his life that kind of
01:05:01
kept him together was a relationship with his mom and he lived with her. And um and they lived in public housing. They were, you know, dealing with economic insecurity like many people.
01:05:11
And someone found out that he was staying with her and it would have put her at risk for her housing. And so he didn't want her to lose her housing. So
01:05:18
he left. But he was newly homeless. and all of a sudden because of just social barriers was dealing with the stress of
01:05:24
homelessness and being alone and um even with kind of all of the connection he'd
01:05:30
had with his mom and with treatment he was found um dead between two parked cars had overdosed alone in the street
01:05:36
and I always think like if and you knew him. Oh yeah, the cascading effects that
01:05:42
you know that it didn't have to be that way. And I think there are so many deaths like that where I just think it doesn't have to be like this. You know,
01:05:48
really no one should die like this. And um and there are so many things that, you know, in the moment feel so out of
01:05:55
our control. And I think that's part of what generates my passion for this work is I can't always save the person in
01:06:02
front of me or change issues around homelessness or housing policy, but I can try to work on a broader scale to
01:06:08
make things different for the next person. And I think that kind of that for me counteracts some of the distress
01:06:14
of of of losing people that I care about. If you were president of the United States, for example, let's just
01:06:20
use this country as an example, and you had to make upstream changes to the way society was designed in order to
01:06:27
mitigate the downstream symptom of addiction and addictive behaviors, etc. What are those things that you would change about the way that our society is designed? You could change anything.
01:06:38
Yeah, I mean, starting upstream, the biggest thing would be building resilience and building connection early
01:06:44
on. So you know I think these things that feel so not related to addiction per se are actually deeply related when
01:06:50
we think about adverse childhood experiences. So we think about prevention for children you know often
01:06:55
people have looked at like education like you know telling people telling kids that drugs are bad that doesn't work. What does work is actually
01:07:01
building resilience in young people. So building resilience building connection. So what does that look like? That looks
01:07:06
like affordable housing. That looks like parks where people can get outside and play sports and exercise and build
01:07:12
relationships. That looks like, you know, supporting families so that families can stay together and so those early relationships and attachment can
01:07:19
be wellformed. That's like the true prevention work is trying to break the cycles of intergenerational trauma,
01:07:25
poverty, substance use, and actually supporting families, communities at the very start. It reminds me of Rat Park.
01:07:32
Yes. Yeah. Rat Park is a great example of that. What is Rat Park for those that don't know? Yeah. So rat park was a
01:07:38
series of experiments that were done um where essentially they took they're trying to understand kind of drivers of
01:07:44
addiction using rat models. And so they took rats and they had one model where rats were isolated in their own cage
01:07:50
with nothing to do and no human connection. And they had access to a substance like morphine or cocaine where
01:07:57
they could push a lever and get more of it. And those animals when they were deprived of connection and isolation,
01:08:02
anything to do more of the drug. It gave them relief. who gave them pleasure. They took those same animals and they
01:08:08
put them in this amazing cage with, you know, areas to play and like wheels to climb on and lots of friends and other
01:08:15
rats. And all of a sudden, they saw the same animals were no longer kind of pushing the lever and trying to get more of the drug. And so, you know, it's it's
01:08:23
a somewhat simplified model that there's lots of it's probably oversimplified, but I it demonstrates that so much of
01:08:29
addiction really is around this idea of connection restoring sort of the world around us, the community, the interrelatedness that we all have, the opportunities and purpose and and
01:08:40
meaning and hope. So, I think that's the real prevention. And then there's how do we actually address folks who are having
01:08:45
a problem? And I think you know what I would do there is first make addiction treatment widely available immediately
01:08:51
when people need it. So the minute you walk into your general practitioner's office or an emergency room, you get
01:08:57
treated with compassion, with science, with people asking you what can they do to help and offering you effective care
01:09:02
the same way they would if you had a new cancer diagnosis or a new diagnosis of a heart problem. And that we really
01:09:08
reframe treatment entirely to look like the way it looks for any other health condition. and that we stop punishing
01:09:13
people who use substances where, you know, a lot of times people are still sent to jail for substance use, which,
01:09:20
you know, is a confusing mixed message of we're saying this is a health problem on the one hand, but we're going to put you in prison or jail at the same time.
01:09:27
Those two things don't necessarily align. Many of us are living in the first model of Rat Park. Yeah, we're
01:09:33
living alone. We're living in these big cities. We're more sedentary than ever before.
01:09:38
um maybe you know we've moved to a big city because we don't h which means we don't have our family around um we might
01:09:45
be doing a job that's incredibly challenging. So, it's no wonder when we think about addiction and alcohol and
01:09:50
some of these other behaviors, but more broadly beyond alcohol um as a substance, other addictive behaviors,
01:09:58
whether it's social media or it's uh what we eat or pornography or in the sort of inverse the good habits, the healthy food, the working out, the exercise, the productive behaviors, why
01:10:11
we're struggling so much. And um I've often wondered if we should all just like go to like communes and live, do
01:10:20
you know what I mean? In like in in groups. I mean, I don't think human beings were meant to live this way. And
01:10:25
it's a relatively new thing, right? We often lived in a village or a community. We lived in these multigenerational
01:10:31
households. I mean I have little kids and I think having kids was such an eye openener of that of like well that makes sense why people live with their parents
01:10:38
and their grandparents and have these big families to create you know community and and a sort of extended
01:10:43
family around you and we have lost that in a lot of ways and I think the ways that we used to get that like religion
01:10:49
maybe not maybe that still resonates for some people but for others it may not and so finding other ways of engagement
01:10:55
of meaning of purpose that can be through lots of different things you know I think people are finding creative ways of doing that it can be through
01:11:02
like, you know, finding a volunteer activity, finding some other type of social group. Some people do it through
01:11:07
sports. You know, they they find connection and engagement with people they don't really know over the shared love around around an activity or a
01:11:14
team. But really sort of seeing that as a priority the same way you'd prioritize other things in your life, in your health. And are you a fan of of therapy
01:11:20
as an approach to aim at the early childhood trauma? Absolutely. Yeah. I mean, I think one of the problems is
01:11:27
that too often therapy has been like forced on people. I think that um I'm much more of the approach of like we need to make treatment available and welcoming and high quality so that
01:11:37
people get value out of it and therapy is a huge part of that. You know, it's about a lot of things. It's about connection. It's about figuring out
01:11:43
those reasons why people are using in the first place addressing and healing those traumas. It also matters that we
01:11:49
have um good well-trained empathetic therapists. So there's been a lot of interesting studies looking at actually
01:11:54
how empathetic your therapist is is probably the strongest predictor of whether you stop make changes to your alcohol or drug use really which is so
01:12:01
interesting because we often think like you you've probably heard someone say like I don't really like my therapist and I think sometimes reaction to that
01:12:06
is like oh like you're you're not that into therapy but they've actually done a lot of studies showing that a therapist
01:12:12
who is less empathetic their client is more likely to use more substances at the end of that course of treatment. So
01:12:18
actually having a really well-trained, compassionate, evidence-based workforce is hugely important, too. And I guess
01:12:24
the same applies for family and friends. Yeah. Yeah. I think empathy is really powerful. Those kind of things that we
01:12:29
think of as soft skills actually matter tremendously. Is it possible to prop somebody
01:12:36
up. You know, because I was talking to I think it was talking to Dr. Anna L about this about the idea that you can play a
01:12:43
role in someone's addiction. Yeah. I.e. I want to help my friend who's addicted and so I I'm there for them. I'm comforting them, but I'm actually in some way reinforcing that addictive
01:12:54
behavior because I'm I'm positively reinforcing it because I'm supporting them so much
01:13:00
and I'm loving them so much and I'm showing them so much empathetic attention that actually I'm playing a
01:13:05
role in continuing that addiction. Is that possible? Yeah. And this is this concept of like enabling which I think
01:13:10
is nuanced. I would say at its core it's really deeply problematic that for the most part love and support are never
01:13:17
going to be harmful. And when I talk to patients often the thing that caused them to ultimately engage in treatment
01:13:22
was not some terrible consequence. It was the idea that someone cared enough about them in a moment where they didn't
01:13:28
love themselves very much and felt hopeless that someone was willing to sort of lift them up and believe in them. And it's these small moments of
01:13:35
kindness, like I'll tell you a story of a patient that we took care of in the hospital who was there for a really life-threatening infection related to
01:13:41
their drug use. And a year to the date after um he was hospitalized, he wrote a letter to our team. And he said, you know, I'll never forget the moments you guys came in and just sat with me and talked to me. And he now sends an email
01:13:53
every single year on the anniversary of when he got out of the hospital. And it's those those moments of humanity of
01:13:58
connection again that connection idea that often are the catalyst for change the kind of hope and belief that your
01:14:04
life could be better somehow as opposed to this idea of like increasing someone's pain and suffering. And that
01:14:10
plays out in different ways. So in families one of the most effective tools we teach people is something called craft which is um stands for community
01:14:16
reinforcement and family training. And it's very different than the like people may have seen like shows where you're
01:14:22
supposed to like stage an intervention and you know tell someone all or nothing but craft is very different. It teaches
01:14:27
people first how do you understand the science of addiction family members. Second, how do you get support for yourself? Because it's really tough to
01:14:33
deal with addiction in a family. And then how do you start to learn about consequences in a different way that you
01:14:38
know if you're a parent and your kid is missing school because they're using, you don't want to cover for them and and
01:14:44
sort of reinforce their pattern, but you also don't need to kick them out of your house. That there's sort of gradations
01:14:49
of consequence that can actually help people change. And one of the biggest sort of motivators for change is
01:14:55
actually positive reinforcement of the behaviors you want to see. So that's been called contingency management in
01:15:00
the kind of treatment world. And you know, health insurance companies, lots of companies have figured this out, right? So if you get money back because
01:15:06
you join a gym or you get those, you know, you get reimbursements for doing something that people want to see, people do more of it. It's true in human
01:15:13
behavior. It's very true with addiction. But we often do the opposite. We try to punish people into getting well instead
01:15:18
of reinforcing kind of the healthy behavior, the what we want to see more of, if that makes sense. Yeah. I I I'm I
01:15:25
guess I'm trying to represent the audience member that's listening to this right now that knows someone in their life that was addictive and they tried
01:15:31
to be empathetic. They they tried to offer support. They tried to give the person help and still nothing changed. Yeah. In that situation, maybe the
01:15:43
person that was struggling with the addiction didn't accept the support. Yeah. Didn't go to the meetings, didn't
01:15:49
speak to the therapist. Yeah. in such a situation where you're offering help to someone and they're not taking it,
01:15:54
they're not willing to investigate different medical um treatments, they're living at your
01:16:00
house, they're in your business, whatever. Is there a point where you say enough is
01:16:06
enough? Yeah. Well, first like it is just so hard to be there as a family member or friend. So for anyone
01:16:12
listening, I've been there. It's incredibly impossible. So have grace with yourself. I think that's a
01:16:18
different decision you're talking about is at some point do you have to make a decision to protect yourself. So let's say you have someone in your home who's
01:16:26
dealing with addiction who you know gets aggressive or is stealing money or is you know causing trauma to the people
01:16:32
living in the house. At some point you may need to decide that for my wellbeing for the rest of the family's wellbeing I can't have this in my life right now.
01:16:38
That's very different than saying kicking them out is going to make them better. So the distinction there is that it's okay to protect ourselves.
01:16:45
Sometimes we have to do that and sometimes there's only so much you can do. But to not sort of fool yourself
01:16:50
into thinking that the action is to help the other person and that's okay. I think the other piece is, you know, at
01:16:56
the end of the day, first of all, it's easier to be a treater. So I've been a family member, I've been a clinician. As a clinician, I can truly be
01:17:02
unconditional. So I can I'm going to be someone's doctor whether they continue to use heroin or continue to drink or don't. And there's something really
01:17:08
beautiful in that. Like my engagement with someone is is not premised on whether they make changes or not. as a
01:17:14
family member, that's harder, especially if you're a kid dependent on someone or you're in a marriage or relationship.
01:17:20
So, you may have to make different choices. But I think at the end of the day, people don't change because of why
01:17:26
we think they should change. They change because they think their life is going to get better in some way. So, the key then becomes figuring out like why might
01:17:32
this person's life get better if they were to make changes to their alcohol or drug use. So, it's a shift where you
01:17:38
become sort of on their team instead of trying to drag them towards water, you know, drag the horse towards water. And
01:17:44
there's this um fascinating kind of human instinct that none of us like being told what to do. So there's something called the writing reflex,
01:17:50
which is it's really hard for caregivers, it's hard for parents because we love to tell people like our great advice and why what they're doing
01:17:56
is wrong and they should take our like brilliant doctor advice. And this can be like telling someone like, "Don't you
01:18:01
see what you're doing is causing harm? You should make changes." It can also be subtler. It can be like lecturing someone or trying to educate them. But
01:18:08
when someone shoves something down your throat, your instinct is to to resist. It's just like natural human behavior. even if it's a great idea, if someone's
01:18:14
like shoving an ice cream cone in your face and like eat it. Even if you like ice cream, you might be like, "Wait, wait, I don't know if I want this ice
01:18:20
cream." And so the key then is not to sort of tell someone what to do. It's to understand why might they want to make changes. And so once you do that, then
01:18:26
you all of a sudden realize like it just feels better. You're not trying to drag someone towards something. It doesn't
01:18:33
you don't have like personal skin in the game about what choice they make, but you're really a partner with them and
01:18:38
figuring out how is this thing causing problems to you and why might your life get better if you were to make changes
01:18:43
to your alcohol use or your drinking or your substance use. What's the difference in delivery there in terms of delivering that message? Because they're
01:18:50
both ultimately getting to the same outcome, but it sounds like the language might be slightly different. Yeah, very
01:18:57
different. So um in kind of like medical speak and therapy speak we talk about something called motivational
01:19:02
interviewing which is it becomes almost like a mind trick but it's um it is basically a way of trying to identify
01:19:08
from the person their reasons for change and reflecting it back to them. And so it's not you telling them you think they
01:19:14
should change but you are trying to elicit their motivation and amplify it. And then at the end of the day you're
01:19:20
turning over the power back to them. So that might look like something someone says you know I'll I'll be your your uh
01:19:25
patient. Okay. So yeah, I I I do drink a lot. I drink a couple of times a day, especially in the mornings, but it's
01:19:31
fine, you know. Uh I'm still managing to get to work every day. Obviously, I have a couple of uh misconduct issues at
01:19:37
work, but other than that, you know, and my partner's left me, but other than that, everything everything else is fine
01:19:42
and I can manage this. It sounds like your alcohol use is causing some problems at work and in your relationships. It is. Yeah. Yeah. I lost
01:19:50
my my partner's left me and um I keep getting these misconduct notifications at work in disciplinaries because I sometimes get there late and when I'm there sometimes I fall asleep etc. and I've obly I work with big machinery so
01:20:02
there's a little bit of a risk there but otherwise it's okay. It sounds like you're worried about your safety at work
01:20:08
and also how your drinking is starting to affect your job and your relationships. That's true. Yeah, I am. You know, I've been on the on the crane
01:20:14
in particular, being um being intoxicated on the crane in particular has caused a few incidences. And you
01:20:20
know, I sometimes do worry that one day it'll it'll go a little bit too far. Yeah. Yeah. It sounds like that's really
01:20:26
scary that you're really worried your alcohol use could cause even like a serious or lifethreatening accident at
01:20:32
work. Yeah. And then what am I going to do for work? You know, because if you get a something like that on your file,
01:20:37
then you I'm never going to be able to be a machine operator ever again. So, yeah. Man, your job sounds really important to you and so important.
01:20:42
Alcohol's starting to get in the way of that. Yeah, 100%. Yeah. And so what are your goals looking forward around your
01:20:48
job or your relationship? Well, I I really should um I really should fix this alcohol
01:20:55
issue that I have and uh I would love to find a partner. I'd really that's really
01:21:00
important to me cuz I want to have a family. So obviously prerequisite of having a family is finding a partner
01:21:06
really. So yeah. Yeah. Yeah, it sounds like you're really committed to thinking about making a change to your drinking
01:21:11
and that you're looking forward to finding a partner and family and you're worried that alcohol might get in the way of that. So, you're what you're
01:21:17
doing there is you're you're you're not leading me, you're kind of pushing me, if that makes sense. There's like a
01:21:23
little bit of like a Jedi mind trick thing where you're so essentially it's actually really it's a little tricky
01:21:28
when you're first learning how to do it because what I'm trying to do is I'm listening for what's called change talk. So, any little nugget you're giving me
01:21:34
about making a change. So, you're saying like, "Oh, I'm starting to get this misconduct. I'm worried about this thing
01:21:40
with safety at work. I want a partner." Those are like it's a gold mine of little kernels of change and I'm
01:21:46
ignoring all of your sustained talk. So, anything where you're arguing for the status quo, it's not a big deal, drinking's not that big a deal, I can't
01:21:52
make a change, I don't even acknowledge it or address it. And that's actually hard because I think most of us pay attention to the negative stuff. So if
01:21:58
you think about like a performance review at work or someone telling you any kind of feedback, we tend to amplify
01:22:03
and remember like the one bad thing that someone said to us and forget the millions of good things. So you have to change you have to like train yourself
01:22:09
to do the opposite to hear those little kernels of change talk and then I'm basically being a mirror but I'm
01:22:14
amplifying it. So I'm taking these little kernels of change talk. I'm reflecting back to your own words. So I'm not telling you that you should stop
01:22:20
drinking because it's unsafe at work. I'm reflecting to you like you're starting to get worried that you might have an accident at work and that's
01:22:26
really serious. And that's kind of guiding the conversation forward. The other key is that if you meet a point of
01:22:33
resistance, you want to pivot because once you start arguing, whether it's about politics or anything, people dig
01:22:38
in. So if you start arguing with someone, you got to find another way. You just got to pivot and roll to a different tactic because the more you
01:22:45
argue, the more people dig in on their point of view. And it's more about like winning the argument than it is about moving forward. What if you want to
01:22:52
change yourself? Are is there a process, a system, a methodology to help you discover what your ideal behaviors are,
01:23:00
what your why is, and to implement change? That's why I say all the time, what's your why? I think that's so
01:23:05
exciting. Like, we all want to live our best lives, whatever that means to us. And so, um, having a purpose, having a
01:23:11
goal is probably the most important thing. Motivation is important. We talk a lot about motivation, but motivation
01:23:17
is fleeting. It can slip and slide over the course of one day. So you may, you know, take kind of a mundane example.
01:23:23
You want to get in shape and you're feeling super motivated one day and then the next morning your clock, your alarm clock goes off at like 5 in the morning
01:23:29
and you're tired and it's cozy in your bed and maybe you stayed up a little too late. Your motivation is going to be
01:23:35
flagging, right? So if you don't have a goal or a reason or a why or a purpose, it's going to be really hard to actually
01:23:40
get up the energy to get up. And so figuring out what that purpose is and then trying to find ways to enjoy the
01:23:46
process because if you're always working towards a future goal, some people are very goal-oriented and that works for them. But finding joy in the process
01:23:53
will help you. So I'll take alcohol for example, like not an addiction issue, just like making changes to your drinking in your life. So if you're just
01:23:59
like, I should stop drinking because drinking is bad for me. That's like a relatively vague goal, right? It's not
01:24:05
really about anything that matters specifically to you and it's going to be hard to stick to that. If instead you
01:24:11
think, okay, I, you know, started to realize that when I drink every single night, I don't get the work done that I
01:24:17
want to get done because I'm too tired and I fall asleep. I don't feel refreshed in the morning, so I'm not sleeping very well. I'm not getting up
01:24:22
early to exercise, and that's something that really matters to me. I'm not like as present with my family as I wanted to
01:24:27
be. Then it's these all these little micro goals that make it much easier to make a change. So, you may decide, you know, I'm not going to drink. I'm only
01:24:34
going to drink two days out of the week, and when I do drink, I'm going to keep it to this amount. But the reason why is not some vague recommendation from some
01:24:40
doctor. It's because like you're working really hard at work and it feels good to be productive after dinner and you're
01:24:46
training for a race and you want to get up in the morning and run. And so you actually notice those little steps like, "Wow, it feels great. I woke up this
01:24:52
morning and I feel so refreshed." Like you're reinforcing your goal right there. You're not working towards some abstract thing that doesn't really
01:24:58
matter to you. So you want to make these like really focused, personalized goals and really anchoring it on what is your
01:25:05
why. And your why may be very different than my why or someone else's why. Um so it may be you know sleep really matters
01:25:11
to you or you know you may have a different relationship with alcohol. So the other kind of example I'd give is
01:25:17
people are different right? We respond differently to things. So some people can open a bag of like potato chips and eat two and walk away. Some people like
01:25:24
they open the bag they're going to eat all of the chips. And so it's just easier not to open the bag. And alcohol is like that too. Some people may find
01:25:30
if they open a bottle of wine or they have alcohol in the house they're going to drink all of it. And the idea of like
01:25:36
trying to keep to these small amounts of alcohol is actually really hard. And it's simpler and easier to just avoid it
01:25:41
completely or to only drink at a restaurant or something. So, you do have to understand like how your goals, your
01:25:46
why, your purpose interacts with your response to whatever it is that you're working on. And that's going to be different for everyone. Are there any
01:25:53
other things, any other habits that we should be thinking about when we're trying to overcome an addiction? So if
01:25:59
we think about alcohol as being at like the bottom of the stream, are there is there anything else upstream that I should be thinking about? So we talked
01:26:05
about social connections and relationships. So I need to be making sure that I'm surrounded by people. I'm socializing because that's going to be
01:26:11
an insulator to like stress and loneliness which is going to cause me discomfort which is going to lead me to
01:26:16
alcohol. But are there any other things that I should be thinking about when I'm setting off to make a change in my life?
01:26:23
Yeah. Yeah. There's a bunch. I think first any behavior change whether it's alcohol or other. If you're feeling like
01:26:29
depleted and tired and not your best self, it's going to be harder to make a change. So, if you think about like any
01:26:34
big decision you made to change your job, to start an exercise routine, to leave your partner, you probably didn't choose like the day that you were
01:26:40
exhausted and feeling anxious and stressed and not your best self to make that change. Like, change is hard. So, you want to try to boost up other things
01:26:47
in your life. Eat well, you know, get enough rest, try to exercise, things are that are going to help you feel healthy
01:26:53
and your best best self when you're trying to make a change. Is that linked to dopamine? Yeah, because I mean so our
01:26:58
natural reward system, the thing that triggers it is exercise, food, sex, connection. So, you know, trying to have
01:27:04
healthy other ways of um of positive dopamine release. And so, I think for many people, alcohol or substances can feel like a way of doing something nice for ourselves, like I'm going to this is
01:27:16
going to help me reduce my stress after a bad day at work. So, the goal then is not that you just like white knuckle it
01:27:22
all night and feel really stressed after work. It's that you figure out like what are some other things that help me reduce stress after work? Maybe it's
01:27:27
going to a yoga class with a friend. Maybe it is, you know, spending time with my family. Maybe it's getting
01:27:34
massage or meditating or watching a show I like. So, you want to, it's not just you're removing the thing that you're trying to change. You want to fill up
01:27:40
the empty space with other things. So, what if I fill it up with like Hargan's ice cream and burgers because that will cause a dopamine hit. Mhm. So presumably
01:27:52
if I just eat loads of sweets and candy then that's going to stop me from engaging in addictive behavior. But we see that all the time. So that's like replacing things. And um you know I was
01:28:03
reading an article people have probably heard of dry January. This idea of like not drinking for the month of January to rethink your relationship with alcohol.
01:28:09
I was reading an article that dry January has become high January because people are just smoking a ton of weed instead of drinking. And so it's very I
01:28:15
think you want to be cautious that you're not just replacing the thing that you're trying to change with something that's also going to cause health
01:28:21
problems. Now, if having dessert once in a while for this, you know, you're not getting calories from alcohol and having
01:28:26
a nice ice cream cone once a week is a way of sort of treating yourself that's healthier and maybe more aligned with
01:28:32
your goals. That's fine. I think thinking about these things, actually thinking about alcohol, the way we think
01:28:37
about dessert, sunbathing, eating processed meats, all of these things have risk and benefit in our lives. I
01:28:43
think where we've gone so wrong with alcohol is this idea that it's like a healthpromoting behavior that you shouldn't be drinking
01:28:50
for your health. It's not going to make you healthier. Um, and also much like many things we do that are not
01:28:55
healthpromoting activities, there are ways of reducing the health harms of that activity so that it's okay in small
01:29:00
amounts in your life. I think B2B marketeteers keep making this mistake. They're chasing volume instead of quality. And when you try to be seen by more people instead of the right people,
01:29:12
all you're doing is making noise. But that noise rarely shifts the needle and it's often quite expensive. And I know
01:29:18
as there was the time in my career where I kept making this mistake that many of you will be making it too. Eventually I
01:29:24
started posting ads on our show sponsors platform LinkedIn. And that's when things started to change. I put that
01:29:29
change down to a few critical things. One of them being that LinkedIn was then and still is today the platform where
01:29:35
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01:29:41
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linkedin.com/diary, you can claim that right now. That's linkedin.com/diary. Just thinking about something we said earlier about how early childhood trauma causes the brain
01:30:11
to change and then results in addictive behaviors. If I went through an early childhood trauma and my brain has changed because of that and then I get into uh I become addicted to alcohol as
01:30:23
a as a young man and then I manage to find my way off the alcohol. My brain is still addicted, right? My brain still
01:30:30
has that addictive sort of predisposition. So isn't it the case that I'll just end up being addicted to
01:30:35
something else that gives me a dopamine hit? So it turns out the brain is amazingly um plastic meaning it can
01:30:41
change. We see that over time. So the first thing is even adverse childhood experiences are not a done deal. So we
01:30:47
talk a lot about ACEs. We don't talk a lot about pieces or PCE positive childhood experiences but actually you
01:30:54
can reduce the risk that someone develops addiction by increasing the number of positive childhood experiences. So take someone who's
01:30:59
experienced some terrible adversity. Their parent has died or they have a parent who's in prison or they have
01:31:05
addiction in their family. If that kid has one single adult figure that they believe cares about them, that reduces
01:31:11
their risk of addiction. So there are a lot of positive ways that we can actually change the trajectory even in
01:31:16
the midst of terrible trauma. When you think about someone who's had a substance use disorder, we actually have good data on this that after 5 years of
01:31:23
recovery and often that is fits and starts. So most people think of like this is one fail swoop that you like
01:31:29
decide to stop drinking and then success is that you never drink again. For most people what we find is that's actually
01:31:34
like a series of steps. So I always like to think of progress not perfection and not have this kind of all or nothing
01:31:40
mindset that for many people they may early on have a month where they go without alcohol and then maybe next time
01:31:45
it's three months and then maybe it's a year and these recurrences happen but ultimately they get to this place where
01:31:51
they go into long-term recovery. After 5 years of recovery, a person's risk of subsequently developing addiction is no
01:31:57
higher than the general public. So your brain actually does change and we see this on functional imaging. We see this
01:32:02
in longitudinal studies that follow people over time. So you actually can overwhelm those things and get to a
01:32:09
place where you don't have a higher risk than other people. Because some people say, "I've got an addictive personality that's they sort of self-label and
01:32:15
selfidentify as having an addictive personality." Sometimes they even reference their brain as being easily
01:32:20
addictive. Is there is there truth in that? Is it possible to have an addictive personality? It's not so much about personality, but we do respond
01:32:27
differently to substances. So um you know, take alcohol or opioids, anything. People feel differently the first time they ever use it. So often if you talk to someone who then develops addiction, they tell you that first time they use
01:32:39
the substance, it was like this amazing feeling. It felt like I've had people describe it as falling in love or, you
01:32:45
know, a warm hug or or like a relaxing bath. These like incredible comforting experiences. Other people, they get
01:32:51
prescribed like an opioid for a tooth extraction. They feel nauseous and kind of like not like themselves and they
01:32:56
don't like the feeling. So how we respond to substances is definitely based on our neurobiology and is
01:33:02
different for different people. Um so some people are both from a genetic reason and and their own brain are just
01:33:08
more wired to be at risk of addiction. And that's important to know about yourself because then you can make different choices. You may decide, you
01:33:14
know, never to keep alcohol in the house or not to drink because the risk is too great. But how much do you think about
01:33:20
other things that are taking hold of society? some of the other things that are non substance related. So, social
01:33:26
media addictions and pornography addictions and what else? What else are some of the big ones? Food addictions,
01:33:31
food, sex, gambling. Um, I think there are a lot of similarities. It's not my particular area of focus, but I think
01:33:37
there are a lot of overlaps. I mean, I think many of the things you just listed, you could talk about. One,
01:33:42
dopamine obviously, but two, this idea of needing to fill yourself with something else. either, you know,
01:33:48
thinking about trauma, thinking about untreated mental illness, thinking about just kind of the deficit of connection
01:33:54
and of meaning and reward um and reaching to these external solutions. Can you tell me about a time where
01:34:00
you've worked with a patient who through the process of working with them and understanding their trauma, you
01:34:06
discovered something unexpected about the root cause of their addictive behavior? Yeah. Yeah. I can think of many patients, but one in particular who, you know, I I had this I knew that
01:34:19
he'd experienced hard things in his life. He'd been in prison, for example, which is a traumatizing experience. He'd
01:34:24
lost his parents and other thing. I never truly understood the depth of his trauma and had he had struggled his whole life um with substance use
01:34:31
disorder and and using lots of things, mostly opioids, but also alcohol and cocaine and um and just had had a really
01:34:38
really hard time. And after I mean years of knowing him, one day he broke down my office and shared that he'd actually
01:34:44
been molested as a young kid. And so sometimes there is that like that thing that people have never felt like they
01:34:50
could share with anyone that really is at the root of so much of what they've been dealing with. And like the person
01:34:55
who whispered to you, I think the pain of keeping that inside. Not only the trauma of experiencing that as a child,
01:35:01
but then holding that secret and feeling like you somehow are damaged or you know that this this thing inside you is there
01:35:07
and not being able to heal it, talk about it, share it with people. I think um is just this like this well of pain
01:35:14
that lives inside people. Did he recover? He actually passed away from substance abuse. From substance use. Yeah. You must carry a lot of this stuff with
01:35:26
you because your line of work sounds like you're dealing with bad news quite often, more so than the average person.
01:35:34
And the news you're dealing with is is a different type of news. You're dealing with somebody sort of reaching the end
01:35:39
of their life um through something that you also have said many times you believe is preventable in many cases.
01:35:46
How do you how do you manage that? Yeah, I mean I think a couple things. one um there are so many stories of hope that I think um counterbalance that for me. So I
01:35:58
think you know the other stories in my mind are you know I carry with me and still care for and are in touch with
01:36:03
people who are living these amazing vibrant lives in recovery and in the US alone there's 24 million people living
01:36:09
in recovery. So there are these stories of people who have overcome just trauma, tragedy, hardship and are doing awesome.
01:36:15
They're parenting, they're working. You probably don't even know they're around you. you know, they don't tell people necessarily that they're in recovery.
01:36:21
And getting to be sort of a part of that process with someone and watching, you know, there's nothing in medicine where
01:36:27
I can actually see as dramatic of a change as with addiction, where someone can be, you know, at a moment where
01:36:33
they're dealing with all of these health consequences and relationship challenges and then they get better and it's just
01:36:38
like the most beautiful thing to be a part of. And so, I think the hope from that, the sort of positivity of it is
01:36:44
what keeps me going every day. Obviously finding ways to care for myself through that and family and connection,
01:36:49
exercise. I run, I write, you know, you gota you have to keep yourself whole through it all, too. But I think I get I
01:36:55
get tremendous purpose and mostly like a lot of hope from working with people and seeing them recover. What is the most
01:37:00
important thing we didn't talk about that we should have talked about? I think one thing is language. It's like
01:37:06
this subtle thing. I sort of mentioned an example where you did it really well where instead of saying someone failed treatment, you said the treatment failed
01:37:12
them. But a lot of the language that we use with addiction actually subtly and not so subtly worsen stigma. And
01:37:18
sometimes this sounds like I'm being politically correct or it's like an issue of semantics, but there's actually really good data on this. So if you
01:37:24
think about words we use for addiction, one is substance abuse, right? So the term abuse, what does abuse refer to? So
01:37:30
it actually comes from an old English word that means like a willful act of misconduct. And it's a word that we use for child abuse, for sexual abuse, for
01:37:37
domestic abuse. like it's only for these like terribly violent acts of commission that are very stigmatized because
01:37:43
they're like terrible things. And yet we use it for this thing that we're saying as a health condition that you're like a substance abuser or you have substance
01:37:49
abuse. And so there have actually been these elegant studies that took like PhD level psychologists, really highly
01:37:54
trained clinicians, and they described a person as either a substance abuser or as a person with a substance use disorder. And the clinician was actually
01:38:01
more likely to recommend a punitive intervention for the person described as a substance abuser. What does that mean?
01:38:06
So in this case, they were given like an option. You read this paragraph about a p about like a fictional patient and
01:38:12
they don't really know what the researchers are testing and they're given a bunch of different options for intervention and one is this like send
01:38:18
them to drug court or send them to jail. One is like offer them, you know, outpatient effective treatment. There's
01:38:24
a bunch of different choices. When they hear someone described as a substance abuser, they're actually more likely to recommend the like jailbased
01:38:29
intervention. So words actually like very in they influence how we think even how we make
01:38:35
clinical decisions. They've also done this to the public. So if you describe someone as a drug addict the public has a more negative view of them than if you
01:38:41
describe them as a person with addiction. So there are these subtle ways there's been this shift in addiction to really using what we call
01:38:48
person first language which has been true across medicine. So like we used to use terrible words like we'd refer to
01:38:53
someone as like the schizophrenic you know or really labeling them as their health condition. And thankfully there's
01:38:58
been a change from that to realize that people are people first who have an illness or not defined by it. So I would never say like I'm going to go see the
01:39:05
lung cancer in room 204. I'd say I'm going to see you know Mr. Smith who has lung cancer. And so with addiction too
01:39:10
like people are more than that. So to say you know person with addiction person alcohol use disorder rather than
01:39:15
saying they're an addict or an alcoholic. And then even terms like clean and dirty which are commonly used when we talk about addiction. So you
01:39:22
know take the word clean. It sounds really positive. Like you're saying, "Oh, you're clean." But like what are you really saying? So you're saying
01:39:28
like, "If you're clean now, when you were actively struggling, what were you? You were dirty." And so I always
01:39:34
remember an example, a friend of mine who's in recovery was interviewing for jobs in the recovery space. And so
01:39:39
people on the on the interview trail would say to him like, "How long have you been clean for?" And he would say, "Well, I've been bathing since I was a
01:39:44
newborn. So I've been clean my whole life and I've been in recovery for five years or whatever." So, I think these
01:39:50
little things actually matter that we should use terminology that we'd use for another health condition. If we're
01:39:55
labeling, you know, people with active addiction as dirty or, you know, people with addiction is the same as child
01:40:01
abusers with that sort of language, um, we're really sort of subtly increasing stigma. So, that's a small thing that we
01:40:06
can all do is just try to use language that's a bit bit more humanizing. It's so interesting because I was aware of
01:40:11
this, but I still found myself accidentally using the word abuse. Yeah. And I' I'd stumble into it. Go [ __ ]
01:40:18
um I try to avoid the use of the word addict. Yeah, it's hard to change, but you know, like everything you just want
01:40:24
to be humble, curious, and keep trying. I mean, there's lots of language that we've changed. Like, think about so many terms we use for, you know, for you
01:40:32
know, people who are born with different abilities or for people of different races or other identities that were
01:40:37
really stigmatizing and we've like learned to use different language even if it feels a little awkward when you're first learning it. I think understanding
01:40:43
the science and the data behind the impact it has to use certain language I think is really useful. Yeah. Because
01:40:49
that's helped me to understand just because now I understand the first principles of it. I need to make sure I describe people as a person first. So a
01:40:55
person with addiction addiction is much better than calling someone an addict. Yep. Exactly. And one thing people ask
01:41:01
me will say well what if someone refers to themselves that way because people may do that and that's I'm that's fine.
01:41:06
People can use whatever language they want for themselves. But I think as a health care professional for sure or
01:41:11
someone who's trying to help combat stigma, like we can choose to use different language. And I've actually had patients sort of ask me like, well,
01:41:18
why do you use that terminology when they use a different language? And it actually can be sort of empowering to be like, oh yeah, I'm actually a person in
01:41:24
recovery or I'm a person with addiction. I'm not going to label myself that way anymore.
01:41:30
Something I've been really um curious about just in my life generally because in conversation, I'll often I said something yesterday when we were at
01:41:35
dinner with with the team here. I said, I can't remember the exact phrase, but it was words to the effect
01:41:43
of I'm not good at that or I'm not that type of person or I'm not organized. And I stopped myself and the team will remember and I go actually
01:41:53
I shouldn't say that. I should say right now uh was you're like defining yourself
01:41:59
as incapable of doing something instead of being like I'm working on organization right now. I think it's so important and we don't think about it
01:42:05
how casually we create an identity for oursel that is like fundamentally limiting or puts us in a box or frames
01:42:12
us having a deficit or captures our whole identity and some kind of deficiency we have often in the case of
01:42:18
the habits I'm referring to does this a similar thing take effect when we're talking about calling someone an addict
01:42:24
yeah you're sort of labeling them as that is the only thing that they are and that they will be that forever and you
01:42:29
know um a friend of mine who's a journalist who is in recovery and writes a lot about addiction. My Solivitz wrote
01:42:34
this great New York Times piece that addiction doesn't always last a lifetime because I think there's this idea in our head that like you know people with
01:42:40
addiction will always have addiction and it's this like incurable thing and that actually people have lots of different
01:42:46
journeys and for some people you know that becomes something they deal with and then they move on their lives. For
01:42:51
other people it's something that they actively manage. But this idea that you sort of boil things down to like the
01:42:57
only thing I am in this world as a person with addiction, um, you really limit everything else about
01:43:02
yourself. We have a closing tradition on this podcast where the last guest leaves a question for the next, not knowing who
01:43:08
they're going to be leaving it for. And the question that's been left for you is, if you could redo or revise one
01:43:17
thing that you have successfully accomplished, what would that be and why? I guess I would say, and I could think
01:43:28
of lots of successful accomplishments I'd apply this to, but I'll take the example of medical training, which is a
01:43:34
successful accomplishment. I think I would be more present that we are always like rushing to the accomplishment to
01:43:40
the finish line to sort of getting to the next goal and I think back and wish I had realized what an amazing journey it was in that moment and I mean even things with medical training that I was
01:43:52
I was never going to be a heart surgeon but to stand in an operating room and look inside someone's chest and watch a
01:43:58
beating heart is an experience that I'll never get again and I think in this journey to always achieve and move forward and get to the next exam and the
01:44:04
next thing we sometimes miss like the miracle that's right in front of us. And so I think I would have um been even
01:44:10
more present. That applies to all of us. I felt like I was being called out. True for parenting, true for everything.
01:44:22
Thank you so much. I'm so grateful for the work that you're doing because there's so much there's so much um
01:44:27
conflicting information, especially as it relates to alcohol. There's been so much information over the last 5 10
01:44:33
years about um the impact alcohol has on us. And I've sat here and and had conversations with people who are pretty
01:44:39
convinced that even, you know, moderate levels of alcohol are good for us. And having read your work, I'm now clear on
01:44:46
what the truth there is. Um thank you for doing what you do. It's incredibly important. And I actually think it's going to become increasingly important
01:44:52
unfortunately because the way that the world is heading, the loneliness epidemic that we're experiencing and um
01:44:59
the the access we now have to digital devices and to um lowcost consumption of addictive substances is is terrifying for me. I know you've got a book on the way which I'm extremely excited about
01:45:09
which is due in autumn, next autumn. Spring of 27. So we have Okay. And what's that book about? Can you give me
01:45:15
a give me a clue? I mean, I could gasp. It is going to be about changing the narrative around addiction and um about
01:45:22
really reframing how people think about it to see it as a treatable good prognosis illness and using some of the
01:45:28
stories of people I've had the privilege of knowing to hopefully help people see things in a different way. Where do
01:45:33
people find you if they want to reach out or learn more? Yes. Um they can find me on LinkedIn, on Instagram, they can
01:45:40
email me. Um yeah, happy to connect and would love to come back after the book is out too. I look forward to that. I'd
01:45:46
love to. So, your Instagram, your LinkedIn, I'll put those details below. I'm sure you'll probably get a lot of messages. Great. Um because these issues
01:45:53
in particular are incredibly um incredibly potent issues in people's lives and um very emotional issues as well. So, thank you for on behalf of all my audience, thank you for your generosity today, but also thank you for
01:46:04
your wisdom. Really, really appreciated and I would love to speak to you again soon when the book is out. Thank you. Thank you for having me.
01:46:13
This has always blown my mind a little bit. 53% of you that listen to the show regularly haven't yet subscribed to the
01:46:19
show. So, could I ask you for a favor? If you like the show and you like what we do here and you want to support us, the free simple way that you can do just
01:46:25
that is by hitting the subscribe button. And my commitment to you is if you do that, then I'll do everything in my
01:46:30
power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback.
01:46:36
We'll find the guests that you want me to speak to and we'll continue to do what we do. Thank you so much. Heat. Heat. N.
01:46:43
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