How to Overcome Addiction to Substances or Behaviors | Dr. Keith Humphreys

Someone says I want to quit smoking. A

good clinician will say why why would you want to do that? So say so tell me why would you want what do you want to get out of this because it's work. I

mean I'm happy to work with you but you know what is it? What are your what are your motives? And and sort of helping

your motives? And and sort of helping them build up you know in their own mind because again this is about them not you. What do you get? And that's what

you. What do you get? And that's what the therapist does. The other thing that's really important is that like any other anytime you're making a behavior change hang out with other people who are trying to make the same change. You

want to start jogging? Join a jogging group. you want to stop drinking, I

group. you want to stop drinking, I would, you know, suggest go check into an AA meeting or one of the other fellowships we have. Having other people on the same journey is good for us. It I

mean everything shows that no matter what you're doing, I'm losing weight.

I'm exercising. I'm more whatever. I'm

quitting smoking because it gives you two things. It gives you support, but it

two things. It gives you support, but it also gives you some accountability. It's

like, hey, you were going jogging and uh Tuesday, you weren't there. What's up?

Are you going to be part of this group or not? And that is uh helpful for

or not? And that is uh helpful for people. Welcome to the Huberman Lab

people. Welcome to the Huberman Lab podcast where we discuss science and science-based tools for everyday life.

I'm Andrew Huberman and I'm a professor of neurobiology and opthalmology at Stamford School of Medicine. My guest

today is Dr. Keith Humphre. Dr. Dr.

Keith Humphre is a professor of psychiatry and behavioral sciences at Stamford School of Medicine. And he is one of the world's foremost experts on addictive substances and behaviors and

how to overcome addictions of all kinds.

He is also an expert on how science, commercial marketing, lobbying, and the legal system interact to create what are called addiction for-profit businesses.

The alcohol, food, and opioid industries come to mind as just a few examples of these, and he's an expert on how all of that shapes things like legal policy.

Today we discuss all the major addictions to give you the most up-to-date information on alcohol, cannabis, opioids, gambling, and much more. Dr. Humphre gives us the unbiased

more. Dr. Humphre gives us the unbiased facts, and more importantly, he explains how to think about the health risks of any substance or behavior in a logical way. For instance, while it may be true

way. For instance, while it may be true that a certain amount of alcohol could afford you some heart health benefits, we hear this, then we hear it's not true. It goes back and forth. He

true. It goes back and forth. He

explains that any heart benefits that exist from alcohol are greatly offset by the increased cancer and other risks of alcohol. And with respect to cannabis,

alcohol. And with respect to cannabis, he explains who may be okay to use it, but who should absolutely not. We also

discuss the most effective ways to get over any addiction. That includes

alcohol pornography stimulants and much more. As you'll soon see, Dr. Keith

much more. As you'll soon see, Dr. Keith Humphre is no ordinary scientist or psychologist or addiction expert. He has

the big picture on addiction and what it means to try and navigate life nowadays in an ocean of addiction forprofit marketing and confusing health information. I assure you that today he

information. I assure you that today he doesn't tell you what to think or what to do about various substances and addictive behaviors, but rather how to think about them and in doing so how to avoid and overcome essentially any

addiction. It's a powerful conversation

addiction. It's a powerful conversation that I'm certain will help millions of people make better decisions. Before we

begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is

however part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, today's episode does include

sponsors. And now for my discussion with

sponsors. And now for my discussion with Dr. Keith Humphre. Dr. Keith Humphre, welcome.

>> Good to meet you, Andrew. Addiction is a big topic but I think for a lot of people it gets slotted into one small drawer. Uh but if we were to compare it

drawer. Uh but if we were to compare it to say mental illness many many things depression manic bipolar OCD and on and

on. How do you parse this thing that we

on. How do you parse this thing that we call addiction in thinking about how best to possibly treat addiction especially when it comes to trying to treat addiction in mass at the level of

policy which we'll also talk about today. So uh put simply how do you frame

today. So uh put simply how do you frame addiction uh and how should people think about it?

>> Yeah it's hard because it's a word unlike say you know maybe it's a little like schizophrenia where people say like ah you know schizophrenic person what they actually mean is you know he's a person with different moods and that sort of thing. addiction is even more

like that. It's in common parlance.

like that. It's in common parlance.

People say, you know, I'm addicted to, you know, you know, uh, a TV show or I'm addicted to my my phone or that sort of thing. But, you know, it's not just

thing. But, you know, it's not just stuff you do a lot, uh, you know, which we sometimes, you know, colloally call addiction. It's the persistence of doing

addiction. It's the persistence of doing something that is harmful. So like the classic animal study, you know, is, you know, James's old study with rats done

in the 50s showing that you could give a a rat uh uh the opportunity to give itself brain stimulation, which they enjoy, and that they would continue to

do that even as they were starving to death next to a pile of food pellets or or run out of water while they were next to water. That is what it was. It's not

to water. That is what it was. It's not

the doing the things over and over or even being compulsive about things. It's

doing them to the point of destruction when you would normally, you know, any other behavior you would think, well, you would just stop doing that. But

people don't and that's the sinquan of addiction.

>> I've tried to uh create a definition for addiction, which is that it's a progressive narrowing of the things that bring one pleasure that it doesn't happen all at once. Like someone doesn't

take heroin once and then stop doing everything else. It's a tends to be

everything else. It's a tends to be progressive. I suppose it could be

progressive. I suppose it could be overnight, but um is that true? I'm

happy to revise the definition.

>> No, that that is true. So, you see um the other types of rewards, particularly natural rewards, start to fall away from the person's life. So, I'll sacrifice,

you know, my relationship with my my parents or my my spouse or my friends. I

will stop going to work when I, you know, which uh would normally generate the things I needed to to eat or I'll I'll give up my housing for the sake of this substance. And then you become not

this substance. And then you become not only more physically dependent on it, but essentially you're psychologically dependent on it because it's the one thing left that is still rewarding.

Everything else has been stripped away.

And that makes it easier to understand why people would still hang on to it in that situation when it feels like it's look, it's the only time I feel good is that that moment when I take that hit.

These days there are a lot of industries that are um addiction for money basically industries and we're going to talk about all of them.

>> Nicotine, alcohol, cannabis, social media, all of these. Um but for the time being, do you think that there is truly something to the quote unquote genetic

bias for becoming an addict? And is it very substance or behavior specific?

>> Um let's start with maybe alcohol for example. Yeah, that's a great question.

example. Yeah, that's a great question.

So, let let me start by just um getting rid of one myth where we say people are born addicted. You'll sometimes read,

born addicted. You'll sometimes read, you know, uh if if mom was addicted to fennel, then the baby is born addicted.

That is not possible because, you know, a a fetus has no association between their behavior and the exposure to the drug. So, they can be physically

drug. So, they can be physically dependent, meaning they'll go through withdrawal upon birth, but they're not they're not addicted. But you can have

risk from birth in your genes. And those

those shared the estimation of you know how much of that shared it's actually quite a bit. You know we look at studies where kids were adopted out of families with parents who you know were addicted

to alcohol. Much higher likelihood of

to alcohol. Much higher likelihood of developing an alcohol problem even if they were raised by tea toters for for example. How big is that? You know it

example. How big is that? You know it varies across you know studies. It

varies across uh substances but it's large. It might be like you know 3

large. It might be like you know 3 point4.5 uh for for most of them and you know you you can imagine that the same gene some

might be specific and some might be more general. So here's an example of a

general. So here's an example of a specific one. Um, if you are born into a

specific one. Um, if you are born into a group like Honchinese are and you lack the enzyme or don't have much of a particular enzyme that is used to metabolize alcohol, it is just a less

enjoyable experience to drink.

>> You, you know, you can't break it down acetal alahhide and acetic acid and all that sort of thing. And so that one is but that would lower your risk for anything else but at least specific for alcohol. But other genes for things like

alcohol. But other genes for things like impulsivity um that that would put you at risk for you know across substances being sensation seeking um you're going to try

more drugs that means it's more likely that you know you're going to get exposed to one another thing we see happening which is really fascinating and poorly understood I've I of course

know doing what I do lots of people are in recovery and I've uh known people and had people in my studies who have been say clean and sober in their you sense

for 20 years and then all of a sudden they develop like a very strong sexual compulsion or they gain 30 pounds because they're just eating and eating and eating and it's like, you know, the

the underlying diiathesis, whatever it is, has found a new phenotypic expression because it was never actually resolved. What was resolved was the

resolved. What was resolved was the particular set of behaviors that went with the addictions they had when they got into recovery. When it comes to alcohol, I've heard it said that there's

a subset of people with um I guess nowadays they call alcohol use disorder.

Can we just call it alcoholism today?

Sure.

>> Okay. Sometimes people will lash back at me if I call refer to someone as an alcoholic. But I have enough friends who

alcoholic. But I have enough friends who are alcoholics. That joke is only on

are alcoholics. That joke is only on them by the way who are recovered. So I

can make the joke um because they're impressive recovery uh stories and they all just say just call it what it is which is alcoholism. There's just so much splitting of names now. Are you I don't want to put you in a position of

saying something that's gonna offend anyone whereas I I can do that.

>> This is worth getting into. So use

disorder is a much broader spectrum thing. So you know when when you if you

thing. So you know when when you if you diagnose them with alcohol use disorder, it can be mild, moderate or severe. And

the people at the mild end, everyone at AA would laugh at, you know, this is a person who occasionally drinks too much, has some harms, but basically life is still put together. They would, you know, and people would be like, you got to be kidding me. that's that's your

problem. It's only when you get up to

problem. It's only when you get up to the severe end where we we see the things that it looks like addiction. So,

they aren't they aren't actually the same thing. Addiction and use disorder.

same thing. Addiction and use disorder.

Use disorders is broader. And it was it was there to sort of >> um move alcohol like other health behaviors that you might start addressing particularly in like primary care. So you know just like we would

care. So you know just like we would like you know doctors to intervene when someone is 15 pounds overweight and has moderate high blood pressure so that you they don't you know later you know

develop a more serious problem. That was

the idea well let's have you know a lower severity problem that a doctor might while the person still has a fair amount of control advise you hey you know if you could just cut back a bit now you could avoid a lot of suffering

later. That's where that came from. But

later. That's where that came from. But

I'm I'm comfortable talking about addiction. It's a good word. It's

addiction. It's a good word. It's

scientifically meaningful and it's something the public understands.

>> Yeah. And if you go to an AA meeting, uh they go around the room saying, "I'm so and so and I'm an alcoholic." They don't say, "I'm so and so and I have alcohol use disorder."

use disorder." >> Oh, that's right. Yeah. So many people who have who are in recovery um define at some level of their identity, not

their total identity, as an alcoholic.

It's actually an important part of the 12step recovery process, which we'll talk about. In any case, not to split

talk about. In any case, not to split hairs here, but I'm grateful that you're willing to embrace that nomenclature.

And thanks for clarifying that why it was split. Um, because sometimes these

was split. Um, because sometimes these clinical uh and naming things are split because of quote unquote sensitivities.

We don't want to offend etc. And we don't want to offend. Okay. So, alcohol.

Um, I've heard it said that there's a subset of people somewhere around 8 to 10% for whom they they drink alcohol and they experience it very differently.

They experience it more as a, for lack of a better term, kind of a dopamineergic, you know, energizing experience for um, and this could relate to tolerance, but that they have a very

different experience subjectively of alcohol than most everybody else who can build up tolerance. anyone can build up tolerance. Um, and then it takes longer

tolerance. Um, and then it takes longer to get into the sedative effects, the depressive effects of alcohol, but I've heard it said that this 8 to 10% are

particularly susceptible to becoming alcoholics because they drink and they feel spectacularly good and they can keep drinking in a way that many other

people either pass out, blackout, crash their car, end up in jail or dead. And

so in some sense this 8 to 10 percent may be at greater risk than everyone else.

>> Yeah. So uh Mark Shookett who's a superb psychiatrist was based in Southern California for most of his career did some wonderful studies of male uh children of alcoholic fathers. And one

of the things he showed is that when given alcohol, their body sway is less at a level you can't even perceive, but he couldn't measure that, you know, yeah. Like how much they moved, like how

yeah. Like how much they moved, like how how hard the alcohol hit them.

>> And they had uh fewer hangovers the next day. And then you might think, well,

day. And then you might think, well, that's great. It doesn't hit you that

that's great. It doesn't hit you that hard, but you know, you can drink a lot.

Like, no, that's the problem because someone else would get the signal of like, whoa, I I you know, I'm feeling kind of dizzy here. I must have had too much to drink or the next morning they get up and go, "Oh god, I'm never doing

that again." They don't get that signal.

that again." They don't get that signal.

It's, you know, less less punishing, more rewarding. And you see that across

more rewarding. And you see that across drugs. Uh, and this is almost surely

drugs. Uh, and this is almost surely genetic. Um, how much people like

genetic. Um, how much people like different drugs, you know, varies enormously. I I'll be personal about

enormously. I I'll be personal about this. So, I uh, you know, had an injury.

this. So, I uh, you know, had an injury.

Uh, I broke my, you know, I I had to take Vicodin for the pain afterwards. I

find taking opioids so unpleasant. I

feel bound up, you know, miserable, groggy that I just took one and said, "Pain is better than this."

I have worked with people clinically who say the first time I had an opioid, it was like a hole in my chest that had been there my whole life filled up for the very first time. That has everything

to do with genes. There's no, it's not due, there's no learning history there, right? But there's something, you know,

right? But there's something, you know, I'm just wired differently for that particular drug than people who get in trouble uh with it is. And these don't necessarily go in groups. So someone

can, you know, hate opioids, but you know, love cannabis or love alcohol. Um,

and that of course is going to change their their risk. How could it not?

>> This is such an important point, and I didn't realize that it extended to things outside of alcohol. uh because

oftentimes when a discussion starts to surface about addiction and whether or not zero is better than any, whether or not things can be done in moderation, I think this is actually a big um unspoken

point of friction because some people really can drink five or six drinks.

>> Oh yeah.

>> And then the next day they're at work hammering away and they're going to say, "Listen, my life's going great."

>> Yep.

>> And you know, liver markers are still within range. Eventually they'll

within range. Eventually they'll decline. you know, they'll get worse,

decline. you know, they'll get worse, but the conversation becomes very difficult to have because it's high, it sounds like it's highly individual how people will react. And there are the

behavioral impacts. Like for instance,

behavioral impacts. Like for instance, um I've heard the statistic that one of the greatest risks for becoming an alcoholic is if your first drink is

before the age of 14. So I find that some people will, you know, have their first drink like you said and it's like a magic elixir for their

physiology. And there are very few

physiology. And there are very few things that can get somebody like that to stop drinking except the risk of losing everything and sometimes even then.

>> Sometimes even then.

>> And so maybe alcohol is the best, you know, template for for talking about this because it's socially acceptable in most places for adults anyway.

>> It's legal. It's marketed.

>> It's legal. it's marketed and um and yet how does one know whether or not they have a predisposition um because those people might want to avoid using something because our

colleague Anna LMK has said that um you can't get addicted to something that you've never done or taken.

>> Yes, that that is the most helpful advice, you know. So I I can never tell you if you know in this game of Russian roulette, the bullet will not be in your chamber for sure. You know, I can say

like you're less likely for this, more likely for that. But the only way to determine that a substance will not damage your life is to never use it in the first place. There's always going to be some some risk. There's been a lot of

work on like kind of genotyping to try to figure out could I tell you tell people, you know, what their genetic risk is for alcohol. And nothing is as good as just saying your parents

alcoholic yeah or no. And if they were, that's like the most useful bit of information. or does you know does

information. or does you know does problem drinking run in your family?

That kind of is crude to question as that is that's more useful than anything we have from snips or anything like that.

>> Does it cross sex? So like if if a a daughter uh um has a father who's alcoholic, does it cross sex as readily as it goes from say father to son or mother to daughter?

>> Uh no. I mean there is there is still risk there for sure, but the father to son link is the is the strongest one you see in in genetic studies. Now, of

course, there's in a sense it's hard, right? Because men drink more than women

right? Because men drink more than women do. I mean, in in our culture anyway.

do. I mean, in in our culture anyway.

And and they drink to excess more than women do anyway, whether they've got an alcohol problem or not. So, if you think this is some sort of unfolding process, right, then men carrying risk would be

more likely to have that risk realized through the behavior than a woman would.

Well, there's still a fair amount of women who don't drink or or drink, you know, hardly any. food. So, it's sort of like the thing if you, you know, if you had all the genetic loading for cocaine in 1800, it didn't matter. There was no

cocaine. If you had all the genetic

cocaine. If you had all the genetic loading for alcohol and you've never drank, then it's really irrelevant.

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Women are drinking more or less now.

Women unfortunately um you know, in the late 90s, early odds, the alcohol industry figured out that uh women had more money and but

they weren't drinking the way men were.

So they uh engaged in a long-term campaign to try to increase women's drinking. So things like, you know,

drinking. So things like, you know, mommy mommy wine juice and those wine wine mommy wine chats online and all that that was really engineered by them.

Even some of the ones that look organic online were engineered by the industry and it worked. Women's drinking went up a lot. Um and the damage per drink is

a lot. Um and the damage per drink is more for women for most things than it is for men for partly due to body size but also partly probably due to some hormonal things. And so it's been you

hormonal things. And so it's been you know a exploitation as I see it you know of women and I notice a lot of young women now like undergraduates I talked

to re-evaluating that like looking at their mom's experience and saying you know I don't think I want to do that and I I'm really encouraged by that. I not

not that I want to control you know the decisions we make but I don't want them making them just because the industry slickly marketed to them um because the industry's sole interest is always going to be to generate profit and you do that

with addiction because you know something like what 10% of our country drinks about half the alcohol so you have yeah you're shocked yeah >> 10% of the country drinks alcohol alcohol right United States so if you're

running the industry you want that group to be as big as possible you do not make money off people who have a, you know, half a bottle of wine on special occasions. You make your money on the

occasions. You make your money on the people who drink drink the equivalent of multiple bottles of wine every single day. So you have a fundamentally these

day. So you have a fundamentally these industries, the more addiction there is, the the better off they do financially.

>> Wow. There's a lot there. The statistics

say that drinking is at an all-time low in the United States right now. At least

>> some statist Yeah. Yeah. statistics

something seems to have changed and and this may have something to do with this new generation.

>> You know there there's less risk behavior in lots of things on you know over the last 10 years. So uh you know less uh you know cutting class less uh less chance of uh dropping out of high

school u fewer unwanted pregnancies all that stuff. So there is that generation

that stuff. So there is that generation will probably be a drier generation than their parents were.

>> Is cannabis use higher in that group?

Everyone likes to just default to well cannabis is up so alcohol is down implying that you have to do something that people have to be using some sort of mindaltering substance.

>> Yeah. With the legalization of cannabis um we certainly have seen a lot more use and a lot stronger products but youth use really has only changed pretty slightly. So the growth has really been

slightly. So the growth has really been among adults including adults who probably stopped at some point and have now gone back in later life to uh using cannabis. We'll get back to cannabis,

cannabis. We'll get back to cannabis, but I want to um parse the alcohol stats a bit more also as it relates to uh to women.

Maybe we can just either put to rest or not this argument that some amount of alcohol, typically it's red wine is couched this way, is more beneficial for

you than not drinking at all. My read of the data, and we covered this in a long episode on alcohol a few years ago, was that zero is better than any. And that

two per week, two drinks per week, and that's getting very specific about ounces for, you know, spirits versus two per week is sort of the upper limit for

adult non-alcoholics that um don't want to incur any additional health risk. Um

the cancer risk very clear the uh disruption to sleep which probably cascades into other things inflammation etc. But is zero better than any is too

safe for non-alcoholic adults because every week it seems I see a new article that says zero is better than any. No

wait it turns out there's some benefit from two drinks per week and I'm getting frank I'm not tired of it but it's almost getting funny.

>> Yeah. the extent to which the uh it's traditional media, not to poke on them, but they just keep flip-flopping. And

then the questions that always come up are, well, did the alcohol industry sort of encourage this study? Because if

we're honest, there's a lot of advertising of alcohol in traditional media outlets.

>> Oh, absolutely. So, uh, statement against interest because I like red wine. I would love to believe it is

wine. I would love to believe it is healthy. It's not. Uh and the whole

healthy. It's not. Uh and the whole thing about red wine per se by the way was never made any sense like why would there be a benefit to red wine that wasn't you know in other alcoholic

beverages right and it came from a 60-minute story I think it was in the '9s was about why do French people why do why why do Mediterranean the red wine red wine cells exploded you know you know this is so great >> resveratrol was an argument

>> yes that's right you know there's such trace amounts that just like ludicrous you know in a grape skin um and so that was just spread and it was just so great for the industry it's better for you than not drinking. Um, and you know,

that's just not true. Uh, you know, it's it's um when you look at they would look at studies and say, well, look, you know, the the the non-drinking group

have higher mortality than the low drinking group and the famous called the J-shaped curve, you know, like that.

Problem is non-drinkers include people who are like in alcoholic synonymous.

That's why they don't drink. They had a, you know, a wretched experience with alcohol. And so, um, you know, they had

alcohol. And so, um, you know, they had they've had different kinds of damage to their bodies. Maybe their health is

their bodies. Maybe their health is isn't as good. They're not going to live as long, but it's not that they would be better off if they went back to drinking. They would things would would

drinking. They would things would would go to hell basically for them. And, uh,

that just got, you know, marketed and and and spread. And it and it's not true. There might be some cardiac

true. There might be some cardiac benefit, okay? But, you know, we don't

benefit, okay? But, you know, we don't we don't get to, you know, live our lives as single organs. We have a whole body. You have to weigh that if that is

body. You have to weigh that if that is true. And it is wobbly. If that's true,

true. And it is wobbly. If that's true, it's smaller than the cancer risk. So

your net is you're not going to get any mortality gain from mortality reduction from drinking alcohol. If you have two drinks a week, and by a drink I mean

like a 12 ounce beer, uh a a 1 oz shot or a uh a glass of wine, a 4 oz glass of wine, you you have slightly higher risk, but it is very very very small. And you

know, it's not the kind of thing if I, you know, if I were giving health advice to the country, that would not be on my top 10 things to be, you know, really frightened about. I think it's it's very

frightened about. I think it's it's very small. It's just not good for you.

small. It's just not good for you.

That's what science has overturned the industry message that this is will extend your life and you'll be more healthy if you drink than if you don't.

There's there's no way we can establish that as being true. You said it very clearly, but I'm going to um just repeat it because I think it's super important for people to take note of that the

cardiac benefit is less than the cancer risk. And I think that's a very

risk. And I think that's a very important way to view these stats. The

episode that we did about alcohol um had a lot of different responses. U

there's obviously a selection bias in the responses. Many people gave up

the responses. Many people gave up drinking who I later learned wanted to quit drinking. They didn't like it. the

quit drinking. They didn't like it. the

downstream effects of the disruption to sleep from alcohol and so on. Probably

part of the effect. Um it was very interesting as it relates to women because um many people including some members of my family really like their post-work glass of wine or want a drink

to just kind of mark an end to the day and and relax. Um

my observation was that many women who stopped drinking either because of that discussion about alcohol or others that they had heard did so when they learned that women have

a particular risk to cancer as it relates to alcohol meaning if the breast cancer risk and other hormone um >> ovarian cancer hormone related cancers

and so forth not always hormone related but the moment it move that the it's probably best to avoid alcohol entirely conversation moved into women's specific

health. It had a a very potent impact.

health. It had a a very potent impact.

Uh which is interesting in its own right.

>> Um and it speaks to what's perhaps required to override some of the marketing because let's be fair, it's nice to relax with friends. And if

people think relaxing with friends is easier to do over a glass of wine or two, then that's a great not just marketing scheme, it's also somewhat true for them until there's counter evidence. And so what I'm really getting

evidence. And so what I'm really getting at here is, you know, how is it that people should frame what they know to be risky versus the other benefits of

alcohol that clearly exist like helps people relax. Um it's social, they

people relax. Um it's social, they stress less >> and so on and so forth.

>> You know, as I mentioned, I'm someone who drinks wine and I know that it is, you know, on average, you know, it's not healthy. Um why do I do that? It's like

healthy. Um why do I do that? It's like

well because it creates other things particularly with exactly that situation that you know uh getting together with friends is enjoyable uh enriching good

food is enriching good food and a and a good wine tastes good uh and I value those things and there are many other decisions we make like that where we endure some risk because uh we care

about something else. you know, it's it's dangerous to, you know, for for someone my age to, you know, hike up a mountain side probably. Um, but, uh, if if the view is spectacular, I can I say, I'm going to accept that risk. You maybe

I'm more prone to twist my ankle or something, but this is just really beautiful. That that's okay. I think I

beautiful. That that's okay. I think I think what the place we got in alcohol that was bad was needing an explanation

to stop. So, how often have you ever

to stop. So, how often have you ever said to someone at a party or seen someone say at a party, "Why are you drinking?" I've never heard that, but

drinking?" I've never heard that, but I've certainly heard a million times, "Why aren't you drinking?"

>> If you don't drink at parties or you refuse an offer of alcohol, people think there's something wrong with you.

>> Yeah. And you have to have to have an explanation like, "Well, I I got a exam tomorrow morning or uh I've got a cold or or or something." It's like, you shouldn't need an explanation. Um, but

people do feel feel that social pressure. And so that's one way health

pressure. And so that's one way health information can work. Why didn't a person just quit beforehand because they may not have had an explanation that worked in their uh their circle and now

you can say well you know I I see those data on uh you know ovarian cancer and uh you know I just I decided to quit drinking. Um and you know that is you

drinking. Um and you know that is you know health is a reason people still accept I think as a uh legitimate for changing behavior. you can make that you

changing behavior. you can make that you know because you know cancer is scary and that may be why uh people quit. Um,

you know, same thing happened when, you know, first surgeon general smoking, uh, thinking about everybody smoked. You had

to to sort of fit in at work, you had to smoke. And when that came out, there

smoke. And when that came out, there were a lot of people who just quit immediately. They clearly were capable

immediately. They clearly were capable of quitting, wanted to quit, but they needed some exp to tell everybody, why are you not smoking anymore? Why can't

Why don't you carry cigarettes anymore?

I can't bum one off you anymore. It's

like that that's why.

>> Why do you think people who drink uh feel uncomfortable about people not drinking around them? When people would ask me uh if I wanted to drink and I'd say no and they'd say why. They often

say that I would say the truth which is I'll say anything that's on my mind without drinking.

>> You don't want me to drink cuz then I'll tell you everything that's on my mind.

>> Oh good.

>> It's true. I I mean like I I will tell people what I'm thinking. Uh I don't need to like loosen up. I'm pretty

relaxed in social settings. I don't have much social anxiety, but I realize some people might have trouble with social anxiety.

>> Yeah. You know, I I I spent a little time in Japan when I was a young man and there's this, you know, culture of getting going out after work like the salary man go to work and and someone getting really really drunk and

everyone's drinking and you're vulnerable with each other and you and then you know that I will I will it's like a trust exercise like that falling backwards thing except it is that we're all drunk and if someone weren't doing

it's like why why are you not undergoing any so we're all going to be vulnerable and you're not and like are you going to exploit us in some way or I'm going to say you I think I hate the boss and then you're going to repeat that at work because you know you you're you're the

one person sober enough to remember I said that. I think that is a real thing

said that. I think that is a real thing that that people have anxiety about. Or

I can imagine you say what what if uh you know a uh a man woman are on a date and the guy keeps giving drinks to the woman and doesn't drink himself like you know what is the natural thing to think are you trying to get me drunk? Are you

going to take advantage of me because you you know you're going to be with it and I'm not because I'm going to be drunk. So those kinds of fears may be in

drunk. So those kinds of fears may be in the soup. Um but I I don't think you

the soup. Um but I I don't think you know so say maybe that's you know rational at some level but I don't think that should drive our sort of routine social interaction with our friends. It

should just be a non-issue you know of what do you want? And if you I want sparkling water I just give you a glass of sparkling water and don't say why haven't you why aren't you drinking this

intoxicating beverage? You know you

intoxicating beverage? You know you shouldn't need to explain it to me.

>> The trust piece is super interesting. So

is the vulnerability piece. Um, a couple thoughts about this and they're just editorial thoughts, so forgive me, but one is for years I thought how crazy it was. I would go to these meetings with

was. I would go to these meetings with doctors and scientists who ostensibly were working on issues related to health and everyone would just get trashed at the bar >> and I wasn't into that. Um, and I wasn't

judgmental. I actually kind of liked it

judgmental. I actually kind of liked it cuz by the third day of the meeting I'm cranking and they're all just I can tell they're all just blery and they and they're also aging much faster than I am. They they they would get what the

am. They they they would get what the tenur look as we would call it or as I would call it like you see them in five years. I'm like what happened to you?

years. I'm like what happened to you?

You aged 15 years. And and I these people tended to drink a lot both at meetings and outside meetings.

>> Alcohol was paid for often by the meeting fees. Gets a little I'm not

meeting fees. Gets a little I'm not trying to, you know, point a finger here. And then a lot of the stuff that

here. And then a lot of the stuff that happened at meetings that turned out cost people jobs was always alcoholrelated.

>> Yeah. In the instance of the the man and woman on a date drinking or a group of uh people at work drinking together in Japan, it sounded like it was men getting drunk with other men. Yes.

>> In my mental picture of the the male female dynamic and drinking, >> I'm going to simplify this. If she

drinks, it makes her vulnerable. If he

drinks, it makes him more stupid and impulsive. Mhm.

impulsive. Mhm.

>> And so in the the world where she's drinking and he's not, you gave the example that perhaps, you know, he would take advantage of her if he's encouraging it. Certainly there's that

encouraging it. Certainly there's that picture in one's mind. He's also can get her home safely. If he's drinking, he can't get her home safely and he might say or do something really dumb.

>> So I feel like no matter how the math is arranged, it always ends up drinking ends up being kind of a bad idea. I

mean, not trying to be judgmental here, like I because I'm not I don't judge what people do. do as you wish, but know what you're doing is my my philosophy.

But I just don't see a world where drinking with your co-workers or drinking on a date with somebody that you don't know very well, male or female, right, for either of them. It's

just like a lack of safety all around.

Um it just seems like a bad idea.

>> As women move into more professions that may have changed that that norm of, you know, everybody goes out and gets drunk because the consequences aren't the same. and and you know I I know a lot of

same. and and you know I I know a lot of you know professional women and friends I don't want to do that you know um you know I don't want to be around the boss when he's drunk you know and so let's

let's have a Christmas lunch together at work instead of you know uh drinks afterwards so I I definitely see that I think in the dating now of course I'm haven't thankfully had to worry about

dating for 40 years I but what I I I think most people would say is just the anxiety you know is you know intense for some people and alcohol is anxolytic

right and so it's probably that that people are you know sort of feeling uh you know it's just it's you know they're too nervous you know and whether they should or they shouldn't that's just I think probably probably in the soup one

of those benefits people people uh care about and there are people it has to be said who are more socially uh engaging when they've had a drink than when they

haven't because they're kind of wound up people when they relax some other stuff comes out and they may seem uh more appealing.

>> It's interesting. We could uh dissect it a number of ways, but I think that's enough contour for people to be able to think about whether or not they have a genetic predisposition, understand that

zero is better than any. um if we hear about some uh cardiac benefit to weigh that against the cancer risk and not just take it as an independent piece of

information and then to think about vulnerabilities of um other people's actions and vulnerabilities of one's own actions and words uh if drinking and then people can make an informed decision. That's kind of how I

decision. That's kind of how I >> a good summary >> how I uh feel about it. Again, do as you wish but know what you're doing is like the the purpose here. Let's talk about cannabis a bit. Uh because eventually

I'd like to weave back to how industries impact use and abuse. Um

cannabis when I was growing up was illegal. You could go to jail for it.

illegal. You could go to jail for it.

>> Mhm.

>> People still smoke pot. It happened. Um

the idea was that it was much less potent. We can talk about that. But now

potent. We can talk about that. But now

it's a whole industry.

>> Yes. And the edible industry has contributed to this greatly because it bypasses the um the blowing of smoke um the the smell um and a number of other

things. So what are your thoughts about

things. So what are your thoughts about cannabis as something that can be used quote unquote recreationally, medically, and its potential for abuse?

and then let's talk about how those things have been amplified or reduced by the fact that it's essentially legal or decriminalized.

So what are your thoughts on cannabis?

>> Yeah, so I whenever we talk about I I make a distinction between sort of old and new cannabis. So, you know, if you go back to the 80s and 90s, uh, when, as you mentioned, it was illegal everywhere, the THC content, that's the

principal intoxicant, would be, you know, 3, four, 5%, something like that on average. And now, you know, studies

on average. And now, you know, studies of legal sales show the average product is about 20%. So, it's dramatically stronger. The other point is how people

stronger. The other point is how people use it is different, perhaps related to that high potency. uh Jonathan Caulkins uh pulled together a lot of really interesting data that got a lot of play

and it showed that about 40 I think it's 42% of people who use cannabis use it every day or almost every day that is also different so back if you go back in

the past you know the more modal user might have been once or twice a week so you put those things together some so you take somebody you know what was like an 80s pot smoke well on weekends you

know I'd smoke a joint at you know 5% but now if it's means every day I'm consuming 20% % you quickly realize like their brain exposure is dramatically higher about 65 times higher uh between

the modes of those two two uh experiences and what you know what so what is 65 times mean well it coincidentally is also the potency difference between a cocoa leaf and

cocaine that is that is 65 times two so it's a big difference and as you know you know you know dose makes the poison so so it is a just a really different

drug than what was back there and this is very hard to get across to parents because their view is like ah I smoked weed you know is is is you know who

cares if my you know 15-year-old is using it. It's like but that's kind

using it. It's like but that's kind saying you drank low alcohol beer and you're not you're you're not concerned that your 15-year-old is guzzling vodka.

That's that's kind of the difference and it's just a bigger deal than it used to be. Even when you take away the fact

be. Even when you take away the fact that you have an industry really pushing it just the drug is stronger, more addictive. Does it have any uh medical

addictive. Does it have any uh medical applications? Almost surely you know the

applications? Almost surely you know the canabonoid receptor system evolutionarily is you know one of the oldest in the the uh in history of homo sapiens. It is both in the brain but

sapiens. It is both in the brain but it's also in the body. There are clearly going to be some applications for pain.

Um you know you know there's many people would say they spontaneously get relief.

It's hard to tell always what that means because sometimes that's just relief from withdrawal, but but you know, probably some some type of medical applications for pain will come out of

this plant. We do have some out of the

this plant. We do have some out of the CBD, which is the non- intoxicating part is a medication that is used uh in seizure disorders in kids, you know. So,

there'll be some other things like that for sure. Um and you know, you know, the

for sure. Um and you know, you know, the it's easier to study this than has ever been before. um you know that um about

been before. um you know that um about 2020 Congress changed the way uh research works. So it's a lot a lot

research works. So it's a lot a lot simpler to to uh do it. So we we'll we'll figure those things out. Um but it is just a more a more dangerous drug

than it was, you know, when I was a young person.

>> I had a guest on the podcast uh who's a cannabis researcher, runs an animal lab.

Um and we invited him on because I had released a solo episode about cannabis.

We touched on some of the risk for psychosis. Yeah.

psychosis. Yeah.

>> In uh young men um and made some points about frankly concerns about cannabis because of the high THC content. Uh he

was not happy with the things I said. He

made that clear on social media. So um

by the way, this isn't the way to get invited on the podcast, but we invited him on and I I think we had a very fruitful discussion where he clarified a few things for me. And one of the things

that he claims uh is that despite the higher THC content that there's a distinct difference between smoked versus edible cannabis whereby people

who smoke cannabis even the high THC cannabis um are very good at gauging the kind of level of high so that they don't go into paranoid modes. they don't

surpass the the plane of high that would make them feel paranoid or um put them into a psychotic episode, but that people who take edibles because it's harder to gauge where you're at if you

can just swallow an edible or even nibble on an edible um often surpass the level at which they would be comfortable, meaning at which there's a psychotic episode or there's paranoia.

So he was making this kind of um soft argument for the fact that the elevated T THC levels in cannabis are not such a problem because people are essentially taking less to offset the the difference.

>> Yeah, I think there's no evidence for that at all. In fact, and and uh people are surprisingly bad, even experienced pot smokers at judging in lab studies of like how strong different cannabis is. I

don't agree with that part, but I do agree we should think about the edibles differently because of the onset is different through the gut, you know. So

when you smoke anything you know you get that that goes very efficiently you know to the brain but when you eat something you know it takes a while you know to have its effect and so

>> particularly when these products came out and a lot of people were uh new to them they would uh you know bite down on you know one piece of the whatever the

bar the cookie or whatever five minutes later I feel the same take another bite still feel the same and then just eat the whole thing and then it would all hit them like like a train. And you know

that that does happen. The other thing that is true is that a lot of these uh products are not wellmade or they're not up to like the standards of like you would have a cookie. You would you would never open up a bag of chocolate chip

cookies in the United States and find all the chocolate chips at one end and just dough and the rest. But that does happen with cannabis products in legal markets. And so if you just bite on the

markets. And so if you just bite on the wrong part, you're getting the, you know, the whole enchilada, so to speak.

um that because it's not evenly blended through and there are some people who've gotten gotten into trouble uh on that as well.

>> Interesting.

What about the psychosis risk?

>> Yeah. So, I was very skeptical of this literature for years. Not not to say that the science was bad, but just like it seemed to me there were lots of ways to explain it. Um, and I'm a lot less

skeptical now, candidly, because, you know, in the in the old studies, they would be there men who had used cannabis in teen years and then they would have higher rates of of uh psychotic

disorders in adult. These were studies based on like Swedish uh registries because everybody has to register for the uh the military, you know, um and um they would track people and it's quite

amazing data. So it is a whole national

amazing data. So it is a whole national data that's good but there's lots of reasons that could come about you know could be a common factor between those two things um you know but um the

evidence has gotten stronger as the drug has gotten stronger and again we got to got to realize people are using it um much more intensely. So if this effect is there it's much more plausible that

it would be from a much stronger drug used you know every day could generate higher rates of psychosis. It's hard to test this because it's a rare thankfully

condition, but I think there is, you know, probably something there. I am sad to say. I wish it I wish there weren't,

to say. I wish it I wish there weren't, but there probably is something there.

Um, I would not use cannabis if I had any first-degree relatives with any, you know schizophrenia schizoid personality, anything in the psych bipolar disorder. I would not personally

bipolar disorder. I would not personally uh recommend that for anybody. I think

that's probably uh probably quite risky.

>> What about the cardiac risk and other health risks? I've heard recently that

health risks? I've heard recently that there's a direct risk of cannabis even if it's not smoked or vaped uh on cardiac health.

>> I'm not sure of that of non-smoked cannabis in the heart. I mean, I haven't looked at that literature, so I don't I don't know the answer to that. Um I

realize there's some one point uh I should touch on that you also raised earlier about first drinking which is everything is different when the brain

is plastic and our brains are most highly plastic um you know when we're young and so a lot of these effects the worst things are going to be because

people start when they're in teen or you know late late single single digit.

That's where addictions overwhelmingly start. And that is where if there is a a

start. And that is where if there is a a psychotic risk, it's almost surely then during that period of brain development before people get their first psychotic

break, which tends to be around 18, 19, 20, 21. I worry about it less for

20, 21. I worry about it less for anything. You know, initiating a

anything. You know, initiating a substance when you're 50 is far less likely to end you up with an addiction or some other terrible thing than uh when you're young.

I'm sure everyone knows at least one person or or has heard of one person who's uh very productive in their life, healthy family, job, etc. Um high energy

who uses cannabis. Um in my observation, they are the rare exception. Um and

there are a lot of examples of people who use cannabis who um don't really go anywhere in life. They they don't go through the normal developmental

progression of finding a job that can sustain them, right? Of

organizing their life, their relationship life, their professional life. And clearly there are other

life. And clearly there are other aspects to life, but those are key ones, right? And um what are the data on high

right? And um what are the data on high THC or just frequency of cannabis use as it relates to life progression? Failure

to launch we call it now for typically it's guys that young men that fail to launch. Um

launch. Um >> and I want to be clear uh not for political reasons but I want to be clear when I say fail to launch. I don't mean that every kid has to go to college and, you know, be a, you know, a varsity

athlete or any of this, but just moving out of one's home eventually, getting a regular job, keeping the job, hopefully having healthy relationships of various

kinds and being self- sustaining. That's

what I'm talking about.

>> Yeah, absolutely true. I mean, for example, I did Ezra Klein show. He's

obviously a very successful guy and he mentioned that he sometimes uses cannabis edibles. I mean,

cannabis edibles. I mean, >> he has that look. No, I'm just kidding.

Sorry, Ezra. Just teasing. Yeah. I mean,

so yeah, there's and you know, you could there are very very very successful people who use cannabis for sure.

Overall though, I mean, I'll steal a phrase Caulkins. It's like, you know, we

phrase Caulkins. It's like, you know, we have performance enhancement drugs. It's

kind of a performance degrading drug.

So, it's not it's not fentanyl. you

know, your your your odds of your death being directly tra traced to it are extraordinarily low. But it does with

extraordinarily low. But it does with regular use undermine certain things that you need to succeed in the modern world like short-term memory and

concentration and being able to keep track of details. And for some people also, it it undermines their sort of motivation to do much of anything. I

mean, the couch lock is a real thing.

Um, you know, I I know families in Palo Alto, where I'm from, very achiev uh, you know, a straight A son, you know, doing everything, starring on sports, whatever, who, you know, 6

months later was just smoking cannabis all day and had no interest in the team he used to star on and the math he used to be great on. And like, that's that's

pretty frightening. And all those things

pretty frightening. And all those things are not conducive to succeeding in in again in a modern world. If maybe back in an agrarian society, it didn't matter

because we you know everything was on muscle power, right? Um but you know to succeed in in this society, you have to be able to do those things. And and you you are in competition, you know, if you

want a job, you know, computer coding, you're you're in competition not just with the smartest kids in your neighborhood. you're in competition with

neighborhood. you're in competition with the smartest kids who are in Mumbai, you know, and and in Tokyo. And if you can't focus or you're just slower and you

can't remember things, um or you have trouble like making sure you uh keep track of time, um that is going to put you at a disadvantage. uh and and uh you

can end up that stereotype of you know living in mom's basement that unfortunately is true of a a chunk of people who are heavy users of cannabis.

>> Yeah. I worry a lot about examples of so and so is very high achieving and they use cannabis. Um I had a friend growing

use cannabis. Um I had a friend growing up who desperately wanted to be a professional golf player and he would cite all these professional golf players who were heavy drinkers. He ended up just being good at the heavy drinking

part. Yeah.

part. Yeah.

>> Um sadly, um I think he turned his life around at some point. But these examples of people who can use very addictive substances and are open about that and

are very high achieving. I think there's a there's a real detriment to that messaging. Now, of course, you don't

messaging. Now, of course, you don't want people to cloak their reality, but it's it's complicated.

>> Yeah. And and it also has policy risk, too. I mean, you know, when you make up

too. I mean, you know, when you make up the rules, uh, you know, you know, your laws and regulations to to think, well, you know, I'm I'm accomplished. I I'm

able to use this, so that must mean it's pretty safe. It's like, that just

pretty safe. It's like, that just doesn't follow logically. The fact that you occasionally, you know, take a snort of cocaine or whatever, and and you're still a state senator. Uh, that doesn't

prove that that would be safe for everyone. And, you know, we we know

everyone. And, you know, we we know people have different levels of risk.

They have different social capital. they

have different incentives in their lives and um you you can't overgeneralize from a sort of a lucky life or a costed life.

Sometimes you can do more of that than you can when you know there's not many uh you know uh nets sort of between the person and the you know and the ground.

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family. it wasn't Robert Patrick

family. it wasn't Robert Patrick Kennedy, excuse me, who's been very open about his own recovery and so many gems in that talk. We'll put a link to it and we'll touch on some of those things again, but just as such an important conversation.

>> Um, and you know, it came up in that discussion that many industries are industries of addiction, alcohol,

cannabis, gambling. Nowadays, I was

cannabis, gambling. Nowadays, I was thinking about what you guys were talking about. And nowadays, it's very

talking about. And nowadays, it's very difficult to look at any industry and not see it that way at some level.

>> They talk about it themselves that way, you know, they they'll if you get together with app developers, they'll say, "How do we make this more addictive?" You know, so it's it's and

addictive?" You know, so it's it's and it and it is good for business. There is

no customer like an addicted customer.

So, of course, that's going to be appealing if you're trying to sell something. I guess the question is

something. I guess the question is healthy addictions or adaptive addictions or things that fall outside the progressive narrowing of the things that bring you pleasure because a kid getting quote unquote addicted to a learning app

>> uh that carries over into a number of things one hopes um in school and uh or even social media. I've learned a lot from YouTube videos. Heck, I even

watched that YouTube video of you and Patrick uh you know uh uh on YouTube. So

there's this double-edged blade piece.

Uh, but when it comes to alcohol and cannabis, what you told us earlier, like getting women to drink more by making it seem like an important part of being a woman in the United States to drink.

>> Yeah.

>> That sounds diabolical.

>> Yeah.

>> Convincing people that cannabis is going to make them more creative and it's not as bad as alcohol, that to me is very diabolical. And I and I worry about

diabolical. And I and I worry about this. Well, it's not as bad as alcohol

this. Well, it's not as bad as alcohol argument because I mean shooting yourself in the head is way worse than stabbing yourself in the head.

>> Well, alcohol also kills, you know, about 150,000 Americans a year. So, if

that's our bar, we should have hand grenades in the drugstore there. You

know, that killed tens of thousands but not 150,000. You know, we should

not 150,000. You know, we should legalize drunk driving because, you know, that only kills 10,000 people. I

mean, that's just a crazy thing to set as the well, as long as it kills less than 150,000 people a year, it sounds great to me. No, that doesn't make any sense. I mean, I I am clear like

sense. I mean, I I am clear like economically I am a capitalist. I'm glad

we have companies. I love living in Silicon Valley. I love all the things

Silicon Valley. I love all the things people create there. And um and I think that is an important part for society to work to have a private sector. Um and at

the same time, you have to regulate addictive uh goods. temptation goods

very intelligently and tightly because you can't count on the sort of rational consumer to protect themselves like you can when you're dealing with cabbage or

lettuce which nobody ever overdoses on.

But we do see people burning down their lives over all these drugs. And for that reason, you know, to pro to protect those people, but also to protect the rest of us from the consequences of

that, that's why, you know, you need things like advertising restrictions.

That's why taxes to which people are people, even heavy users respond to price. Um, you know, that's a really

price. Um, you know, that's a really important tool to regulate them. I would

do I would do much more with cannabis particularly, you know, just some of the promotion is so naked and a lot of it is in places where kids are exposed particularly and this has just been a long-term fight. You know, we had it

long-term fight. You know, we had it with the tobacco industry. Almost any

nasty thing you could say about the tobacco industry turned out to be true.

I mean, you know, they did work to make it more addictive. They worked to defeat uh any type of health regulation. They

were marketing to kids, all that stuff.

So, that those are the economic incentives. And so you you you should

incentives. And so you you you should not be naive um if you work in this space about what the financial incentives are if you're making an addictive product. More addiction is

addictive product. More addiction is good for your bottom line. So us on the on the other side have to say we're going to put in laws and regulations so that that is harder to achieve. Never

going to get rid of all of it. But you

can make it a lot lot harder. Gambling

is a great example. I mean, I'm just amazed that we have just given up on any restrictions on gambling now. I mean,

when I was a kid, Pete Rose was not allowed to go into the Hall of Fame because he had once placed a better on his own team. He wasn't even doing anything corrupt, but he was he bet on his own team would win. He was kept out of the Hall of Fame. Now, you can't

watch a sporting event without having gambling ads shoved in your face. Like,

that's an example of something that should just not be the case. That is

terrible for anyone who's trying to quit gambling. It's terrible. A lot of young

gambling. It's terrible. A lot of young men particularly, but not just young men, are just ruining themselves economically over over sports gambling.

And we we did we don't need this. We we

can we can do without it. The gambling

thing is a real concern. We had a guest on this podcast who's a self-admitted uh gambling addict. And um

gambling addict. And um a friend of mine who treats gambling addicts said uh it's among the worst of the addictions because they live with the reality. It's true that the next

the reality. It's true that the next time really could change at all.

>> And he said eventually they get addicted to the shame of losing.

>> They just get so winning becomes a thing of the distant past. I mean, this sounds crazy to to the rest of us, but it's fascinating.

>> Um, it's fascinating and it um and disturbing. Um, and gambling addicts

disturbing. Um, and gambling addicts will say that every addiction is gambling.

>> Yeah, that's good. That's good. There's

a tremendous book uh Addiction by Design and I'm afraid I'm going to mispronounce the the name of the person who wrote I think it's Schull but I'm not sure but I know the title Addiction by Design about

gambling and she profiles people who play video poker uh many of whom work in the casino. They basically get paid and

the casino. They basically get paid and then they go pay the casino back by giving it away. But some of them will take a toothpick and bend it and force the bet button down and they won't even touch it. They'll just sit there and

touch it. They'll just sit there and watch in kind of a dissociative state as as it just runs and runs and runs until their money is gone. You know, that's like, you know, it's like zombification,

you know, of this stuff. And that tech has been perfected to be addicted. If

you I do I do go to Las Vegas like once every couple years. I just find I not for gamma, but I just enjoy the sort of pageantry and the food and all that. Um

it's very hard to see dealers at tables anymore because dealers don't give the perfect timing of reinforcement that machines can do and you know they don't you know you have to wait you know for your reward and all that kind of thing

and you wait till you find out and there's a social component. Well that

all slows down the process whereas a machine can give you exact timing between your press the button and then you get your reward or or you know your your win or your loss. Uh and you and it

can just go infinitely 24 hours a day unlike a dealer never gets tired. And so

all the casinos like chopped up dealers and now you're just playing with a machine.

>> Incredible. Um I don't want to spill off into too many anecdotes on my side. Um

but I will share uh something that was shared by a previous guest on the podcast you may find interesting. Um

Michael Easter is uh is at a university out in Las Vegas and he got access to one of these. Um he wrote the comfort crisis about getting outdoors, getting away from things and >> basically carrying weight on your back

and walking as a therapy of sorts. Um an

important one to do regularly. Um but he got access to one of these uh research casinos.

>> And it turns out that >> slot machines used to be a small fraction of what the of the income of casinos. Now it's 80% or more. Yeah. And

casinos. Now it's 80% or more. Yeah. And

he said that that came about because um a father who worked for the casino industry was at home watching his kids play video games. And he realized that the kids weren't playing to win. They

were playing for the novelty of what was on the next screen. And the kids didn't realize this, but it became clear to him. So now, and I think this will help

him. So now, and I think this will help people. This is why I'm taking the time

people. This is why I'm taking the time to share this once again. Uh

now, if you play a slot machine, you think you're trying to win. and hear

that ching ching ching ching ching ching and the bells go off and you and you won. You think that's the dopamine

won. You think that's the dopamine reward. But they figured out that unlike

reward. But they figured out that unlike the old rotor machines where you have some cherries and bells and stuff in the electronic landscape, you could have an

infinite amount of novelty through novel combinations. So now they figured out

combinations. So now they figured out that people will play to win 50 cents on the dollar. So they lost 50 cents,

the dollar. So they lost 50 cents, right? and they know that rationally or

right? and they know that rationally or they could know that rationally, but they'll continue to play until it's all gone as long as you give them novelty. So,

people aren't even really playing for the money anymore. They think they are.

They're actually just being stimulated with enough novel combinations that their bank account gets drained, the house takes it all.

>> Yeah.

>> Yeah.

>> When I heard that, I it changed my view of gambling and because I always thought it was about winning money and leaving.

It's actually more about playing and it's more about the novelty that's introduced in each quote unquote hand or spin. And the I think knowing that

spin. And the I think knowing that carries over certainly to sports and the excitement that you're feeling about the potential that you could win, but that that it's a a novel combination of

things um might prevent hopefully somebody from becoming a gambling addict or might help people realize that what they're addicted to, if not already shame, might actually just be the novelty. And that's why they're losing

novelty. And that's why they're losing all their money.

>> Yeah. There's an industry term for that.

It's LDWS, losses disguised as wins. So,

you know, you put in a dollar and you get a hundred credits and then you pull the thing and it, you know, it does its thing and then it goes like, you know, d you you've matched this way, you've won 10 and it goes off and you've matched

that way 20. Oh my god, I've won again 40. I've won 40 20 and 10 with all these

40. I've won 40 20 and 10 with all these exciting things. I just lost, you know,

exciting things. I just lost, you know, 30% of what I put in. But it feels like a win. And they realized, as you say,

a win. And they realized, as you say, people will keep playing even while objectively they're just pouring money down a sewer.

So glad I'm not addicted to gambling.

But I could see how I could be. Even

though I would like to say I couldn't be, I could see how I could be. Um

because the brain is just so prone to these kinds of things. We all have these circuits.

>> Absolutely. And uh it's interesting too, you know, casinos are one of the few places where you can still smoke uh you know, indoors and uh you get free

drinks. And so it's it's really like um

drinks. And so it's it's really like um absolute dense pack of of addictions and and a huge number of people problem gamers are problem drinkers and and also are addicted to cigarettes. Um and and

so when I when I go to Las Vegas, it's almost like a anthropology experience for me. I just look at all this like,

for me. I just look at all this like, wow. And there there was a story in

wow. And there there was a story in Scho's book which I just found amazing with a bunch of people playing playing playing playing and somebody had a heart attack at one of the machines fell over on the floor in a group of them and none

of them even reacted. They just kept playing as this person died.

>> What a metaphor for society. Well, I

just decided if I'm ever going to Las Vegas, I'm going with you. Okay.

>> Sorry to invite myself, but you seem like a safe person to go.

>> I'm pretty safe. Yes. You you may win or lose five bucks and that'll be the end of it.

>> Love it.

So, industries that drive this stuff, okay alcohol um, cannabis, it's going to be very interesting to see what happens with cannabis now and going forward. Is it

the case that in states where it's legalized or decriminalized that the state collects it taxes on it?

>> Yeah, it depend depends. Those are

different regimes and and this is a really important point to get into when you think about policy. So,

decriminalization is about the user and that's to say, look, we're not going to punish you for using pot. Okay? And that

is a pretty popular it's always it's been a popular policy for a long time and doesn't it seem to really affect use that much you know maybe a little bit

but not a lot. Legalization is making the production processing marketing and sale legal bringing in a corporation and that is fundamentally different um you

know because the corporation is going to have very smart people who are you know good at selling and they will increase you know consumption of the product. Um

it at this point, you know, I I don't know the exact state count, but it's mo most people in the United States population-wise have access at this point to a recreational uh cannabis. And

virtually every state, I believe, has something if it's not recreational, it's medical or there were these uh due to hemp, there was sort of a way mistake they made in regulation. There's a way to process hemp that you can make these

like delta 8s and delta 9. Even in

states that are prohibited, there's quite a bit of like, you know, hemp laced beverages which are quite strong.

>> Is cannabis a gateway drug? We were told that when we were in school.

>> Yeah. So, all drugs are gateway drugs.

The the lie in that was that you know cannabis had some unique role um you know that was going to lead you to use heroin use. But the truth is anything

heroin use. But the truth is anything like you know if you're a teenager and you start smoking or you start drinking or you start uh you know using cannabis or or you know stealing prescription

opioids from your parents or whatever that will increase your likelihood of progressing to other substances you know for multiple reasons you know one you might like it say okay well I guess I'm

convers let me try some others two your social networks may change so you're around other people who do this and so they're you're comfortable with them they're comfortable with you and they're also more likely to have something else

you might want to try. And then the third thing is it could be some brain sensitization you know going on uh that you know makes you know drugs more rewarding and there is some interesting work with like identical twins and

different states which seem to suggest that you could be starting some unfolding process when you expose a young young brain to it. So all those processes is how gateways work. The lie

was that it was just cannabis. And this

actually fits with the general lie I would say is that alcohol is a drug and we pretend that it isn't. So you you know you you mentioned like people getting drunk at science conferences or

health conferences. I have seen

health conferences. I have seen conferences, political events where people spend all day demonizing drug users and talking about, you know, the threat of drugs and how evil drugs are

and how we have to, you know, destroy all drugs and then they all go to the bar and get drunk as if they are not drug users. not wanting to admit that

drug users. not wanting to admit that alcohol is a drug is a very useful for the industry but it was also disuseful politically because you know you could say well the big threat to kids is cannabis when you know it's much much

more likely a kid was going to get in trouble with alcohol than with cannabis these days there's a lot of discussion about psychedelics

broad category of drugs LSDs psilocybin MDMA is an empath not a psychedelic but somehow it's been lumped into it mmethyl uh it's a methylene dioxymeth

Methamphetamine MDMA ecstasy folks it's methamphetamine with some modification. So, it's not a

modification. So, it's not a psychedelic. It's an impathogen. Um, but

psychedelic. It's an impathogen. Um, but

it gets lumped with that. Ketamine gets

lumped with it. Dissociative anesthetic.

It's not a psychedelic. So, if we're going to have a conversation about psychedelics, I want to be really clear.

Um, maybe we just put psilocybin >> and LSD on the table and then talk about the impathogens and ketamine and all the rest separately because so often these

get lumped and and it leads to a lot of confusion.

I know several people who feel they've benefited tremendously from doing clinical work meaning with a guide in

safe setting etc on highdose psilocybin maybe only two or three times total and that's it.

>> Mhm.

>> For treatment of depression sometimes for alcohol issues and other issues. I'm

not talking about micro doing they do a high dose to two two to five grams. Mhm.

>> A lot of addicts who use other things are interested in or currently using or considering using psilocybin LSD less so uh as a means to get over their

addiction. I'd like your thoughts about

addiction. I'd like your thoughts about that and your thoughts about these compounds specifically. Yeah, I mean

compounds specifically. Yeah, I mean they're exciting uh in in part because we haven't really made much progress in pharmarmacothotherapy in the last 20 years, you know, for lots of things for

depression, for for addiction, you know.

So the thought that these might work and I think there other than the GLP1s, you know, one of the, you know, probably say the second I'd say my second bet on that, I put my first one in GP1 agonist.

Um there is an awful lot of hype. Um but

real things can be hyped. um you know so the fact that there are a lot of extravagant claims being made and also again talking about industry you know there are people who are you know hoping

to make a huge sum of money on these on these medications um but there's also something there um you know you you can look at different pilot studies um you

know small trials they are encouraging um and uh I'm glad that um you know it's a lot easier now to do these types of studies you know we just had my friend Dr. Todd Coris down to Stanford you know

he's from Oregon you know Oregon is doing these things probably similar experience to what the you know your your friend had where you get you know you have a prep you have preparation you with a with a trained person you get the

medication and then you do the integration session afterwards and there are again people would say it's you know is transformative for them um there are also people who have very bad experiences on them too though it has to

has to be said and that's why we don't just say all right let's just use this as our front line you mean during the psychedelic experience end afterwards >> or afterwards like flashbacks, you know, you're driving along and then you have a flashback, you know, and you know that

that is both upsetting depending what you're doing at the time, you know, could could carry some risk to it. Um,

we don't know that well how well these exactly how these drugs work, you know, the sort of seroteneric kinds of kinds of drug. The one thing we do know good

of drug. The one thing we do know good though, keeping on the topic of addiction is thankfully um you know there's no evidence that people get addicted to psilocybin or uh to LSD if

they have abuse potential. It's

extremely extremely slight. So I' I've always worried about them far less uh as a class of of drugs than I do things like stimulants which I know and you

know and alcohol.

My read of the literature and this might have been updated since uh is that there is zero evidence that micro doing psilocybin has any benefit.

>> Yeah, I think that's just silly.

>> Um there is solid evidence that in a clinical setting as you pointed out and thank you for pointing it out. We're

talking about at least two or three talk sessions without psilocybin then a psilocybin journey that's typically two guides for safety purposes. Now that's

kind of how it's being explored. M

>> so they're um to avoid exploitation conditions because there has been some exploitation mainly in the MDMA trials but um and then followup that it's been

somewhere between 60 and 70% of people who go into that sort of thing with major depression that hasn't been resolved by other approaches um get

either significant relief or uh full remission after two full versions of what I just described at fairly high dosages. is when I think about the

dosages. is when I think about the negative impacts I certainly there's the quote unquote bad trip um phenomenon what I've observed quite a lot and uh I

hear from a lot of people in the psychedelic space is that post MDMA for trauma posts psilocybin for major depression and addiction issues there's

the not euphoria but the feeling that something significant has changed in the weeks and months afterwards and then some period of time later a significant sudden drop in mood and that frightens

them >> and that they're able to recover from, but that it's a real thing, a real trough. And this, by the way, is

trough. And this, by the way, is separate from the very well-known trough that comes 2 days after MDMA use. We

could talk about that, but um you get high and then there's a low, you know, very well explained >> as with stimulants.

>> As with stimulants, right?

>> I'm divided on this psilocybin to treat addiction thing. Um it seems very

addiction thing. Um it seems very precarious because of the lack of kind of standardization of how this would be done outside a clinical trial.

>> It's hard, >> you know. I mean, you hear about some you hear shaman practitioner guide and there's no because it's illegal. There's

no Yelp reviews for these people.

>> There's no board that's overseeing it.

>> Well, there is in Oregon. That's

actually what Todd was presenting at, which is Yeah. Um because you It is legal. Um,

legal. Um, >> it's legal, not just decriminalized.

>> Correct. Yeah.

>> Okay. Because in Oakland and California, it's decriminalized. Silicon is

it's decriminalized. Silicon is decriminalized.

>> Yeah. Oak Oakland's very different.

Yeah. No, in Oregon, you actually you you are licensed by the state to do this. I see. So, yeah. So, that that's

this. I see. So, yeah. So, that that's what we'll find out. I mean, to me, this is like pretty probably this is case where it's easy to be a scientist.

Sometimes it's annoying to be a scientist. Makes life harder. Makes it

scientist. Makes life harder. Makes it

easier. It's like I don't know if this works.

>> It's really important to figure out if this works. We have really good methods

this works. We have really good methods to do that. So let's spend the dollars to get good people to do those studies and and they this is the night of view you know national institute on drug they

are funding quite a few studies you know of this sort um and I I imagine NIA which is the alcohol institute is doing it also um I say good because to me it's

really I I think people get a little scared of these drugs and sort of like uh think um well you know you can't use them in medicine it's like well you we use lots of things in medicine that are

a lot riskier than this, right? It's

just a question of what is the effect on the patient? What is the balance?

the patient? What is the balance?

>> Electric shock treatment.

>> Oh, yeah. I mean, you know, you know, um, Oxycontton, you know, you know, there's all kinds of things, right? But

we figured that out by running really good research and that's that's what this area needs and I'm glad it's getting the investment. It's getting a fair amount of philanthropic investment, too. Another important thing is that the

too. Another important thing is that the people doing the studies are at equipoise. So um you know there's been

equipoise. So um you know there's been some bad work and it you know in this area you know over the last 50 years or so because it was people who were super enthusiastic to the point that they

weren't careful and critical uh you know about you know what the evidence said and they sort of overclaimed what they found because they believed in themselves. You maybe because they'd had

themselves. You maybe because they'd had very positive experiences themselves and just like that is not in the long run a good way to do science. You know, you really want people who design a good study and then let the chips fall where

they may and then tell us all and then we can decide, but they don't. They're

not, you know, shouldn't be a spin doctor. That's not good.

doctor. That's not good.

>> Fun little factoid. And then uh another note about psilocybin. I was curious as to why there's so few studies about LSD.

And uh a colleague of mine who works in this space, he runs clinical trials at UCSF said, "Oh, it's it's very straightforward. Most of the studies on

straightforward. Most of the studies on LSD clinical trials that is are done in Switzerland. Um because the LSD trip can

Switzerland. Um because the LSD trip can last up to 13 hours and they'll work very long hard hours. In the United States, it's hard to get the the staff to come in 2 hours before a 4 to 8 hour

psilocybin session and then make sure that the person is okay enough and taken care enough to go. So um I'm not suggesting we extend uh work hours anymore than we already have but it's kind of interesting that I mention it

because sometimes practical issues drive the science. It's just as simple as

the science. It's just as simple as that.

>> Yeah. It will drive also a health care system. So if it took that long to do

system. So if it took that long to do the odds that this would ever be scaled up in health system are pretty low.

Right. So there there are real reasons why if you can do something in less time, you do it.

>> And there is a movement now, meaning a a solid effort in laboratories to figure out whether or not they're non hallucinogenic, non- psychedelic

experience related compounds within these compounds. Meaning the psychedelic

these compounds. Meaning the psychedelic experience may not actually be critical to the anti-depressant effect.

>> Right. No. So that's one of the interesting things about ketaman like if you blocked you know our our our late great friend Nolan Williams you know was looking at like if you could block like

say with a some kind of nrexone molecule block the uh you know the the blink of lights and the the visions and all that stuff would it still have the same effect that is a great question uh you know for science to figure out now some

people say but that I like that part it's like okay but a lot of people find that actually pretty upsetting but if you know they could take ketamin and not have that kind of vivid good dissociational stuff and they were

depressed and help them. That would be a good medicine to have, right?

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helix.com/huberman to get up to 27% off. SSRIs,

selective serotonin reuptake inhibitors, and all the other anti-depressants have gotten kind of a bad rap in recent years. Uh there's the idea that all the

years. Uh there's the idea that all the school shooters were on SSRIs. Um

whether or not that can be separated from the data on how many kids are on SSRIs, you'll tell us. Um

talk therapy, SSRIs, and other prescription anti-depressants, psilocybin, and any psychedelic for the treatment of depression and on and on

all funnel into brain plasticity. If I

sit in your office and I tell you what's bothering me and you give me insights and over time I work with that, that's and I get better. It's the consequence of brain plasticity that so I think of all of these things whether or not

pharmacologic or talk therapy or combination or TMS >> or TMS transcranial magnetic stimulation. Thank you. Yeah, it's it's

stimulation. Thank you. Yeah, it's it's all about rewiring brain circuits. And

so it's not about the psychedelic experience. Where I get frustrated is

experience. Where I get frustrated is when people say, "Oh, you know, these things open plasticity." I think to myself, oh my god, somebody who studied plasticity, David Hub and Torrren Weasel, who essentially got the Nobel Prize for it, were my scientific

great-grandparents, like they would be I think Torrren's still alive, but David would be rolling over in his grave or you know, like no, like you don't want to open plasticity because it can go in any direction. You want directed

any direction. You want directed plasticity >> and so while talk therapy is slower, while um TMS might be slower, I mean,

plasticity needs to be funneled. It just

can't be let's just open plasticity. And

I think people are very intrigued by the idea of just opening plasticity as if that's going to solve the issue.

>> Plasticity, which we have naturally the most when when we're young, is absolutely a two-edged sword. So, you

know, if you try to learn, you know, French at my age, it's just really really hard, you know, to to pick up that new habit. Whereas, if you, you know, grow up speaking it or you as or you try to learn as a second language

teenager, you you're going to have much more capacity to get it and and retain it. That's true. Is also true that if

it. That's true. Is also true that if you start smoking cigarettes in my age, you probably will not get addicted. And

if you start smoking cigarettes when you're 13, you almost certainly will. Is

that true?

>> Yes. Same thing. Plasticity. Almost all

addictions start when people are young, you know, and you can I mean, could you think of it as a learned, you know, it it is it is a you know, it's maladaptive learning, but it is learning, you know, that you you know, you acquire those

things and you stay all the way through.

It's why, you know, some sometimes older people I can remember getting mad like shows they like got cancelled and people were watching them. I remember the show because my parents watched it. Dr.

Quinn, Medicine Woman. Well, why?

Because old people watched it and advertisers don't want to pay for old people. The advertisers want want young

people. The advertisers want want young people.

>> Lifetime users.

>> That's right. And to instill those habits when people are young, okay, is how you get them to do it for 50 years.

You can't really persuade many people my age to start eating Cheerios or Frosted Flakes or whatever, but you you start it when people are young. And that just underscores the point you're making of

like it plasticity isn't good or bad.

It's it's this capacity the brain has and it can be used in in very different ways.

>> Maybe it explains why for despite some minimal effort, I can't get addicted to TikTok. It just it's it's aversive to

TikTok. It just it's it's aversive to me, thank goodness.

>> But maybe if you'd started when you were 13, it didn't exist then. But you know if it did you might have you might have found it far more far more engaging uh and and picked up that habit.

>> Chances are I mean based on what I observe uh and knowing myself. You

mentioned ketamine. Ketamine is an interesting one. A not a psychedelic

interesting one. A not a psychedelic dissociative anesthetic has some proven benefit for depression although maybe transient >> but high abuse potential. And here in

Los Angeles, not six months goes by without hearing about some famous person dying of ketamine, which means that a lot more non-famous people are dying of ketamine, and we're not hearing about it.

>> That's a good point. Yeah. And I I don't know if you can if you can post articles, but we did a review Todd Todd Corside and some other colleagues of the potential therapeutic effect of this whole drugs. And and the thing about

whole drugs. And and the thing about ketamine that struck me, yes, it is FDA approved for treatment resistant depression. So, it is approved. There's

depression. So, it is approved. There's

a lot of negative trials for depression.

I mean it didn't like vault over the you know efficacy thing. It cleared it.

There are some positive trials and I I can say I know a couple people who I judgment I trust said it was very very valuable to them in a deep depression but um I didn't view it as quite the knockout I thought it was going to be

before I read all these studies. And

then you you do have the other problem.

It is addictive. It also and so we have a lot of people getting addicted and then also the bladder you know damage you get from it. You know, you get young people with, you know, sort of, you know, 60 year old bladders from ketamine

and like that is, you know, most urologists have seen this now. It's like

why why is someone at 25 coming in with this? It's like because their bladder

this? It's like because their bladder has been damaged by ketamine. So those

are significant, you know, side effects.

So not would not be the thing I would jump to if I if I had treat resist depression, which has got to be said is a terribly, you know, challenging, you know, condition to deal with. I'd be far

more likely to actually do the same protocol that Nolian Williams developed with RTMS because the the effects of that for treatment resist are so much

clearer in my view and the downsides are far as I can see virtually nil. Thanks

for bringing it up again. TMS

transcranial magnetic stimulation is a non-invasive brain stimulation that can either activate or decrease neural activity in specific brain areas. Right.

>> Um very good data on this. um how soon will that be available to folks in all parts of the country in the world >> in our country? I mean RTMS for

depression is approved, you know, and so you can get it, you know, at at clinics that have this technology. These are big expensive machines, so I'm sure there's lots of places where they're not local.

Um but um you know, yeah, it's it's uh it's covered. I think Medicare actually

it's covered. I think Medicare actually covers it. Um whether they cover the

covers it. Um whether they cover the specific protocol that Nolan did, I'm honestly not sure. you know, because there was a lower intensity one and

Nolan's, you know, genius was to to compress this treatment. So, people

would come in, you know, five five days in a row and have 10 minutes on, 50 minutes off, I believe that's the the thing uh uh the the rate all day long, 5

days, and uh at at a with a theta burst setting for the RTMS. And you know, I've seen some people's lives just absolutely changed by that. And you can you can see his tri I mean, it's a trial. It's a

good trial. Unlike with psychedelics, you really can fool people that they're getting RTMS. You know, it's always tough to interpret psychedelic vision because everybody knows when they've gotten the psychedelic drug.

>> The people in the control experiment know they're in the control experiment.

>> That's correct. But not true in RTMS. You you can put these coils on on the head. I've actually tried it and it

head. I've actually tried it and it feels like something's happening and it's just a sham. And when you ask people again, guess which condition uh they're in, they can't guess. So um

these are this is really some good science and that that's where I would go next if I were I would look at the saint protocol is the name of it maybe we can I don't know if we can put >> yeah we have links we'll put links to any papers any any outlets you know I

hear from a lot of people with >> um depression issues people have become very wary of SSRIs uh because of the side effect profiles probably also because of what they've heard

>> um I remind people that um SSRIs have been very very helpful to the community of people who suffer from true OCD. Not

like, oh, they're so OCD. People who

have debilitating levels of obsess of obsessions, excuse me, and compulsions.

So, I don't like to demonize any compound.

>> No, we shouldn't do that. There's lots

of people who benefit from SSRI. There's

no question.

>> But maybe uh TMS would be something to where people would want to explore. But,

um, as long as we're on SSRIs, um, do SSRIs make people shoot other people or themselves?

>> No. No. I don't believe that the mass shooting thing. Um, I mean it it doesn't

shooting thing. Um, I mean it it doesn't fit the data where mass shootings are. I

mean, there was just a mass shooting in Australia. Think that is so rare that

Australia. Think that is so rare that you see these in developed countries other than the United States. That was

their first mass shooting in 30 years.

There's plenty of people take SSRIs in Australia. Why weren't there mass

Australia. Why weren't there mass shootings? Europe didn't let many people

shootings? Europe didn't let many people take SSRIs. They don't have the level of

take SSRIs. They don't have the level of mass shootings. So, that I don't think

mass shootings. So, that I don't think that is the explanatory variable. I

mean, I think the explanatory variable is that it's extremely easy to get highowered weaponry in our country and it's harder pretty much in the rest of the developed world.

>> Not pushing back for sake of pushing back, but I I've seen data, I don't know how solid the data are, uh that something like 70 plus% of the

prescription drugs for depression are consumed by the United States. So that

the the relative percentages of a population maybe that's a better way to frame it taking SSRIs is much much higher in the United States than it is say in um northern Europe or in

Australia. So yes they take SSRIs but at

Australia. So yes they take SSRIs but at a much lower frequency.

>> Yeah. But you would you would not go 30 if if there were significant risks there you wouldn't go 30 years without a mass shooting in a country Australia what does it have 25 30 million people in it.

I mean, you know, e even at a lower rate, there would be the the disparity is so huge in where mass shootings occur that that's just not going to be the, you know, the likely explanatory variable.

>> What about suicides?

>> There is some worry about adolescence on SSRIs. This has been a really

SSRIs. This has been a really hard-fought, you know, debated issue for years and and it's tough because depression of course raises suicide risk, right? So you by definition if

risk, right? So you by definition if someone's getting an SSRI they already have some some risk present. I think

there's some legitimate worry with teenagers I would say it's nonzero but to be honest it's not completely in my wheelhouse. So I'm just going to leave

wheelhouse. So I'm just going to leave it at that. Uh there are people who've worked on this uh um much more uh deeply than I am. Still though I would say there are many teenagers on these medications who benefit from them also.

There's no doubt about that.

>> Yeah. And folks who are interested in this, I'm I'm working on a on an episode with a guest about some of these long-term effects of SSRIs that some people seem to experience. There there

is a cohort of people out there. Um this

is one of the great things about the internet who have rallied together and saying, "Hey, you know, we have the same constellation of symptoms. Uh we don't have any bias against the medical industry, but we were prescribed SS

SSRIs in uh in our teen years and early 20s." And there's a constellation of of

20s." And there's a constellation of of um mainly sexual side effects and and mood related side effects that don't seem to resolve even after coming off.

We also see this with finasteride which was used to treat baldness. And our

colleague uh Mike Eisenberg um >> came on here and and said look the data aren't really there but I hear from a lot of young guys who were given these you know anti-hair loss drugs and they come off the drugs and they're still

experiencing debilitating sexual side effects. And so it is true that the

effects. And so it is true that the medical profession sometimes takes 10 20 years to catch up to what many people are experiencing. So I'm I'm not trying

are experiencing. So I'm I'm not trying to make a a an anti-SSRI statement here, but I think there there is >> there are people walking around out there that are convinced one way or the

other that SSRI mess them up pretty bad and they have loud voices. And so I think that's where the concern comes from.

>> Yeah. I I I honestly don't know the you know uh what what the evidence is in that particular case. I will say just something very general about medications how we approve them. They're approved on

short-term trials. I mean, if you look

short-term trials. I mean, if you look at like the typical trial for opioids and pain, you know, it's like 9 weeks or 12 weeks.

>> And there's lots of medications, you know, and opioids are a good example that that doesn't necessarily mean that taking them for a year gives you the same effects because you, you know, for example, you become tolerant to them or you might become addicted to them and

all that. And that is a general just

all that. And that is a general just challenge of how we regulate these medications. There are post marketing

medications. There are post marketing studies, you know, that that are done, but um particularly if something is a uh

complicated and rare uh from a widely used medication, it it's it's hard to figure that out. I mean, doctors will make reports that get, you know, aggregated up, but um that's hard that's

hard to figure out. Before moving on from the discussion about psychedelics, our late and indeed great colleague Nolan Williams. Sadly, he passed um a few months ago. Um we may talk about

that later, maybe not. Either way, I'll put a link to his uh information because he's a critical figure in this general space around the treatment of of

depression. Um because of his work on

depression. Um because of his work on TMS, the Saint protocol as it's referred to, uh as well as IEN, which is a very unusual psychedelic. Uh but he was

unusual psychedelic. Uh but he was running trials on veterans mainly taking Ibagane out of country, illegal in the United States, so he had to do it out of country. Um it's a 22-hour long

country. Um it's a 22-hour long psychedelic experience. Uh you have to

psychedelic experience. Uh you have to be heart rate monitored. Nobody does

this recreationally and nobody should do it recreationally. Sometimes it was

it recreationally. Sometimes it was followed up with DMT, sometimes no. But

from my last discussion about Nolan before um he passed, it seemed like the data were very encouraging

such that people who had veterans who had PTSD and/or addiction issues would do Iain once under this intense

supervision, sometimes followed by DMT and would experience a total remission of everything bad. Frankly, they're back to

everything bad. Frankly, they're back to life. And it was pretty striking, at

life. And it was pretty striking, at least the way it was being described. So

much so that I was anticipating that Ibgainain would be the first FDA approved psychedelic in part because it's not the kind of thing you can just do hanging around with your friends and

you wouldn't want to. It it involves a lot of uh scary experiences in there that one works through. What are your thoughts about the Ibagane work and Ibagane as a potential first through the

legal door of of psychedelics? Yeah. So,

um, Nolan and I were office neighbors and I really liked him. It was a huge loss. I think he was one of the great

loss. I think he was one of the great psychiatrists of his generation. There's

enormous respect for him as a person and as a scientist and I I I miss him every day when I walk by his office. Um, uh, I think what he did with I was really

fascinating in part because he did the important thing he imaged uh, people nor imagage them before and afterwards and he was able to see a lot of these changes. And why does that matter?

changes. And why does that matter?

because you know um people you know there there's certain experiences people might have described very enthusiastically and think they're really different but they aren't in fact different but he actually documents that

is different so you know I think that's was really groundbreaking and it's sad he's not going to get to continue that work the thing say is this is an open label trial with no control group so

that's that's what we have so far so that now the thing is to do a proper trial you know and and see, you know, there is a lot also of sort of ceremony

around this. You know, it's sort of like

around this. You know, it's sort of like as a colleague might describe as it's like the final mission for the soldiers.

They go down, you know, to Mexico, they do this, there's a lot of camaraderie, there's a lot of other good stuff packed around it. And so like is that part of

around it. And so like is that part of the therapeutic experience or is it entirely, you know, a chemical experience? That's a thing you would

experience? That's a thing you would find out in a a trial. You know, you would have sort of, you know, you do do all that other stuff, but you wouldn't have the ibeine at the end. And you

know, absolutely worth worth uh studying and uh you know, uh it newer hands will have to pick this up, but I really hope people will.

>> Yeah, I I'm very curious as to where that work is going to go now that because it really was Nolan spearheading that work, but there are people who are working hard to keep it, you know, going

forward.

Stimulants, um I'm a heavy caffeine user.

>> Okay, >> my caffeine tolerance is insanely high.

I mean, people have teased me online.

There's no way that's true. 800

milligrams a day of caffeine. Child's

play. Meaning, when I was a kid, I've got a photograph of me drinking yerba mate. My father's Argentine out the

mate. My father's Argentine out the gourd, which is fairly um uh stimulatory, although nice even flat ride. You know, you can tell I like

ride. You know, you can tell I like stimulants by the way. I talk about them when I was three or four years old.

>> 800 milligrams of caffeine, no big deal.

you know, a gram of caffeine a day.

That's kind of like where I'm nearing my my limit. I can drink caffeine all day

my limit. I can drink caffeine all day long. I stop around 2 p.m. so I can

long. I stop around 2 p.m. so I can sleep well. Not a problem.

sleep well. Not a problem.

I think 90% of the world uses caffeine.

Adult world uses caffeine.

Is caffeine I'm asking this for my own reasons. Is caffeine addictive? Is it

reasons. Is caffeine addictive? Is it

dangerously addictive? It makes me more productive. Um I love life on caffeine.

productive. Um I love life on caffeine.

I can handle life without caffeine if I have a flu or cold. Otherwise, I'm not interested in finding out what life without caffeine is like.

>> I'm probably the worst person to answer this because I I love coffee. And as as I like to say, I don't have a problem with coffee. If I had to choose between

with coffee. If I had to choose between coffee and my children, I can make that decision.

>> Sure.

>> But I would really miss them.

That one I knew that was an okay joke to say cuz my sons laughed when I told it to them. But um the the um yeah it's a

to them. But um the the um yeah it's a stimulant so it's rewarding and it is potentially addictive but you know so how what would you see if someone were addicted you would someone come in and

says I'm drinking so much I'm wretching I'm having you know shooting stomach pains I can't sleep said are you going to stop and if you know I I've actually never met but perhaps there are some

people said no I can't seem to stop using okay that would be addictive but I've never met a true what I consider a coffee coffee addict uh person because it's not that intense of a stimulant and the you know the the things you know you

can GI symptoms things like that that would be the main thing or or jitteriness and sleeplessness but almost everybody who experiences those seems to quit um so or at least everyone I I've met seems to quit more generally on

stimulants I have to say this is the biggest disappointment of my career uh what the in the addiction field I started my career in the late 80s and going into um uh in the lower east side

of Detroit which was very rough uh crack cocaine is everywhere and the treatment offering to people who were addicted to crack cocaine then in the late ' 80s is

not very different from what it is today uh you know which is almost 40 years later >> no phicotherapy at all um nothing no evidence of anything that that works in

phicotherapy um a lot of uh uh psychotherapies that don't really seem to work very well um you know and you know groups and stuff like that you know which have sort of

like very most modest effects. I'm

talking about therapy groups. Um that's

not a lot of development and a lot of people have tried I mean they've tried all kinds of you know medications for for stimulants and just not been able to succeed. The only thing that seems to

succeed. The only thing that seems to work is contingency management which are these things where you uh Steve Higgins I think was the first person to do this where he showed against the idea that

people have no control in addiction which is in fact rare. They have

impaired control but not no control. He

started experimenting with people addicted to cocaine saying, "Well, you're coming into treatment. How about

tomorrow uh we'll do a ur analysis when you come in and um you know, and if it's a negative urine analysis, the first day we'll give you two bucks, and the day after we'll give you four bucks, the day after we give you eight bucks, day after

give you 16 bucks." And he found out people stopped, you know, they they they wanted those rewards. And that's that's managing a contingency. You can use that

to change stimulant uh users behavior also for other things you know like uh uh you know well if you you know if you come in there's some kind of reward or you um if you fill out a job application

there's some kind of reward that is the only thing that really looks good for stimulant use disorder and it's fine as a behavioral technology and I'm glad to say it's been expanded a lot um you can

you can do it um under you know it's covered by insurance now in most places but it's just disappointing to me that if you if you trans, you know, took Keith 2025 back to late ' 80s and like

talked to those same people I was meeting coming into treatment, they say, "Wow, what what new things happened for people like me over the next, you know, in the 40 years in Man from the Future?"

And I'd say, "I'm sorry, basically nothing." And that is really

nothing." And that is really disappointing.

>> What about all the prescription stimulants, Adderall, Viviance? I feel

very lucky that those didn't exist when I was in high school and college and graduate school. probably in part

graduate school. probably in part because I like caffeine enough that yeah, I worry that I might have liked them. I've never taken any of the things

them. I've never taken any of the things I just mentioned. Yeah,

>> back then we had a fedra and ephedrin pills and things like that that were sold over the counter and >> that that always felt too stimulatory.

Um nowadays I would say ha yes at least half of my friends with

male children those children are on amphetamines for the treatment of ADHD.

>> Uhhuh.

>> And they start them young and then they call me because I have a network not because I can treat but not a clinician but then they call me because they're worried about the um growth stunting effects.

>> Mhm. They're worried their kids aren't going to achieve maximum height. Then

they're worried that their kids aren't sleeping or eating. And then so all the classic symptoms of stimulant addiction and general sets of issues. So what are

your thoughts about you know Adderall, Viveance um and similar?

>> Those are tough calls for parents. Um

there are kids whose lives are transformed positively by by brittle you know who who cannot sit still cannot do their homework you know and and it is

transformative um they're at the same time I would say overprescribed maybe example drug that is sometimes is both underprescribed and overprescribed there's probably people could benefit or not getting them and

there's a lot of people who are getting them that you know I I think there's just less tolerance for some variations in how all our brains worked in

medicalizing everything. Um, and I

medicalizing everything. Um, and I noticed that a lot. Um, and which makes parents anxious. You know, your, you

parents anxious. You know, your, you know, your kid has his thing and all that as opposed to could be well, you know, he is kind of an active kid or he doesn't pay that much attention, but he

doesn't have an illness that needs to be medicated. That that I worry about that

medicated. That that I worry about that just very generally. I worry like a kid can't be shy anymore. they have to be on the spectrum, you know, or uh you know, uh and and and carry a diagnostic label.

And I I think there's, you know, u a lot of that going on, unfortunately. And I I I sympathize with the parents. I'm not

judging any of them because I know those those calls are really really tough to make. Um and uh and again, I know I know

make. Um and uh and again, I know I know some kids whose lives are meaningfully transformed by them. So, it's it's that's tough. That's tough. Tell me if

that's tough. That's tough. Tell me if you disagree with this, and forgive me for citing previous guests, but because I'm not an expert, uh, but I hosted a a psychiatrist on here who's expert in

ADHD, and his claim is that non-treated ADHD is a poses a much greater risk for addiction than treating ADHD with

substances that in nonADHD folks are addictive. In other words, if a kid or adult has ADHD and doesn't medicate, they're at much greater risk of abusing drugs.

um if you do medicate they're at much lower risk because it lowers the impulsivity.

>> Yeah, that could well be true. Uh it's

not my core area but the there it could well be true. I there is a very high rate of ADHD among people you know in adulthood you see are alcohol addicted which doesn't seem to be you know a

coincidence you know so um it you know that that could well be true.

>> So when you look out on the landscape of like energy drinks and nicotine has made a a big comeback. Yeah,

>> big comeback. Um,

>> interesting stimulant because it's both a stimulant, but it also relaxes you to some extent.

>> I tried it for a bit. The gums despite my uh caffeine tolerance, I very um sensitive to drugs. So, I can do like 2 milligrams of nicotine gum and it I

notic it gave me spasms in my throat when I wasn't taking it. Um, and I was told that's because the the muscerinic acetyloline stimulation. So, you start

acetyloline stimulation. So, you start your throat starts spasming then you feel like you need it. It's actually a physical sensation. than the oral health

physical sensation. than the oral health folks tell me that it's bad for gum disease and the skin folks this this always gets uh typically women but here in LA men and women um it definitely

ages skin faster because of the vaso constriction in the skin so it makes you look older even though you're not smoking at the oral nicotine but >> here I just have to pepper with what I've heard we have a Nobel Prize winning

colleague I'll just name him it's Richard Axel at Columbia who told me long ago and many times nicotine is protective against Parkinson's and Alzheimer s, which is why he chews or

did chew tons of nicarette uh per day.

Um, so what's the deal? Nicotine seems

like it has some benefits. It might make you look older. It might maybe you need to take better care of your teeth. It's

a stimulant, but highly habit forming and addictive. So, what's your view on

and addictive. So, what's your view on nicotine as an industry and as a substance?

>> Yeah, I mean, it's a poison. If you if you consumed all the nicotine in a carton cigarettes, it would kill you. I

mean, you know, that that's remarkable uh that it that is so popular because of that. It is exactly the reason you say

that. It is exactly the reason you say it's both I feel sharper and then um I uh yet I feel I feel relaxed at the same

time. Um I I I think a lot of people who

time. Um I I I think a lot of people who use it are mistaking uh the treatment of withdrawal for a drug benefit.

>> Can you elaborate on that?

>> Yeah, sure. So like if you let's say you smoke when you sleep obviously you're not smoking and the nicotine blood level goes down and you wake up feel jittery and jangly and all that and you have your first cigarette and it feels great

because you're you're it but that doesn't mean wow cigarettes are really good for you. Look you smoke and you feel really good. what you're doing is just the withdrawal that makes you agitated and angry and annoying goes

away and you attribute that well you know it's the use of the nicotine but you know it could just be you are dependent on this drug and what you actually need to do is persist through

the you know the days where you will feel cognitively sludgy and maybe a little bit keyed up and all that but then you know once you go through the withdrawal you won't need it to get to that point I think there's a lot of people like that happens with cannabis a

lot too I mean a lot of people say I can't sleep without it. It's like, yeah, well, one one sign of cannabis withdrawal is sleeplessness. So, are you sure that you've got like a sleep disorder that you're treating and not

that you basically just are trapped in a cycle of withdrawal and medicating withdrawal? Happens to opioids, too, is

withdrawal? Happens to opioids, too, is another example. People think my pain's

another example. People think my pain's coming back and it's like my injury.

It's like, well, could be, but it could also be you're dependent on opioids.

>> What's your advice to those people to ride it out? There are treatments that can make, you know, withdrawal easier from different types of drugs. But yeah,

I mean, if you can get past that point, you you could be free of using it at all. And wouldn't that be nice to do?

all. And wouldn't that be nice to do?

It's definitely worth running the experiment.

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a lot of people, including me, are interested in how to avoid getting addicted to things and how to get over addiction to different things. And I'm

very curious as to whether or not the field of addiction treatment has started to parse early, middle stage, and kind of late stage addiction or whether or

not it's all just considered addiction.

Like for instance, a number of people now are suspecting that they might be addicted to social media or their phone or texting or something uh something

electronic. they are suspecting that

electronic. they are suspecting that they might be uh too dependent on food.

>> Uh they might be addicted to X Y and Z.

And I think that represents the great success of you and your colleagues and people like Anna Limkkey and people being public advocates about what addiction is and isn't. Mhm.

>> But to me, it seems like independent of the substance or the behavior, if somebody is early in the experience of feeling like they're weighed down by something and it's hurting them in some

subtle way, very different than somebody who's like raising a hand hopefully um or thinking hopefully not about taking their own life because they're so hopelessly addicted to alcohol or drugs,

they've lost everything. So, as a clinician, what's your approach if somebody says, "Hey, I I think I might have a problem with X."

>> First off, you would say, um, "Wow, I'm so glad you told me." Um, this is something that tens of millions of people experience and many of them stay silent about it and therefore people

feel and you may feel that you are strange or this is shameful or uh, you know, or um, an odd experience when it is really an extremely common experience.

and you're saying that so the person doesn't feel embarrassed and they feel comfortable, you know, talking about it.

Um, other thing is you convey optimism.

You know, there are probably a surveys give something like 24 million Americans are in recovery. Uh, we just don't notice them because someone in recovery looks like anybody else. We notice them when they're actively addicted, but not

when they're in recovery because they they sort of returned and they just look like, oh, that's just a school teacher, that's an accountant, that's a police officer, whatever. but that there's a

officer, whatever. but that there's a lot of reason for rational hope. And uh

in the particular case you're talking about when someone's just starting to worry and it's early stage the odds that they will um recover are dramatically

higher. So you know you it's it's much

higher. So you know you it's it's much much easier to sort of pull out before you've burned your life down around you.

So you know it's real it's tough when people come in and you say all right well do you have family support when my family doesn't talk to me anymore? Okay.

Uh, do you have at least a safe place to live? No, I lost my I'm I'm, you know,

live? No, I lost my I'm I'm, you know, sleeping on a couch right now. Um, you

know, well, at work or, you know, I lost my job. You know, that's tough for the

my job. You know, that's tough for the person to rebuild everything. But if you still have those resources, there's still people who love you in your life, you still have a meaningful role where you're contributing and you also have

some accountability, that's going to help you make that behavior change, whatever it is. I would say that about any behavior change, not just one uh connected to substances. And then what do we do when we we we work with people?

Well, we we always think about motivation. Um it's hard. This may seem

motivation. Um it's hard. This may seem strange, but someone says, "I want to quit smoking." A good clinician will

quit smoking." A good clinician will say, "Why why would you want to do that?" Um you think like, "That's dumb.

that?" Um you think like, "That's dumb.

You aren't supposed to say, "Yeah, good, great, good." It's like, well, if you

great, good." It's like, well, if you don't want to do it, it doesn't matter what I think, right? You know, and also there's quite a few people if you push

on it, they actually become less likely to do it if you sort of nag them to say, "So tell me why would you want what do you want to get out of this because it's work? I mean, I'm happy to work with

work? I mean, I'm happy to work with you, but you know, what is it? What are

your what are your motives?" And that's, you know, reflecting on that like, well, here's the thing. I like all my clothes stink and I hate the way. So, you would you would you would enjoy and help them elaborate. So you would like get up and

elaborate. So you would like get up and your clothes would f smell really good and you'd feel good about go. Yeah.

Yeah. Yeah. It's like you know and I and I'm spending a lot of money. Say how

much are you spending you know you know whatever 2,000 bucks a year. So if you had 2,000 bucks because you hadn't smoked in year what would you buy for yourself? What would be it something

yourself? What would be it something you'd really enjoy? Tell me about it.

And and sort of helping them build up you know in their own mind because again this is about them not you. What do you get? because this is going to be tough

get? because this is going to be tough and maybe I want to do it today, but in three days I'm going to be in withdrawal and I'm going to feel like I want to go back and I need to think about wait a minute, you know, when I if a year without smoking I get, you know, that

$2,000 trip to Cancun I've always wanted to take. Um, so I, you know, that helps

to take. Um, so I, you know, that helps that helps motivate them. And then you talk then we do some like sort of behavioral analysis of where do you use, how much do you use, what do you use,

are there cues to use? often for many people there are, you know, um and and also to non-use. Are there places where you would never use? Well, I'd never use, you know, I never at my mom's house. Huh. Okay, that's good to know.

house. Huh. Okay, that's good to know.

Maybe you could visit your mom more often. Or, you know, uh you know, uh I

often. Or, you know, uh you know, uh I never smoke on a holy day and whatever my religion is. Oh, okay. So, that let's talk about that. How do you get through that day? What are the techniques you

that day? What are the techniques you use there that we could try on try on other days? Um and also, what are the

other days? Um and also, what are the things that get you in trouble? you

know, like, uh, I'm trying to quit drinking. Well, what if I went into your

drinking. Well, what if I went into your house and opened up the cabinet, what would it be? Well, there'd be like, you know, 20 different type. So, could that go somewhere else? Could you give that away so that it's behaviorally harder

for you to uh, you know, get this? You'd

have to go down the street and go to a liquor store, that kind of thing. Uh,

help people and stuff like that. And

then, you know, there's often practical skills in learning that, like, how do I manage a social interaction without alcohol, for example, or what do I do for fun? you maybe you don't think like

for fun? you maybe you don't think like that or or how do I hang out with my friend who loves to drink and explain to him what why I can't drink anymore. Um

those kinds of things as well. And

that's what the therapist does. The

other thing is really important is that like any other anytime you're making a behavior change, this is maybe seem like incredibly simple, almost dumb advice, but hang out with other people who are

trying to make the same change. You want

to start jogging, join a jogging group.

you know, you want to uh you want to stop drinking, I would, you know, suggest go check into an AA meeting or one of the other fellowships we have, Life Ring Recovery or or Smart Recovery.

Having other people on the same journey is good for us. It I mean, everything shows that no matter what you're doing, I'm losing weight, I'm exercising, I'm more whatever, I'm quitting smoking because it gives you two things. It

gives you support. Um but it also gives you some accountability. It's like, hey, you were going jogging and uh Tuesday, you weren't there. What's up? are you

going to be part of this group or not?

And that is uh helpful for people the the combination of the two. So all those things we encourage people to do.

>> That's wonderful to hear um some concrete questions that one would ask because I think people have heard of you know just quit. I think a lot of people

who aren't familiar with addiction as a chemical brain circuit hormonal full body full brain issue but mostly a >> brain. Sorry. It almost makes you laugh

>> brain. Sorry. It almost makes you laugh just think like like someone's going to say, "My god, why didn't I think of that before? Thanks, doctor." And stamp on a

before? Thanks, doctor." And stamp on a cigarette and walk out. Yeah,

>> it's wild, right? I mean, this addiction used to be looked at as a character defect.

>> And um I certainly addicts have character defects, but I would argue at no greater rate than non Everybody has character defects.

>> Everybody has character defects.

Exactly. Um, and part of the reason I think it was viewed as a character defect is that a addictions vary and susceptibility to

them varies. So if it's been easy for me

them varies. So if it's been easy for me to quit drinking alcohol and I wasn't aware of what addiction is, I might look at somebody who is having a hard time quitting drinking and just think, well,

just quit. I did it. You can't this kind

just quit. I did it. You can't this kind of thing. And and u and just swap

of thing. And and u and just swap whatever substance or behavior for alcohol there. Um and then I think the

alcohol there. Um and then I think the other reason is that oftentimes sadly um addicts hurt people around them in their addiction.

>> Yeah.

>> This is you know they lose money that wasn't theirs. They um they harm

wasn't theirs. They um they harm themselves or others in very in psychologically or physically and and um I mean I know drug addicts that it had

to come down to their kid getting into their drugs and almost dying before uh they finally quit. And even at that time they were concerned that they might not

be able to quit even though they adore their children and wife.

>> Y >> fortunately that person is still sober some years later. But

>> it's like you can imagine I from the outside it you can come up with some pretty good character defect arguments when you know

when you observe that kind of thing.

>> But when these people get sober it's spectacular how the real person seems to emerge. um which points to the fact that

emerge. um which points to the fact that the addiction masks something about who they truly are, not the other way around.

>> I agree with that. And I think you're right that a lot of the explanations for addiction come from people who are hurt and angry, you know, with with good reason. You know, they had they had an

reason. You know, they had they had an addicted parent and that was hard for them or their their marriage is disintegrating and so they're mad and they're going to so they're going to have a certain amount of venom in how they explain this, you know, sort of

understandably. And in addiction, you

understandably. And in addiction, you know, people do do things they would not otherwise do. I mean, like you're

otherwise do. I mean, like you're saying, you know, um lying about lots of things that there's no they normally wouldn't lie about. Like, I promise I'll show up to the baseball game and watch you watch you play your game or um you know, yeah, I'm going to save up some

money and we're going to get that uh you know, the plumbing fixed, but I'm actually spending on on drugs. Those

types of things. And you know that uh hurts people that that I I've I've and I and it's very important to acknowledge that because sometimes the language about the message that sometimes

government public health people have given about addiction is a disease sounds scolding to people who have been harmed by addicted people. Like like I'm saying you you know you're we don't feel

sorry for you. We feel sorry for this person. They're ill. And you know it's

person. They're ill. And you know it's almost like how dare you be angry at at at your mother. She was ill. It wasn't

her fault. It's like it still hurts. You

know, it doesn't, you know, if if someone who has dementia, uh, you know, goes on a, um, an angry rant and says a lot of nasty things, it still hurts.

Still scary. The fact that it's a diseases doesn't change your experience, you know, as a person. And, uh, so I'm always I'm always uh trying and public messaging to acknowledge that the pain

is enormous. It's really tough to live

is enormous. It's really tough to live with an addicted person. It's hard.

It's a complicated problem uh from a public health and uh psych just psychologically. I mean we're in the

psychologically. I mean we're in the wake right now of the uh Robert Reiner and his and his wife being yeah >> killed by stabbing which is seems additionally violent and horrible by

their son. It seems he's been charged

their son. It seems he's been charged anyway. Um who was an addict and the

anyway. Um who was an addict and the photos of him that are going up uh make him look quite angry and deranged frankly. It's going to be interesting to

frankly. It's going to be interesting to see how that shapes people's views of addicts and addiction and the fact that he was um supported by his parents for a long time in that addiction. They even

made a movie together which wasn't a very good movie and everyone knew it. It

was sort of like it felt like a desperate attempt to rescue his son through his profession and and it just this ended as tragically as it possibly could. Mhm.

could. Mhm.

>> Um and then we have this home homeless quote unquote homeless problem which is perhaps also an addiction issue >> in part. Yes.

>> In part.

>> Thanks for mentioning that addicts are in pain but the people around them are in a lot of pain also.

>> Um be interesting if in the future addiction could be framed as as like a context as opposed to like a person. Uh

but it's hard to separate the behavior from the person.

>> That's right. If you grow up with an addicted parent as a kid, you know, you won't understand all that anyway, right?

You just know like you're you're wanting love and attention and you're not getting it. And um that's a very common

getting it. And um that's a very common experience to grow up with an addicted parent. And that can generate lifelong

parent. And that can generate lifelong uh negative feelings about to people.

And again, I say understandably um you know, even if you do eventually come to the view that yeah, you know, dad had a disease or mom had a disease, you still didn't get what you wanted at the time. And so there'll be, you know,

the time. And so there'll be, you know, grief and sadness about that.

>> Asking why would you want to quit?

>> Yeah.

>> Is very interesting question.

>> Seems strange, doesn't it?

>> Yeah. And I want to talk for a moment about the carrots and the sticks.

>> Mhm.

>> Um the sticks are kind of obvious in most cases. Well, if I wasn't smoking, I

most cases. Well, if I wasn't smoking, I wouldn't have to pay for cigarettes. I

wouldn't smell bad. I would I wouldn't cough so much. Um

the carrots are often a little more cryptic and probably harder for people to think about for the addict to think about um if they're very far into their addiction. Um recently there observed

addiction. Um recently there observed some spectacularly enormous frankly weight loss achievements of some famous people. Uh

country music singer Jelly Roll, forgive uh me that's his name. Um I didn't name him that. He that was his name. He was a

him that. He that was his name. He was a giant man. and he was like close to in

giant man. and he was like close to in excess of like 400 lb or something. Lost

over 300 lb and he's a transformed human being. The way he talks about what he's

being. The way he talks about what he's doing, he's he's running 5ks and half marathons. I mean, he's a completely

marathons. I mean, he's a completely different person. And um but for

different person. And um but for somebody who's still stuck in the very large body, they can't imagine those carrots because they've never really

lived in them. And so, how do you make a a carrot motivation, a positive motivation feel real for a patient um in a way that it can really pull them forward as opposed to just all the stuff

that they're not going to feel because you have to be pretty close to losing it all for the the sticks to really matter.

>> Yeah. Yeah. So all people to some extent, you know, discount future rewards to some, you know, like so we buy the $5 latte instead of putting it in our retirement, even though if we did that every day, we would have a million

dollars, you know, when we were 65, right? And in addiction, they do it even

right? And in addiction, they do it even more. So when in in in addiction, if you

more. So when in in in addiction, if you ask people about what, you know, what about something would you would you take, you know, uh $5 today or $20 tomorrow, they're more like to say $5

right now. Almost as if tomorrow doesn't

right now. Almost as if tomorrow doesn't exist. So this really is a problem and

exist. So this really is a problem and you can't really say to people, you know, if you if you get in recovery after like five years, you're probably going to I bet you'll meet a nice person and you you'll get married and settle down and you and then you'll go back to

school and get it's like that's all like, you know, fantasy camp kinds of stuff, right? So you have to it's okay

stuff, right? So you have to it's okay to have those long-term goals. sometimes

those are very motivating. But you want to focus on things that are immediate because that's the world they're living in. A world of immediiacy that you know

in. A world of immediiacy that you know you know for example you will have more money every day. You know you will not if you're using illegal drug you your your risk of arrest will drop to zero

immediately once you stop engaging in these transactions. Um you will feel

these transactions. Um you will feel physically better um you know very very quickly uh than than you feel right now.

And you know social reinforcement really matters too. This is one of the geniuses

matters too. This is one of the geniuses of the people who developed the 12step fellowships. The fact that you get

fellowships. The fact that you get literal status by how many days you have not you or years you have not used the substance and you get you know respect

and and we you know we care about those things for very good reasons. They've

been central to the survival of the species. I' I've always thought it was

species. I' I've always thought it was clever of the of AA to have the um one day at a time concept. Um you know, which maybe seems like hokey, like a

slogan, but you can't suddenly quit drinking for the rest of your life. It's

not here yet, right? And that's just seems inconceivable. But can you not

seems inconceivable. But can you not drink today? Not drink today and go to a

drink today? Not drink today and go to a meeting and get some reward for that.

Yeah, you can probably do that. And so

just do that every day and then you will have 30 years eventually. But you you don't have to wait for all those rewards because it's very very very few people can do that. And of the ones who really

can, they're probably not very prone to addiction. People who are think that far

addiction. People who are think that far ahead all the time uh and have extremely high self-control say they'd be less likely. And what about the addictions

likely. And what about the addictions where people either believe or it's actually true that it helps them be more functional in other areas of their life.

Less social anxiety with two or three drinks. Um yeah, you know, taking a

drinks. Um yeah, you know, taking a prescription stimulant and can get your work done. Uh maybe they are true ADHD,

work done. Uh maybe they are true ADHD, but you know, not revealing anything, you know, that isn't already known. I

mean, stimulants raise levels of alertness. Alertness is a prerequisite

alertness. Alertness is a prerequisite for focus and you're out the gate.

whether it's caffeine or or people who are taking and I think even on our dear Stanford campus I would bet that there are students who are not prescribed aderall vivance and other stimulants that take them

>> in order to get work done it's a very competitive place and they're driven and um no one wants to feel tired when you got work to do >> so this is also part of when you when you look at motivation so some people think what you do is you say drugs are

bad look at all these things it's ruining you know it does this it's hurting you this way that way this way in effect you're kind of telling the person they're an idiot, right? If you

if you actually do that. So, you get them to articulate. Well, clearly you like some things about it. What are

they? And put them on the table. Well,

you know, it's just like my friendship group has always drunk and I would just love those hunting trips. We all get, you know, shitfaced together and it's really fun. Okay. So, that'd be one

really fun. Okay. So, that'd be one thing you What else? Tell me. And you're

you're take you're not framing this as a struggle between you as the punishing force that's going to deny that this person has enjoyed something about this or get something out of it socially and

you say it's so this is why so this is what we need to decide these are the costs and these are the benefits it's your life not mine you know do you want to go for this or not and you let and

you you acknowledge the grief of those things like you know man I'm used to be so much closer to my college buddies and now I had to skip our annual trip the first time because I was afraid I would

relapse like wow that's that is a real cost. I mean that has to be grieved. Um

cost. I mean that has to be grieved. Um

you know and there there are many things like I I I know people with relationships where um one person nagged the other to quit drinking and then when the person

got sober left them because they changed a lot in ways that they didn't like and they it turned out there were certain aspects of person you know their drinking problem that worked for that other person whether it was well I had

more control over the checkbook because you were you were always drunk and I got to make my spending decisions by myself or um you know I didn't have to I find now that we're talking more I I realize I don't like a lot of things you say.

Didn't know that before. And that that that is all that's all real. I mean

those those kinds of things happen.

Drugs always work in some crude sense, you know? I mean necessarily beneficial,

you know? I mean necessarily beneficial, but they have some function, right? And

you got to figure that out because that will change if the drug use changes.

>> Yeah. The the partner example is interesting because there's this whole notion of codependents teaming up with or partnering up with addicts. This is

why things like codependence anonymous and um >> yeah I think that's a bit overstated honestly but yeah yeah yeah one of the really interesting studies was done by Ruth Kronhite who was my colleague for a

while and it was of women who were married to alcoholic men and um did you know all the things that fit the codependent thing but then the when the men got sober and they went back and

studied them a year later the women looked exactly like women of men who had never been alcoholic. So, a lot of the things that are attributed to the personality of the codependent person is

actually reaction to addiction. You

know, they're hyper responsible. They

have to be because the mortgage won't get paid. Um, you know, they're they're

get paid. Um, you know, they're they're placating. Well, they have to be because

placating. Well, they have to be because they've got this volatile person, potentially dangerous person. That's

where a lot of that comes from. And I

think I think it was a bit unfair. I

mean, obviously there people have bad tastes and partners. There's no no doubt about that. But maybe a bit unfair to um

about that. But maybe a bit unfair to um not appreciate a lot of things families do are are more reactive than something that was pre-existent and fit with an addiction.

>> That's a really important point because I think um most people think the addict codependent pairing is almost like a prerequisite. Um and it actually reminds

prerequisite. Um and it actually reminds me of this whole literature which I think is an important literature uh that became popular about you know avoidant attachment versus anxious attachment and

this idea that people always pair up along these dimensions. But the studies that have been carried out subsequent to the that those naming categories is that um put each of those people in a

different context and they behave very differently. And you know, you can, you

differently. And you know, you can, you know, so it's it's so we're more plastic in our in our psychologies in in our in our romantic pairings than perhaps we we assume.

>> And it's also true that, you know, there people who 10 years into addiction find they're not married to the person they married, you know, cuz that person has changed an awful lot. So, you know, maybe they were originally pretty

social, pretty competent, pretty honest, and then after 10 years of of heroin use or whatever, they are none of those things. And the, you know, it feels like

things. And the, you know, it feels like to to the marriage person, it's like this is this is just not the person I I I married in the first place. That's why

we don't match. Not because I picked the wrong person, but that person changed.

>> Yeah.

>> In keeping with that and the original question, which was different stages of addiction perhaps requiring different approaches.

There's this idea perhaps um trying to remove my neuroscientist lens here, but I I believe I'll just be open about this. I believe that at some point if

this. I believe that at some point if you use certain substances long enough, the brain is changed significantly enough that the opportunity for recovery is different depending on whether or not

you go to a meeting, which certainly works for, let's just say, all of the addictions early on, probably most of them in the middle, but I know a few ex heroin addicts,

>> they're different.

>> Mhm.

>> They're still different even though they're sober. I knew them before. Now

they're sober. I knew them before. Now

it's not a perfect experiment because there was time etc. But we know that certain drugs actually kill neurons.

Certain drugs certain drugs rewire the reward circuitry and the person is different. It's not to say that they

different. It's not to say that they shouldn't quit. U they should. Um but

shouldn't quit. U they should. Um but

it's harder to imagine sitting down with someone who's been using heroin or methamphetamines for a number of years and say all right let's think about how you're losing. to see what you could win

you're losing. to see what you could win in the circumstance. I mean, I I hope that's the case.

>> Mhm.

>> But it seems like they're rewired.

They're a different beast.

>> Yeah. Well, that is fundamental to the understanding of the disorder. That is a change in the brain. And there's, you know, you can call it disease and call it disorder. I often think of it as um

it disorder. I often think of it as um deeply maladaptive learning. You know,

I'm like I'm like that rat who really really believes the most important next thing for me to do is to consume this powder. and when I'm ignoring all the

powder. and when I'm ignoring all the things that I'm I'm evolved to do instead. Um so so um is definitely true.

instead. Um so so um is definitely true.

You see these changes and you can observe them in the brain and and it and it's amazing. You can even predict

it's amazing. You can even predict things that the person can't even report on. So we did some work uh myself,

on. So we did some work uh myself, Claudia Padulla, Brian Kudson, Kelly McNan up at the uh the VA in Menllo Park of uh people who were in a residential

program addicted to methamphetamine all of them off methamphetamine while they're in the residential thing and uh then uh giving them imaging them uh and

showing them cues of meth associated things like the pipe or the powder and all that and asking them how much do you like that? What do you feel towards

like that? What do you feel towards that? Well, independent of that, there's

that? Well, independent of that, there's also nucleus encumbent activation that you can see and that predicted who relapsed.

Not what they said, but what there was going on in their brain. They didn't

even necessarily know it. We should say nucleus ccumbent is a critical node within the dopamine reward circuitry of the brain that underlies the path to addiction and many other things that initially feel good.

>> Yeah.

>> Um Yeah, that's right.

>> So, so the brain was report could nucleus come. Let's just put in dopamine

nucleus come. Let's just put in dopamine activation as a proxy.

>> So levels of dopamine activation, so to speak. We're being neurosciency here,

speak. We're being neurosciency here, not technically precise. Levels of

dopamine activation predicted whether or not the person would relapse better than their own self-report of the subjective feeling of whether or not they would relapse.

>> I crave this. I like this. I want this.

And it helps explain why um you know addicted people sometimes get unfair rap in terms of well they you know they lie you about what their desires are. I

really really want to stop using. Well

you know I would assume if they're in a residential program for 28 days they they do in fact want to stop using but they don't have complete insight to what's going on on the inside of brain like like anyone else is. So that that

person those two people would both say I really really want to do this and one goes out and relapses and the other doesn't. It doesn't necessarily mean the

doesn't. It doesn't necessarily mean the the one who relapsed lied. It may just be I didn't realize how deeply my brain has been changed. And it's pretty hard for me given, you know, the neighborhood

I live in to walk around and see no one using drugs ever. Uh to see no uh illusions to drugs in TVs or movies, to see no pipes, to see no powders. Um and

and that and I'm going to relapse because I have rewired uh my my reward system. So in 12step one they talk about your addict brain or one's addict brain. That's my addict

brain. That's your that's your addict

brain. That's your that's your addict brain talking. That's not you. I think

brain talking. That's not you. I think

this study that you refer to I think pinpointed the addict brain is at least in part nucleus dopamine reward circuitry activation.

>> Q elicited. Yes.

>> Q elicited. So something that that anticipates the uh or predicts the use.

>> Yep. That's right. And and and you think particularly when you get into legal products that is a hugely important thing. I mean when you can it's very

thing. I mean when you can it's very hard to watch TV and not see an ad for beer for example >> or pharmaceuticals.

>> Or pharmaceuticals. Yes. Right. Um and

uh it's depending where you are around cigarettes. You know this is very driven

cigarettes. You know this is very driven by class but there's still a lot of neighborhoods where quite a few people smoke and it's pretty hard to get through the day without being exposed to the queue of the smell of tobacco smoke

or the smell of cannabis smoke for that matter. Um and so Q elicited, you know,

matter. Um and so Q elicited, you know, craving is going to be a driver of of relapse and you and that is clearly something that you were not born with.

That is something that you learn through a repeated exposure of your brain to a you know pretty powerful drug. So, for

folks listening uh who pick up their phone and find themselves scrolling social media knowing they have other things to do or playing video games knowing there are other things they really need to do and feel like they

quote unquote can't stop there. I think

what you're pointing to really represents the the divide between that inner voice that we think of as us telling us like why am I doing this? I

know I shouldn't be doing this but I feel like I'm compelled to do it almost in a kind of automaton kind of way. It

is extremely common experience just in life, right? You know, I know I

life, right? You know, I know I shouldn't need that ho. I've been trying to lose weight, but I'm tired today and I'm going to have it. Like just the fact that we have a contradiction between our idealized self and our own head and our behavior. That's that's probably just

behavior. That's that's probably just being a person. But when it gets to the point that I'm actually I'm going to flunk this exam, which is important to me not to flunk if I don't start studying and I'm on my third hour of

scrolling through TikTok and I know and I'm not that then you then you start to worry, right? because now you're going

worry, right? because now you're going to do damage to yourself for the purpose of consuming this brain candy, you know, which has no nutritive value at all, um,

but is clearly seductive.

I'm out of the lab these days, but if I were to go back into the lab, I'd want to team up with clinicians like you and some of our engineering, bio-engineering friends and develop something which

would be similar to what Nolan and company developed for depression, right? brain

stimulation, not just willy-nilly, but of particular brain areas and circuits to try and undo major depression.

Wouldn't it be wonderful if there was a brain stimulation device that could tweak the reward circuitry in the presence of a cue?

>> Yep. that predicted methamphetamine for the amphetamine addict or alcohol for whatever process behavioral addictions and wouldn't eliminate the ability to

experience reward but would eliminate the the essentially the bad addiction or or tamp it down. tamp

down the rewarding properties of the bad addiction and at the same time do an experiment a parallel experiment where you ramp up the reward circuitry in uh in the presence of a uh something that

cued for positive behavior because I don't think you can just tamp down reward circuitry. This is uh one of the

reward circuitry. This is uh one of the challenges I have with the um you know okay obviously abstinence is going to be critical but for somebody that has a nucleus ccumbent

and we all do uh it's going to want to latch on to something and I've seen so many addicts pivot to the next thing.

Sometimes it's a healthy thing.

>> Many ultrarunners are addicts.

>> I've met people like that too. You can't

go to a a 12step meeting, and this is somewhat cultural and uh also, but you can't go to a 12step meeting and not see people with lots and lots of tattoos. If

they have issues with um and I'm not demonizing tattoos, but uh if they have issues with drugs or alcohol, um typically smoking will pop up in its place. They need something. We need

place. They need something. We need

something. And ideally it would be, you know, school and family and connection and community and uh public service.

Great. if we could, you know, but a device that could help um tune the the specificity of reward, I don't think is outside the realm of of possible. I'm

thinking like a Stanford guy now. We we

like to engineer everything, but but why not? It's being done for OCD. It's being

not? It's being done for OCD. It's being

done for depression. It's being done for PTSD. It's being done for for so many

PTSD. It's being done for for so many things. I mean, after all, it's

things. I mean, after all, it's plasticity that we're after.

>> Yeah. I mean and you're you're right that the one of the challenges is you know addiction is it's not like it's introduce something new into the body.

It's working on the very system we use to negotiate life. It is this thing we use for you know learning you know acquisition of knowledge acquisition of skills. So it's um it's not like if if

skills. So it's um it's not like if if we just didn't have that we would be better off. We wouldn't be better off.

better off. We wouldn't be better off.

We we couldn't survive without it. The

only neurosurgery patient is at West Virginia University, you know, who had a very uncontrollable addiction and got not exactly sure the nature of the implant. If it's a stim stimulating implant, uh that's happened once. It was covered. People want to

once. It was covered. People want to read about a Lenny Bernstein, a friend of mine at Washington Post who interviewed that that patient and the team. But I think that is likely that we

team. But I think that is likely that we will see uh something like that. I

suspect we will see more RTMS, you transmic stimulation because it's not so invasive, not so expensive, and not so risky. We're we're about to start led by

risky. We're we're about to start led by Greg Salem who's a really good psychiatrist, a multi-sight study with u uh RTMS to the dorsal lateral prefrontal

cortex for um people who are cannabis use disorder addicted to cannabis. Um

there are lots of people working on these uh protocols for for alcohol, for cocaine doesn't always work. uh you know RTMS is kind almost saying like RTMS is almost like saying we put them on pills

because there's you know what brain region at what intensity that kind of stuff but um that is a way you know to intervene far more directly you know to

the brain than talk therapy for example um so um you know I think I think that is certainly possible uh in in implants made possible this particular case was

someone who was very very very had tried everything on earth and still couldn't stop and interestingly even with the the implant still needs medications, goes to lots of 12step meetings. It's it it

didn't just made it make it disappear.

Cancer though, I mean, we haven't talked about GLP1 agonist if we want to get in that. That is maybe something that would

that. That is maybe something that would have the lasting effect on changing what one wanted.

>> I definitely want to talk about GLP1s. I

think be just before we pivot there.

>> Okay. Um,

when I think about the quote unquote homeless problem, yes, >> living in California, you can't but see this.

>> Um, I think of it as at least, you tell me where my numbers are off, 50% an addiction problem, either first or also >> um, >> in this economy. Yeah.

>> Yeah. I mean, those folks aren't going to go to 12step meetings.

>> Yeah.

>> It maybe maybe I would love for them to.

They live outside my door and I talk to some of them and um they're not going to 12step meetings. No way.

12step meetings. No way.

>> And many of them are their brain circuitry is altered. Maybe it was altered before. This is not all homeless

altered before. This is not all homeless people. In fact, I don't even know if

people. In fact, I don't even know if homeless is the right word. And I'm not going to the unhoused thing. Like

they're homeless, okay? They they don't have homes, you know? Um I don't think we need to split hairs with the naming.

Many of them have serious substance abuse issues.

>> Yeah.

>> And or mental health issues that may have stemmed from that.

>> Yeah.

>> I'm not asking you to solve the whole problem here in, you know, 5 minutes or less, but like how do we wrap our ourselves around the the legislature? I

know you've been involved in things related to this.

>> I mean, how do you get somebody on the street to understand what's going on and rescue themselves?

>> Yeah. So first off, yeah, it is a very high rate of substance use and mental illness, higher now than in other periods because unemployment is low. Um,

you know, if you when the economy is really terrible, there are a lot more people who don't have anywhere to live who are, you know, just need a job basically. You know, they're not they

basically. You know, they're not they didn't fall out of a you housing or a family. They, you know, there just they

family. They, you know, there just they need work. Um, but since, you know,

need work. Um, but since, you know, unemployment is historically quite low now. So who's left are the people who

now. So who's left are the people who cannot even when we're near, you know, full employment cannot find a shelter.

And those tend to be people who have problems like mental illness, like addiction. You can do some things and

addiction. You can do some things and we've good evidence you can do some things by combining housing, you know, nice housing that people would want with

uh recovery culture. So uh you know there's a model called Oxford House which is run by the people who live there and uh they all contribute a bit to the rent and they have a culture which is basically you can't you can't

fight you can't be violent and you can't use substances or bring them in but otherwise that's it and they they have sort of recovery communities like 10,000 of those things. Those kind of things

have really good evidence of of benefit.

So some people will for that leave you know the streets and live there and make and make that trade. You can't use your drugs anymore. you can't drink anymore,

drugs anymore. you can't drink anymore, but you can at least have a nice clean place with nice people who like you and will support you. Um, that can help people. Some people in my opinion uh

people. Some people in my opinion uh have to uh it would be a courtmandated uh thing. And there's two mechanisms for

uh thing. And there's two mechanisms for that. If someone is so impaired that

that. If someone is so impaired that they are imminent grave imminently gravely disabled, an imminent threat to themselves or others, you can through the civil commitment process make them

go to treatment. Um if someone has committed a crime and many people do like you know grab someone's iPhone, knock them over and run away and you get caught that that is a different type of leverage we can do through things like

drug court where you say look you know you you shove that person you assaulted them you stole their phone we could send you to jail for this but we don't want to send you to jail instead you know if you will comply with this treatment

regimen you will not have to serve the penalty for that and we'll we'll expune your record at the end those kinds of things are going to be necessary for some people now there are many people uncomfort with that? Like, are you going

to use pressure to put someone into treatment? Isn't that really unethical?

treatment? Isn't that really unethical?

Um, well, if someone with Alzheimer's disease wanders away from a nursing home, uh, we go find them and we bring them back whether they want to or not because we assume that the the disease

is affecting their judgment. So, if they think they can survive out there, they're wrong. And so, we take them back

they're wrong. And so, we take them back whether they want to or not. Well, the

same thing is true, absolutely true of addiction. It dramatically changes our

addiction. It dramatically changes our judgment, impairs our judgment, and without pressure, many people will not stop using. There's a study I like to

stop using. There's a study I like to quote by Doug Pollson and colleagues of people seeking help for alcohol treatment. And why this is a good one is

treatment. And why this is a good one is because alcohol is legal, right? So it's

not the war on alcohol made them go.

Well, alcohol is legal. But he asked all of them, "Has anyone leaned on you basically to quit drinking in the past year?" And 91% of them said yes. The

year?" And 91% of them said yes. The

wife said, "I'm moving out with the kids. If this continues." The boss said,

kids. If this continues." The boss said, "You show up drunk one more time, you're fired." My uh uh you the my lawyer said,

fired." My uh uh you the my lawyer said, "This is your third drunk driving arrest. You better get into treatment

arrest. You better get into treatment because so the judge might take some some mercy on you." They're pressed in in a way you don't have to press people to seek care for say chronic pain. You

like chronic pain sucks. Everyone was

happy to leave chronic pain, but people are ambivalent about giving up substances because again, it's rewarding. That's why people do it. And

rewarding. That's why people do it. And

so that press is necessary. And so we're going to have to do that with the sort of criminally involved homeless addicted population. We're going to have to get

population. We're going to have to get comfortable with with protections for sure, protections for civil rights, need to give them quality care, but to push

um them into treatment where they can regain their reason and then make better decisions for themselves. I know you've been involved in legislature and it's always nice when I guess I can say you

did that under a Republican administration and a Democrat a Democratic administration. So, uh we

Democratic administration. So, uh we don't have to get into partisan politics here. Uh two administrations uh opposite

here. Uh two administrations uh opposite sides of the aisle. Your goal there was to get better legislature as it relates to addiction and treatment of addiction.

>> Correct. Y

>> So, where are we at? What do we need >> since like 2008 up to the present moment? has been the best addiction

moment? has been the best addiction treatment policy we've had as a country.

And that was because 2008 is when parody legislation came in. This means like Blue Cross, Etna and all those when they cover stuff, they have to cover mental health and addiction too at at at a

comparable level. And those laws have

comparable level. And those laws have expanded to cover more and more people on the private side. Then on the public side, the expansion particularly of Medicaid has become the the backbone of

a substance use treatment system. like

in places where I'm from, West Virginia have known it's the biggest spender, you know, of the addiction treatment system.

That is good. That has made treatment um better quality, easier to access, and because Medicaid is a mainstream health care player, it helps integrate addiction care better into the rest of the healthare system.

>> So, excuse me for interrupting, but practically speaking, so somebody's got a son or a daughter who's got an opioid issue or an alcohol issue, and they want help. Um, if they have insurance, they

help. Um, if they have insurance, they can go to a treatment center and it will mostly or completely be covered by insurance.

>> It depends on the plan. I want to promise anyone in particular. But here's

what used to be legal. It used to be a plan could say your co-ayment for an outpatient visit is five bucks unless it's mental health or substance use. In

that case, it's 25 bucks. Or you're

allowed to have up to, you know, six months of hospitalization a year. Unless

it's mental health and substance use, and you're allowed to have 14 days.

Those kinds of things which made very skimpy benefits are now illegal in almost all plans.

>> Interesting.

>> So the odds as a mom or dad when you open up the plan today that your whatever you got through your work or or wherever >> will give your kid something that they

need is just way way higher than it's ever been before. And that was due to advocacy and in changing the law and changing the regulations because obviously covering care costs money.

Insurers don't like to you know cover care. they you know they have to but

care. they you know they have to but they also don't want to and so you know keeping the pressure on they have to follow the law so in that sense we're in a better place on the private side the

challenge on the public side will be the uh contraction of Medicaid so you know the the budget bill that was passed this last year takes about a trillion dollars roughly out of Medicaid over the coming

years and you know a number of people on Medicaid have substance use problems so how they will get substance use care and and other care that they need is not

entirely clear. So, I'm quite uh I'm

entirely clear. So, I'm quite uh I'm worried about the impact of that, especially on low-income Americans who are dealing with addiction.

What are the options for people without insurance andor who don't want to go to a treatment facility? Um I'll just be direct about this. What's your opinion?

What are the data on 12step programs?

because 12step programs um have this phenomenal aspect to them which is they're happening every day and night online and in person. It is anonymous um every city

in person. It is anonymous um every city all over the world. It if you go to a meeting, you don't like it, you leave, you find a different meeting. Um

you don't have to pay for it. You can

donate to support. I mean, there's just so many things about 12step that make it arguably the most accessible addiction treatment program ever. And if

anything, it's growing right now.

>> Uh, but what are your thoughts? Does it

work? Is it a cult? What's the upside?

What's the downside?

>> It is not irrelevant that those programs were designed by people who have the problem and therefore understood what it is, what you need when you've got that problem. So, I think about this like

problem. So, I think about this like where I am in Palo Alto. Let's say some engineer wakes up in Palo Alto on a Saturday morning with a, you know, his 20th or 30th or 40th beastly hangover of

the year and says, you know, what am I doing? You know, I've got a great, you

doing? You know, I've got a great, you know, I've got this great life. I have

this, you know, $200 million one-bedroom condo that I really like and and you know, and I'm messing up my life out call. Let's call Stanford psychiatry

call. Let's call Stanford psychiatry department, okay? And try to get some

department, okay? And try to get some help out. Well, they're closed in the

help out. Well, they're closed in the weekend. You know, you you you'll get a

weekend. You know, you you you'll get a message. you can then then on Monday you

message. you can then then on Monday you can call back and then you'll get on a waiting list and eventually you might get in. So for a condition characterized

get in. So for a condition characterized by ambivalence and impulsiveness I want to quit now two hours later I don't.

That's like the health care system is the worst possible design. Whereas how

is AA design be like I'd like to go to AA. You can go on the AA website look in

AA. You can go on the AA website look in the area. Oh my god there's like 15

the area. Oh my god there's like 15 meetings today. And not only are there

meetings today. And not only are there 50 meetings, but there's like a woman's meeting, a men's meeting, you know, a spiritual focus meeting, a you know,

LGBT meeting and you can just go and that that moment you have at this moment I want to change. You can just you you know follow through and then you can get immediate reward, social reward for

taking positive steps towards it. you

know, the treatment system will never be that good at at at sort of, you know, being that accessible. And of course, no health insurance, no paperwork, no no pre-approval. That's amazing. Does it

pre-approval. That's amazing. Does it

actually work when people get there? So,

I started my career. I didn't really know anything about addiction. My first

job, I took it because I was literally flipping burgers and there was a job that paid another dollar an hour in the medical school where I didn't have to wear a costume, a Wendy's outfit. So,

that's why I got into the addiction field. That's the truth. So, I didn't

field. That's the truth. So, I didn't know anything about it. And I met while I was on this job, uh, I met some people said they were in AA and I I I thought

they were like the people who get your car battery for you on a cold, you know, that's what I think of when I think of AA. And I didn't know what AA was. and

AA. And I didn't know what AA was. and

they they explained it to me and I talked to my mentors about it and and my mentors were professors in medicine and they were very dismissive you know they're like well you know they don't have doctors they don't have medications

it's kind of folk medicine you know that kind of you know um you bit bit of professional snobbery there um but I wasn't so far along in my education that I was incapable of learning so I I

thought well will you take me can I go and they're like well you can't go to a closed meeting but there are these openings okay because I want to see this and I was so impressed with just the authentic icity and the caring and the

warmth and the wisdom really just you know um uh made me think maybe there is something here and so I did I started doing research on it as a number of other people were at that time and you

know it just keeps coming out really really good in studies you know and so finally few years ago me John Kelly and Mara Ferry did what's called a Cochran

collaboration uh review this is the creme de la creme most rigorous review of evidence in medicine as a method and uh looked at all these studies of

alcoholics anonymous done in diff by different people with different viewpoints in different cities and different countries even and it came out extremely well relative to very good therapies like the one I was trained to

do like cognitive behavioral therapy motivation enhancement therapy on abstinence outcomes if you ask like do people stop entirely AA and also 12step facilitation kinds of counseling to help

people get into AA was winning you know by 50% higher rates routinely of that.

And then when you looked at other outcomes like did the person at least cut their drinking or reduce the damage of drinking or less dependent or better family, you know, functioning, whatever,

it was as good as amazing for something that's free, you know, and um so anyone still left saying, "Hey, it doesn't work." They

really and often people think there's no evidence. There's a ton of evidence.

evidence. There's a ton of evidence.

There's randomized trials all over.

There are quasi experimental studies.

there are healthcare utilization studies. It's amazing. Um

studies. It's amazing. Um

and I so I always I always say to anybody whether it's a patient or just a person I care about, you know, if you want to stop drinking, that'd be a place to try. You know, um there's there's

to try. You know, um there's there's it's really no harm to it, right? You

know, if you if you go to a bad movie, you're out in the evening and 15 bucks.

You go to a bad a meeting, you know, you're just out in the evening. It's a

it's not like a high-risisk endeavor to just give it a go. And there are some alternatives, too, by the way. are

smaller. But if you live in a area like San Francisco Bay area where there's a there's more choices, you know, there's also like uh smart recovery and women for sobriety and uh uh and and I forget I'm forgetting some of the other names,

but but choices if you don't like particular a model, but that experience of mutual support, people are on the same journey with me, they're further along the same journey and they're doing well. It spires hope. They've given me

well. It spires hope. They've given me useful information. All of that is

useful information. All of that is really potent and that's why it's survived and thrived as an organization.

My 195 countries or something have AA in it. Just want to mention if people are

it. Just want to mention if people are interested in AA and this isn't it's not like I've been sent here to advocate for AA but they have uh Keith mentioned open meetings. If you look up, you know, an

meetings. If you look up, you know, an AA an open meeting is one that anyone can go to even if you are not an addict and you're just curious or you have a different addiction and you want to go to an AA meeting because the AA meetings

is are tend to be more established and they're more of them than the other um uh letter anonymous meetings, you know, for gambling and other sorts of addiction. Um

addiction. Um I've been to many meetings. I'm super

impressed by how AA can do what it does.

is really um it's is just a shining example of humans self-organizing into something that keeps going, doesn't walk around with a basket. There's no

GoFundMe. Uh

>> no tax dollars.

>> No tax dollars. They just they they stay out of politics. It's it's really cool.

And um I know some people that couldn't get sober any other way that did it. I'm

curious what the data are on the other addictions that are treated through the 12step model. So, um, narcotics

12step model. So, um, narcotics anonymous, overeaters anonymous, gamblers anonymous. Uh, there's so many

gamblers anonymous. Uh, there's so many of them now.

>> Um, and I imagine there aren't as many studies, uh, but the model is pretty much the same.

>> Um, so I wonder how they hold up.

>> I I was very interested in this question for the drug groups. There's there's

very little on gambling and sexual addicts, those those things. So, the the other big pool of data we have to extend we have is on the NAC cocaine anonymous, narcotics anonymous. There were a couple

narcotics anonymous. There were a couple things were interesting. One was it's harder to get people into those groups.

So, we were looking at at studies where there was uh what's called 12step facilitation counseling. So, where

facilitation counseling. So, where you're you're you're in there, you've got somebody who knows the program is introducing you to it, encouraging you to go and then talking about, you know, how did the meeting go and did you get a sponsor and all that kind of stuff. And

the uptake was much lower. So, if you do that in a in an alcohol program, you know, you get these, you know, doubling or tripling of the rate of patients going into AA. and the effect was much

much smaller to to with with the elicit drugs to get people to attend C. And we

don't know why, but it wasn't as easy to get people in. Um that definitely there were correlations pretty consistently that people who were going, you know,

longer were doing better, but the evidence wasn't quite as strong from a, you know, external validity, I'm sorry, internal validity point of view. In

other words, they're not the same kind of trials, you know, randomized trials that we like to have, you know, when we draw inferences. So, I I characterize

draw inferences. So, I I characterize the evidence on uh 12step groups for drugs as positive, encouraging. I would

certainly try it, you know, so not harmful, but it's not as strong. I I

don't feel I feel comfortable saying AI know positively has a causal effect on alcohol. I have no doubt about it. And

alcohol. I have no doubt about it. And

um I'm less sure about that whether that's true uh for the maybe in Andrew's case but on average it was harder to demonstrate that effect. I was being somewhat facitious when I asked whether

you think AA is a cult. But one of the reasons why sometimes people will call it a cult is I'm just going to be very blunt here is that often, not always, but often enough I should say, uh people

who get into AA, discover sobriety in the AA community or other uh 12step communities will talk a lot about it and how much it's changed their life and they've got a new set of people they

hang out with and uh in the name of sobriety and they um and then that can uh be if it's not handled correctly, it can be seen as somewhat of a separator

by people around them. That's one. Um

they'll there will always be instances where certain groups are not in a healthy dynamic, but I would say 95% of the time it seems to be healthy dynamics. Um but there's this other

dynamics. Um but there's this other piece that I think sometimes gets tucked away and no one wants to talk about, which is that a critical component of 12step is that um the addict acknowledge that they're not in control of

everything. They certainly can't control

everything. They certainly can't control other people but perhaps they can't even control their own mind and they have to have a higher power in uh notion you and I think some people interpret this to

think that one has to suddenly become uh formally religious >> either Christian or just or to believe in God as an entity and and um >> uh but that my understanding is that

12step well I know because I I've been to a lot of meetings uh 12step hinges on the the acknowledgement of

some sort of higher power, but people can self assign what that higher power is. Some people say God, some people say

is. Some people say God, some people say Jesus Christ, some people will say u nature, some people say the universe, some people will say um the collective.

So I think that's not discussed often enough. And then people say, well, I

enough. And then people say, well, I don't want to go 12step because like it's going to be a bunch of, >> you know, Jesus freaks coming at me about and I'm going to have to do a bunch of other things and you know what's what's happening.

>> Yeah. So there's a lot lot there in those questions. So on the cult thing,

those questions. So on the cult thing, why I wouldn't call it a cult. Cults do

two things AA doesn't do. One is cults take everybody's money. AA literally

won't let you give them money. I mean

it's amazing. They've survived

orization. They were Rockefeller off the money. They said, "No, we should limit

money. They said, "No, we should limit that. That would be too grandiose." So

that. That would be too grandiose." So

it's it's very, you know, and they're perpetually broke by design. They have

just enough to keep going.

>> You pass the hat. Do you want to or not?

You don't. But if you don't, you are not looked down upon.

>> Yes. They give away the literature, you know. So they're they don't do that. The

know. So they're they don't do that. The

other thing is they don't stop anybody from leaving. Literally any meeting you

from leaving. Literally any meeting you can you can literally stand and say I'm gonna go get drunk. It was bye, you know, and that's that's different than a call.

>> You just can't show up drunk. This is

important.

>> Yeah. The desire to quit drinking or the other behavior or substance and you can't show up intoxicated.

>> You can you can they will usually let people sit as long as they don't as long as they're quiet if they're drunk rather than throw them out. If they start talking, then that's a different thing, but usually they will. Um, and you know,

relapse is a normal part of recovery and every nobody knows that better than people in AA. I mean, they they they appreciate that. Uh, even though they

appreciate that. Uh, even though they don't want to hear from a drunk person, obviously. Um, but then the religious

obviously. Um, but then the religious thing, yeah, they got the word God there, right? And so there are um people

there, right? And so there are um people who just have had bad experiences, you know, and just that word is a a repellent to them. um you know it

doesn't really in a sense it doesn't even matter how if they know how the organization defines it they just like look I was you know I went to Catholic school I hated Catholic school I hate I hate religion and this sounds like

religion so I don't want to go some of those people might be happier than in programs like smart recovery which doesn't have that component uh to it um but yeah it is incredibly

um flexible you know in terms of how that's why it's really a spiritual not religious organization it is you know you know the it says In the text, the 12 steps are but suggestions. Okay? Can you

imagine that in in a Christian church saying, you know, Jesus was the son of God or maybe he wasn't. Who knows? It's

really up to you, right? You know,

that's what in a religion, no. He was

period. That's non-negotiable point. Aa

everything is negotiable other than you what you believe. It's like it's like it's what you do. You know, you go to meetings, stay sober. They don't really care. My my friend Barry Rosen uh passed

care. My my friend Barry Rosen uh passed away too young. Unfortunately, was

addiction psychiatrist. He said would say to people look the god na can be anything. It could be Buddha. It could

anything. It could be Buddha. It could

be Jesus. It could be your group. It

could be the doororknob. It just can't be you. You narcissistic so.

be you. You narcissistic so.

And that's what they were really concerned about with the people who founded is that it was the hubris the ego of I am in control and I don't need

any help. I am the god basically. and uh

any help. I am the god basically. and uh

breaking that belief it's like no you're whipped you know you have lost your control out of the sub you and admitting that is the critical point how you end up explaining the spiritual part is

really up to you but that part is is non-negotiable why why else would you be there if you thought no I can still control my drinking they would say well then then you shouldn't come here because we can't that's why we're here

>> Bill and Bob the founders were good psychologists they understand understood the juxosition of of the narcissism and the shame that is addiction.

>> Yeah. Yeah. You know, they were they were really uh uh great Americans. I

mean, they changed uh they changed the country.

>> Before moving on from this, again, if you're curious, you can go to an open AA meeting if you want to. It's

interesting. And when they go around the room and people say, "I'm so and so. I'm

an alcoholic." Some people say, "I'm so and so." And I'm their first name only.

and so." And I'm their first name only.

Uh, of course, and they're an addict.

But if you're a visitor, you just say uh you could say nothing. You could say pass. No one would pay much mind to it.

pass. No one would pay much mind to it.

Or you could say your name and just say, "I'm just here to learn."

>> Mhm.

>> And that I've seen that a number of times. And it's it's usually family

times. And it's it's usually family members of of addicts or family members that want someone in their family or a friend to go to 12step. And this is an interesting little trick tool. Sometimes

it's easier to get someone to go to 12step if you yourself have gone. And if

you're not an addict and you want someone to go, saying, "I went."

>> Yeah.

>> It's it's and I'll go with you. Right. I

mean, uh, this sounds very, uh, kind of hokey on the one hand, but I've seen the incredible things that 12step can do.

It's so awesome. It's free. How many

things are completely free, accessible all the time? It's a wild It's a It's a wild invention.

>> It's the closest by by John Kelly and my friend who did the review said, "It is the closest thing we have to a free lunch in public health."

>> Speaking of lunch, let's talk about GLPS.

>> Okay. Um, I'm struck by how many people have lost a lot of weight who couldn't lose weight previously. I'm also

delighted, thrilled, so so relieved that I don't have to look at these stupid arguments online anymore about whether or not obesity was the consequence of some other thing besides overconumption

of calories relative to caloric expenditure. Mhm.

expenditure. Mhm.

>> You know, there's no blame in that statement, but it like people were going back and forth and back and forth and um the laws of thermodynamics apply. We now

know thanks to GLPs, if you eat less than you burn, you lose weight. It's

just very hard for people who are very overweight to eat less and burn more.

>> And it runs against all the evolutionarily, you know, uh hardwired circuitry of desiring over consumption.

>> Yeah. So here we are at a time where there are these peptides that people can take to lose significant amounts of weight. The cost on those peptides is

weight. The cost on those peptides is coming down now through the compoundingies and people are taking half doses. People, by the way, people

half doses. People, by the way, people are sharing their GLPS. People are

splitting them. Not supposed to do that.

It's illegal. That's not a suggestion.

It's incredible how low a dose of GLP is required for people to get the desired effect. And people are are picking up on

effect. And people are are picking up on this. The pharmaceutical companies hate

this. The pharmaceutical companies hate this.

>> But um people are getting them through compoundingies.

They're um uh extending their dosages.

They're sharing their their don't share prescriptions, but they're doing it. And

people are just losing weight easily.

>> Some are losing muscle and everyone gets, you know, inflamed about that, but you can do some resistance training to offset that. And they're awesome weight

offset that. And they're awesome weight loss drugs.

>> Yeah, they're amazing. Um and they >> I'm not on them, by the way, but I would take them if I needed them.

>> Yeah. Um and they may have other benefits, too. You know, we haven't

benefits, too. You know, we haven't fully figured out. Yeah. So, I'm I'm extremely interested in them. their

effects on substance use. Um, you know, it it I have a friend who's addiction psychiatrist. She said what my patients

psychiatrist. She said what my patients desire is they want not to want.

>> So, which is different than like I want to conquer my desire. Like, I just wish I didn't desire this drug as much as I do. And I I link that with something a

do. And I I link that with something a friend of mine said to me over lunch. A

friend of mine who I noticed had lost a lot of weight. And I said, "Wow, you've lost a weight?" He goes, "Yeah, I'm on JP's." And he said, "I used to spend all

JP's." And he said, "I used to spend all day not eating and now I don't think about it." it was effortful all day

about it." it was effortful all day long. Don't eat, don't eat, don't eat,

long. Don't eat, don't eat, don't eat, don't eat. And and now that that voice

don't eat. And and now that that voice is just gone. And so what if we could do that for say cocaine or or or alcohol?

You know, they are sort of in the same kind of family of behaviors. And uh

there are some interesting studies. Now

to be clear, there's some studies that are negative. You know, it's not, you

are negative. You know, it's not, you know, not nothing ever works out perfectly for everybody. But when I look through animal studies, small trials, and um opportunistic epidemiological

studies, so like you go through the hospital, you know, here's 10,000 people who uh, you know, had a diagnosis of cocaine use disorder and let's see if the ones on JPS went to the emergency room less, something like that. None of

these, you know, they're vulnerable to different kinds of selection effects.

But still you I see this pattern particularly with simaglletide which is the GLP that is in uh wave and uh ompic

and alcohol uh drops in alcohol use and so I'm and and the other thing I think is perhaps important and what why I'm I'm working now with the VA and Novo and

and a philanthropist to to do something like this is that alcohol is the most like eating of of drug behaviors. Right?

So to the extent these drugs create a sense of satiety and fullness, right?

>> To me that seems more likely to change you know swallowing something a drink versus say injecting myself or snorting a powder and you know the most it's you

know eating like behavior. And so that's why I was optimistic at least that's where I want to want to start. If that

works, it'd be fantastic because we have, you know, if you have a drinking problem, you're about 70% more likely to also be overweight and Americans already pretty overweight. Just think of the

pretty overweight. Just think of the twofur benefit of this uh you know, for for you know, transforming people's life. You know, lose 30 pounds and stop

life. You know, lose 30 pounds and stop your drinking problem. And in the last one, you mentioned my dear friend Anna Lumpia, my uh colleague, she said, "What's great is there are patients, I don't really want to stop drinking, but

you know, I just love losing weight."

So, you know, because I've been overweight my whole life and so I will take the ompic here in the addiction clinic, not because I'm that motivated for the addiction part, but boy, when it comes with this other thing I really

value, then I'm going to do it and then they get the benefit, you know, they saw they their drinking cuts back. So, it's

really thrilling. Um, the another nice thing is these are old drugs. They've

been around like 20 years. People don't

realize that. So, and millions and millions of people have taken them. So

that makes it less likely that there's some awful side effect, you know, that doesn't show up for 10 years to them. So

there's just a lot of lot of potential upside here. And I think the next couple

upside here. And I think the next couple years of science in this area are going to be super exciting.

>> What aspect of alcohol craving is sugar craving?

>> I don't think very much. I mean maybe some I mean certainly the lore is you know when you're hung you know when when do you uh are likely to relapse you know in fact a people say this you know uh

hungry angry lonely tired you know um and some people feel that way like if they actually also some feel this way about carbs you know when they you know are short of carbs they want a beer so

maybe it's something in there but I don't think that's the fundamental thing that is the driver I think it's more the subjective effect of consuming

There's a movement toward removing uh advertisements for pharmaceuticals on television um online. I mean on television. Does anyone watch television

television. Does anyone watch television anymore? You know,

anymore? You know, >> that's a good question. I don't know what effect it's going to have now that so few people watch television, but what what are your thoughts on that? I mean,

and of course there are medications for hives and and allergies and all these things. So, it's a broad category, but

things. So, it's a broad category, but I'm specifically thinking of things that have an addictive potential. the Lancet

Commission on Stanford Lancet Commission that I led, you know, partnership between Lancet and and and the medical school. That was one of the points we

school. That was one of the points we made is that there's only two countries on earth that have television ads all the time, which is us and New Zealand. I

have no idea why New Zealand, but it's just us. And when people from other

just us. And when people from other countries come here, that's always a jolt to them. like you know what you know come you go to your super like god all these ads for ask your doctor about this ask your doctor about this ask your

doctor about this I I I think it can create I can't prove this but I think it can create a a a sense that everything

is perfectable if you just bully your doctor enough and you know and that is just not the truth so that's the the downside I think the worry about them particularly for you know uh like you

know we don't have thank you oxycontton ads on television, but we do have bankshot commercials. Like, so by that I

bankshot commercials. Like, so by that I mean there was one actually in the Super Bowl of an ad for opioid induced constipation. So who is that, you know,

constipation. So who is that, you know, really for? I mean, that's a way of of

really for? I mean, that's a way of of bringing up the subject of, you know, are you on, you know, opioid painkillers? But mostly we don't have

painkillers? But mostly we don't have that. And I think that's good. Um, you

that. And I think that's good. Um, you

know, we need opioids clearly. Um and uh we uh and you know they they're I I've worked in hospice for 10 years. No one

needs to tell me how incredibly valuable they are. But at the same time, you

they are. But at the same time, you know, overpromotion was clearly part of what triggered the opio crisis. And I

don't just mean TV. I mean everything. I

mean people uh you know gifts and uh you know other types of promotions, gifts to schools um that weren't separated enough from the industry. Um, all those things

we we highlighted in the the uh Lancet Commission.

>> Social media probably doesn't have its own 12step yet. It probably will soon.

Um, social media is here to stay. Let's

be blunt. I'm sure there's um been discussions in the past about television is ruining society and now everyone's staring at a box in the evening. You

know, this I mean, this has happened multiple times throughout history. Uh,

but do you see social true social media addicts or video game or YouTube addicts? Uh, do you ever observe um like

addicts? Uh, do you ever observe um like intervention working? Uh, what does that

intervention working? Uh, what does that look like given that it's not quite like eating, meaning you have to eat at some point? But to tell a young person or an

point? But to tell a young person or an older person, but to tell a young person, look, you you can't ever be on social media isn't reasonable. It's like

saying you're not going to talk to your friends unless they're standing right in front of you. And uh it's not going to work. It's just

work. It's just >> so I will quote a perceptive uh Stanford freshman who said to me, "I hate uh I hate social media. I think it's bad for

my mental health, but I have to be on it because everybody else is." And that is really tragic. And I think lots of

really tragic. And I think lots of people are in there. And I I I read another study actually was on the on the plane coming here of >> how much would you have to how much would you demand if you had to leave social media and people will say a

certain money you know >> but you say if everybody else were leaving it >> the same people would say I would pay money to be one of them.

>> So that that is why things like the Australian social media ban are going to be really interesting because it's not really an individual punishment. You're

not being exiled from the party. It's

more of life is going to happen in person for teenagers.

>> And so that you you know that that will make that real life more appealing than than being online. So I'm really fascinated. I mean we don't know what's

fascinated. I mean we don't know what's going to happen but really fascinated to see what happens. We do see all across the country more people coming in with

these types of problems, you know, like feeling like they can't stop looking at their phone. um that there or games or

their phone. um that there or games or pornography is a really big one, you know, delivered through through uh these media. And of course, there are now

media. And of course, there are now gambling apps you can use on your phone and that kind of thing. And really um have extremely um uh difficult lives. I

mean, they really have become absolutely consuming uh for them. We don't know yet of what the natural course is of this um you know what um because it's new like

so what is the five-year course of social media that's really literally impossible to answer at this moment.

What for what portion of people is a developmental thing that they will get out of for you for example if you go into a college campus you will see a lot of people drinking at levels that would qualify them for some level of alcohol

use disorder and a huge number of them five years later will be married and have a job and drink very little. I mean

there there are you those kinds of maturing out effects. Is there a maturing out effect in social media or not? Um you know for me it was easy to I

not? Um you know for me it was easy to I used to do a lot of X and then and then I stopped or I just do a teeny bit. Now

that was particularly easy but of course I had 40 years of my brain not touching it. Will that be as easy for whatever

it. Will that be as easy for whatever the most popular thing kids probably Tik Tok or Instagram or something. If you've

been doing that, again, thinking in that plastic, you know, neuroplasticity from the time you were 8, 9, 10, 11, 12, is it developmental? When you're 25, will

it developmental? When you're 25, will you be ignoring your kids? Uh or will you not have kids because you you you don't have sex because you don't have a date because you're in all day looking at the phone? Like, what what will that course be? We don't know that yet.

course be? We don't know that yet.

>> Yeah. I see a lot of adults addicted to social media. I don't I don't know if

social media. I don't I don't know if I'm addicted. I don't think so. Um

I'm addicted. I don't think so. Um

because if I say I'm not, sounds like an addict, right? So, I'm just going to say

addict, right? So, I'm just going to say I don't think so. But I found great benefit to taking an old phone when I upgraded my phone, which I do far too seldom, but I finally upgraded my phone

and I took my old phone and I put X and Instagram on that phone and it remains much of the time in a um Supermax prison lock box that you can't code out of. So,

you put like one day or you know 19 hours or something. You click that and you'd have to saw it open and that wouldn't even work. And uh it's very helpful cuz once it's locked away and

there's no opportunity to uh look at it.

If people send me things, I can't open it on my other phone and the impulse to pick it up is blocked. It's very useful.

It's a portable box and and it doesn't require I mean the box costs 30 bucks.

I'm sure I recovered more than that in work output and recreation output and just hanging out uh with my girlfriend and not looking at my phone.

>> Yeah, I know other people who have done things like that or switched back to a dumb phone. Um, and uh to to avoid the

dumb phone. Um, and uh to to avoid the constant Bing notification da da da or there's there's also software you can get that like you know will suppress a lot of that stuff unless you

specifically go in and enter a code and say bring it all to me. Um you know and those are you know useful things like it's so new right that we haven't got a lot of social norms about it but you

know uh think of something like drinking before noon all right there's no law against drinking before noon and yet a huge number of people abide that norm

right in like oh well don't it's not noon you know and we might over time evolve some kinds of things about social media I would hope you know like you

know things that we all find sensible like don't do social media at the dinner table would be I think a good good one or people or don't do social media in a restaurant or whatever. I you know I

hope we'll do something because you can't solve this problem just through individual clinical medicine. That's

crazy. I mean there has to be some just like we've built a lot of norms around alcohol. We've built norms you know

alcohol. We've built norms you know don't don't drink and drive. That's

that's one that most people now broadly find believable. building some about

find believable. building some about social media I think is going to be sort of the task of you know this generation that has grown up with them.

>> Yeah. I have three real life examples of young guys whose parents I know who um essentially contacted me because um different situation for each but there's I'll just describe the overlap. Each one

of them was looking like a failure to launch. you know, graduated high school,

launch. you know, graduated high school, was not highly motivated to go off to college or went to community college, then stopped doing that, was working, then lost their job or they were not in

a career path that was going to sustain them independently. Um, YouTube or video

them independently. Um, YouTube or video game enthusiasts to say the least, and all were convinced they had ADHD, all medicated

by now. um happy to say uh with some

by now. um happy to say uh with some explanation of reward circuitry and Anna's book, giving them Anna's book, Dopamine Nation, and obviously really

hard work on their part uh is really what did it. All three of them in higher education situations, great universities, off medication. They all

had to quit video games or YouTube for some extended period of time um and recapture their attentional capabilities and most importantly recapture their sense that they have agency in the world

that they can make things happen for themselves.

>> Yeah.

>> Not incidentally all of their parents are reasonably high achieving um and none of them have patterns of addiction that would have predicted any of this.

So there is a way to escape the the vortex of this stuff. But I mention those stories because I think a they're success stories and I'm proud of those guys and um but often times it's

multiffactorial. I can't say oh it was

multiffactorial. I can't say oh it was the medication or oh but but the medication didn't rescue them or oh it was YouTube or oh it was video games is there's a sort of a pattern of of

progressive languishing that's set in this context of media. They weren't

talking to me about porn, although I suspect that was in the backdrop of some of these cases. And and um and they're kicking butt right now. All three of them in healthy relationships, working

hard, working out, >> happy, which is the most important thing. I mean, they're one kicked

thing. I mean, they're one kicked cannabis, the other >> doesn't drink, the other one can drink, it seems, without any issues. I mean,

when I think about what they have to deal with relative to what I had to deal with growing up when we didn't even really understand what addiction was, there's just so many more things coming at them to impair them. It's like

they've unshackled themselves from five or six different ball and chains.

>> That's great. And and um the point you make too about there's so many pathways out of this, you just you see that, you know, everywhere. Many many pathways to

know, everywhere. Many many pathways to recovery. I mean, I know people who

recovery. I mean, I know people who like, you know, a dear friend of mine, um, you know, just tried to quit smoking for for, you know, years and years and years and was very just felt totally

defeated by it until he saw his baby.

You know, as soon as he was a father, he's just like, man, I got to stay around for this beautiful being and quit that day. um you know there's you know

that day. um you know there's you know changes in the sort of homo racial system because of life changes that um that I have another friend a dear friend who um it was going to prison you know

which is a terrible thing you think how would anybody benefit from being in prison but he said I just needed like you know uh you know many many months off of methamphetamine for my brain to

heal and I sort of realized wow that was really crazy um and you know and he didn't get any treatment it was just being away from the drug for an extended period and there's you know, infinite number of stories like that because this

is a condition, you know, experienced by tens of millions of people, right? So,

there's going to be lots and lots of pathways out. That is one thing, by the

pathways out. That is one thing, by the way, surprises a lot of people of people who had a substance problem and are now doing well in in big representative surveys. Very few of them actually went

surveys. Very few of them actually went to see anybody like Stanford psychiatry.

That is an unusual pathway to go through addiction treatment. People change in

addiction treatment. People change in all kinds of ways for all kinds of reasons.

>> Yeah, one of our team members here has been open about this. So I feel comfortable saying it. He managed to kick alcohol and a pretty almost lifelong alcohol and cannabis addiction.

Didn't go to meetings, made the but made the decision and um lost a bunch of weight too. He was already super

weight too. He was already super productive. You know he was doing well

productive. You know he was doing well enough that wasn't a forced thing but he was just tired of you know yeah tired of being tired as they say and he flipped the switch in one day has never gone

back. And I remember asking him recently

back. And I remember asking him recently I was like wait did you go to meetings?

He's like no I went to the gym. He found

a replacement behavior. He got healthy.

He kept doing all the other things he was doing. And I don't want to take the

was doing. And I don't want to take the words out of his mouth, but he's gone on a few podcasts talking about the relationship with his kids improving tremendously professionally and his

relationship to himself, you know, just and and broke a long family line of alcoholism. I mean, I think that's what

alcoholism. I mean, I think that's what sometimes people forget is that you can break the chain in one generation, which is really spectacular.

>> Yeah. Yeah. G genes are risk. They're

not destiny. And that's very important.

Even if you come from, you know, a hundred generations worth, that doesn't mean that your life is necessarily going to going to come out that way. And and

you're raising another point, too, about what is beautiful for a lot of people about recovery. Is then you start

about recovery. Is then you start acquiring more reasons not to use that you didn't have at the moment you started because you you burned those relationships out or you'd never form

them because you have been living in your mom's basement smoking cannabis and being online all day. And then you start to get like, "Oh, wow. Having a like job where I'm respected and I feel important is nice. Getting paid is nice. Um, you

is nice. Getting paid is nice. Um, you

know, being uh, you know, mentally present, you know, and instead of high all the time is nice. And then it just makes it easier month by month, year by year to just live the rest of your life

that way."

that way." >> There was a question that I forgot to >> ask earlier. Okay.

>> And it's a somewhat of a touchy subject.

>> Okay. Um

I've observed and I've heard that sometimes the smarter the person is or the more intellectual they tend to be or

ideas oriented um the worse 12step works for them. Whereas people who just kind

for them. Whereas people who just kind of go, "Okay, like chop wood, carry water. I can do that. Follow step one,

water. I can do that. Follow step one, follow step two, follow step three, step four is pretty uncomfortable. Do that.

Okay, fine. That one's harder than the other ones." And they just kind of do

other ones." And they just kind of do it. They don't overthink it. Um, I've

it. They don't overthink it. Um, I've

observed this quite a lot.

>> And I don't want to get into notions of IQ. I think it's just some people have

IQ. I think it's just some people have this prefrontal cortex that lets them see five different strategies simultaneously. Other people are like

simultaneously. Other people are like more plugandchug.

>> Y >> and um neither is better or worse. is

just different. And um I I have observed that for people who just kind of like ratchet into the work and don't overthink it. What's this about? Is it a

overthink it. What's this about? Is it a cult? What do they want? Like but

cult? What do they want? Like but

there's this one instance like will I ever drink it? They don't think about too much. They just do the steps and

too much. They just do the steps and they're out.

>> That is what a asks. I mean one expression is your best thinking got you here and and in other words keep keep it simple. like you don't have to you know

simple. like you don't have to you know do a philosophical critique of the 12 steps you just have to don't drink go to meetings don't drink go to meetings it's that you know and it is an action

program whereas so it's different in that sense from a lot of psychotherapy styles which are you know more intellectual and analytical um you know and less focused on you're actually

going to do certain behaviors um and so if you dislike that yeah I can see why AA would bother bother you. I mean, that

said, AA is it's just not one thing. So,

you can find, I'm sure, within a few miles of where where we are sitting, you can find an AA meeting over a gas station with guys who are smoking

tobacco and have jail house tattoos who are who are talking about the steps. And

you will find meetings with professionals who will talk about, you know, enst and things like that. And and

you sort of find your own people. And

I've known some very intellectual people like professors who go to an AA meeting with other people like that and they they're still working the steps and all that but they are also you know they're going to talk about kirkugard you know

it's it's like and again like a is like fine you talk about kard just remember don't drink and go to meetings you talk about whatever you want and you need to find your peeps and I and and that's

also why I I when people are thinking of going I say think of this like dating like you know you wouldn't go on one date and say I didn't like that person I guess I'm going to be alone the rest of my life. You go on a group of dates,

my life. You go on a group of dates, right? So, pick some different meetings

right? So, pick some different meetings at different times of day and different places and they will be different.

>> Mhm.

>> And then go back to the one that felt like home.

>> Speaking of carrots, uh you know, there's no wisdom like the kind of wisdom you can get from a really good share from someone at an AA meeting that you thought when they stood up and

started their share that you had nothing in common with this person. you you are from two univer different universes and inevitably there's some kernel of of

truth for you or something that you disagree with and therefore you have insight it's it's a spectacular thing really >> yeah I mean and they were very conscious about that if you read you know that it's you know called the big book it's

actually just ac was called the big book because it was printed on cheap paper so it was sort of fat and pulpy this was back in the depression right um it says flat out this book is mostly stories and

we tell stories in the hopes that something in them will catch you and say, "Gosh, that life is like mine and look where he or she is. Boy, I wish I were there. Well, if they're kind of

were there. Well, if they're kind of like me and they got to that good spot, maybe I can get to that good spot." And

so they it's a conscious and very, I think, clever organizational strategy to tell people, you know, there's a place for you here. There's people like you here.

>> I want to ask you about death.

>> Okay. Um,

you worked in hospice.

>> Great experience.

>> As Americans, we're not comfortable talking about death. Um, it, uh, it evokes

sadness, um, fear. Um, but I think there's a lot to learn about it um, from hearing about someone who's been close to it a lot. And one can't live very

long without losing someone. and we're

all going to go eventually and that's you know hard hard truth but why did you go into hospice and then um what did you learn about in hospice that has informed

your sense of life and death >> yeah so I loved being a hospice counselor I did it for about 10 years uh and there's so many beautiful things about it first off when I tell people

they go like oh god that must be really depressing hospice staff were the most upbeat people I've ever worked with >> optimistic compassionate seen everything and in a way I could sort of understand

it because you know it's accepted the person's going to die like so what's the worst that could happen right you know you don't think like oh if I say the wrong thing maybe you know in our session you know it'll take an extra 3 months to develop more trust like

they're not going to be alive that long there that is we've accepted the worst right and so then we can just do well and help this person have a good death and help their family have a good death

and work work you know through their grief experience and So they're just very upbeat and so I I I never found it depressing at all. I did it partly

because I had um I'd shifted to doing more research and I just missed taking care of patients and I thought I wanted to you know obviously been well why didn't I just do more addiction thing I

think I just do something different and the other part was I was scared of death and I don't like being afraid. I'm a

countobic person. I am not brave but I'm afraid of being afraid so I do things that look brave. So when I and I know about phobia like the most basic thing is exposure, you know, reduces fear and

anxiety. Running away from things makes

anxiety. Running away from things makes them scarier. So I thought like, all

them scarier. So I thought like, all right, I'm scared I'm scared of death.

Um I So how do I solve that problem? I'm

going to spend as much time around death as I can. And uh it's a very intimate experience. You know, you're in people's

experience. You know, you're in people's homes. It's not like when they're

homes. It's not like when they're sitting in your office, but you know, people's, you know, bedroom could have like, you know, what is that? Well,

that's my, you know, I I was a high school baseball player. We won the, you know, the nationals and, you know, or what's that? That's my wedding picture.

what's that? That's my wedding picture.

That's my wife and I 40 years ago. You

know, it's very intimate and sweet.

And being the last friend somebody ever makes is an incredible honor.

And I always felt that that when I had to say goodbye, I had been honored by them in that way. The last friend they

made. So I uh I just found it profoundly

made. So I uh I just found it profoundly a moving experience and it took away that fear and then I was able to help other people uh get free of that fear

cuz when you've been around it for a while and then the family you know comes in and they're scared or maybe some doctors are scared of death. You can be the person who says this is what's going

on. This is what your mom, your dad,

on. This is what your mom, your dad, your uncle's going through. Um here's

what's going to happen likely. here's

how long he's likely to live. Here's

what we're doing for him. And you and then that helps them because you you are radiating that acceptance that they need to come to, which is hard. So, um I'm

I'm just so glad I did that and I I really would recommend that to anybody who wants to like give back to community, but also just come to a place

of peace with with dying. The way to do that is to is to be with the dying, not to run from them.

>> You got me, man. Um, maybe it's cuz we both know

man. Um, maybe it's cuz we both know Nolan. I think I just got uh was just

Nolan. I think I just got uh was just feeling your feeling your feelings. Um,

yeah, death is is it's like he the way you describe is like heavy and and you wo some lightness in there, which clearly I'm not a hospice worker. I I

don't I don't have that relationship to death. But um thank you for sharing

death. But um thank you for sharing that.

>> I think um it is a universal experience and um being in there with people alongside them. Um clearly something

alongside them. Um clearly something that I think many people young and old run from. It's it's like

run from. It's it's like uh >> Yes.

>> Yeah. There's something there, >> you know, and we can in the society, you know, I've I've done work in developing countries. You can't not see death. It's

countries. You can't not see death. It's

it's you know everywhere people die in the street literally and so there is less odd oddly enough there is more death and less fear than there is in our

advanced technological society where death is hidden and and and denied. So

Americans I find are much more terrified of it than you know people I met in Iraq for example. Um so um that's why you

for example. Um so um that's why you really have to make an effort you know because you're so you know that to um get past those norms and those structures if you want to be in in

companion connection to people who are dying.

>> I didn't anticipate asking what I'm about to ask but it's been on my mind a very long time and it's directly related to the two major topics we've covered which are addiction and death. Um, I've

heard it said by a gambling addict that all addiction is gambling of some sort.

You know, am I going to get trouble this time? Am I, you know, am I going to get

time? Am I, you know, am I going to get fired this time? And, you know, and I've thought a lot about addiction. And I've

wondered if all addiction is an attempt to escape our fear of death. And this is not an

attempt to get philosophical or or um deeply psychological, but um I mean it's a weird thing. We don't know what other species think, but it's a weird thing

that the portions of our brain that let us think into the future and plan and build technologies that made us the curators of the earth and not like the house cats or the elephants or something

um can logically know that we're going to die someday. And

if we really drop into that feeling, for most people, it is scary. It's really

scary and really sad. And and I think if any of us dropped really deeply into that and we've created any sort of connection to anything or anyone, it's deeply terrifying. Mhm.

deeply terrifying. Mhm.

>> And one thing I can say about addiction is that um the states of being high,

whatever the thing is for that person, um they have a timelessness to them.

You're out of the real world where you're operating in the real world as if you had superpowers. I mean, in the in the one's mind. And so I wonder whether or not the fear of death uh is something

that addicts in particular are running from. And that raises the question is

from. And that raises the question is embracing death as a very real thing, overcoming that fear, the counter phobia. Um do you think that

perhaps could be used to help treat addiction or avoid it?

>> Well, that's a really interesting idea.

I mean, I I think very broadly speaking, a lot of heavy

substance use is some desire for um oblivion uh to get away from unpleasant truths. And I think I I one

unpleasant truths. And I think I I one of those is death and suffering, but I think it's broader than that. So, it

could be I just can't be in this uh PTSD anymore or I can't um you know, I was sexually abused as a child and I I just need to stamp out those visions and

those memories for an hour. Uh you know, and step outside them. Um my marriage has disintegrated and I'm miserable and uh my spouse and I hate each other and

this is the one moment where I am above that or unconcerned about that. that

often times there's something awful uh that and frightening or or humiliating or or or painful that this is the escape

from. Mhm.

from. Mhm.

>> And you know, and they do provide that, you know, at least in the short term, the high high-term costs are are hard, but in the short term, you know, everything can be falling down around you, and if you're high on a stimulant,

you can still feel, you know, euphoria, at least for that brief moment. And what

can be tough about recovery is when you stop using, those things are not gone.

You're still going to die. If your

marriage is bad, your marriage is bad.

If you were abused, you were still abused.

And that is enough to persuade some people never to stop because it's a lot harder to actually deal with those things

um head on uh than than avoiding them through uh intoxication.

Thank you so much for this discussion.

Um you shed so much light on substances, routes to sobriety, uh stages of addiction. um very interesting work on the GLPS

um 12step. We'll provide links to all these

12step. We'll provide links to all these resources and papers. Um if you're willing, before we walked in here, I solicited um X of all places uh for questions about addiction.

>> Oh, sure.

>> So, thanks to you, most of the questions that were asked um are already answered material covered uh before, but there were three that I think are worth uh touching in on uh that weren't. And the

first one is uh are men getting addicted to things more than women or are they just showing up for help more often?

>> Men are larger consumers of addictive uh substances in every culture on earth and are over represented uh in all the major addictions. You know, opioids probably

addictions. You know, opioids probably for a man to every one woman. uh alcohol

probably about 60 40 um you know used to be higher but uh women have been drinking more. The one thing you see in

drinking more. The one thing you see in clinics that is close the one is prescription medication that those are those are a little closer to 50/50 but otherwise it's predominantly male.

>> Why the relationship between addiction and lying >> and not just lying about the addiction?

Uh Anna our colleague has talked about this before. Is there overlapping

this before. Is there overlapping circuitry there?

>> No I don't think so. I think it's just you end up in these situations that are possible to cover over without lying.

So, you know, where where you know you were supposed to, Dad, you were supposed to pick me up after school. Where were

you? Uh I what I I was drunk, right? But

I don't want to say that. So, I say, "Oh, you know, the car I had car trouble, you know, couldn't do it." Um

or um you know, the boss, what happened to the you know, money for the Oh, yeah.

It was unexpected tax bill because I'm not going to say I stole it. And so I think that is why. The other thing of course is sometimes we make uh addicted people lie. I always point this out to

people lie. I always point this out to residents that um if you watch how doctors sometimes ask people about their substance use it's absolutely clear the

correct answer. If I say you don't drink

correct answer. If I say you don't drink do you or you don't use drugs do you? or

it's some look and so and when you're addicted you get very good at at reading people like what is this person going to say if I tell them that I use methamphetamine and uh sometimes they lie not because

they want to but because they know they'll get a negative reaction from the person asking them.

>> The other question was about relapse. Um

is it the case that relapse can occur just as easily when things are going well as opposed to when they're going poorly? What do you see in your clinic?

poorly? What do you see in your clinic?

>> Yeah, I mean pe people relapse uh in both ways. I mean, it's um I'm a a

both ways. I mean, it's um I'm a a friend of mine in college, I remember his dad after years and years of drinking um got sober and just

miraculously got an extremely highpaying, respected job despite an incredibly erratic work history and uh immediately relapsed, went out and drove the wrong way on a highway and and uh

killed himself. and just think like how

killed himself. and just think like how could you know everything was going right but you see that a lot it's sort of like you know I got money in my pocket I'm happy I know I'm okay now the problem's behind me and so I'm going to

do what I always did and then be shocked that I got the same result I always did you see that broadly speaking though relapse is most likely in times of you

know stress you know whether that's uh transitory stress like uh you know spat with the spouse or with the boss or I'm just really, you know, I was exhausted.

Um, you know, didn't didn't sleep well a couple nights in a row, that kind of thing. Or something bigger like, uh, uh,

thing. Or something bigger like, uh, uh, you know, maybe my my kids addicted also, and I'm dealing with that, and that makes me more likely to relapse.

>> Last question is from me. I'm just

curious. You're you're a dad of two college age boys. Um,

what advice did you give them or do you give them about addiction? um not

assuming that they're particularly prone, but just they're in life and to be in life now means that you're prone to addiction, period.

I can hear them rolling their eyes even from Southern California um because they they've they said like oh another

another talk about addiction you know so I um talked to them a lot about fentanyl >> because I've known so many families

where kids like them you say like you know nice nice family middle-ass kid have died from fentanyl that they took as in the form uh that looked like something else and you know this

happened in college campuses happening in high schools you know these these printed pills that look exactly like an Adavan or an Adel think I'm going to try that and you don't realize you're taking fenoline and you die so I I always

warned them about that like never to take anything you know you you can't know what it is if you didn't personally acquire it you can't know what it is and then the other thing I told them is you know the the point that you're going to

have make these decisions yourself but the only thing I can tell you is you will never get addicted to something that you choose never to to use. That is

your maximal point of control. And what

happens after that point, what you started using is something I can't know.

More importantly, something you can't know.

>> Thank you. Well, Dr. Keith Humphre, uh, thank you so much for coming here today.

>> Thank you. I really enjoyed the discussion. I mean, it's obvious to

discussion. I mean, it's obvious to everyone that you have immense knowledge about this area. And the fact that you have not just knowledge, but that you're a clinician and you help people get into

and through recovery and stay sober in all these different dimensions is itself amazing. But I think um I'm certain I'm

amazing. But I think um I'm certain I'm not alone in saying that what's so awesome about the work you do and you is that it and that became evident today is that you combine incredible expertise

with in incredible compassion for people. That's uh you didn't have to say

people. That's uh you didn't have to say it. It's just in every aspect of of what

it. It's just in every aspect of of what you shared. Um and you know it's an

you shared. Um and you know it's an honor to have you here. It's an honor to be colleagues and to meet you finally.

Um, but mostly I'm just grateful that we were able to create a environment where you could share your knowledge and your compassion and I'm certain that it's going to help a lot of people understand themselves, understand people around

them, and hopefully take action if they need to. So, thank you so much.

need to. So, thank you so much.

>> Thank you, Andrew. It was a real pleasure to be on your show.

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