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

t to qu ing.
ll say, uld you want to do that?
e, what want to get out of this?

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es?
them b in their own mind,
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therap s.
t’s rea ortant is that like any other,
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people e trying to make the same change.
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check i AA meeting
fellow e have.
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shows t matter what you’re doing,
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for pe
dcast, e discuss science and science-based tools for everyday life.
, and I ofessor of neurobiology and ophthalmology at Stanford School of Medicine.
r. Keit reys.
is a p r of psychiatry and behavioral sciences at Stanford School of Medicine,
e world most experts on addictive substances and behaviors and how to overcome addictions of all kinds.
t on ho ce, commercial marketing, lobbying, and the legal system interact to create what are called addiction-for-profit businesses.
and opi ustries 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.
ll the ddictions to give you the most up-to-date information on alcohol, cannabis, opioids, gambling, and much more.
us the ed facts, and more importantly, he explains how to think about the health risks of any substance or behavior in a logical way.
it may e that a certain amount of alcohol could afford you some heart health benefits,
we hear ot true, it goes back and forth,
y heart ts that exist from alcohol are greatly offset by the increased cancer and other risks of alcohol.
cannab explains who may be okay to use it, but who should absolutely not.
most e e ways to get over any addiction.
ol, por y, stimulants, and much more.
Dr. Ke phreys is no ordinary scientist or psychologist or addiction expert.
ure on on and what it means to try and navigate life nowadays
ction-f it marketing and confusing health information.
oday he t tell you what to think or what to do about various substances and addictive behaviors,
hink ab m, and in doing so, how to avoid and overcome essentially any addiction.
versati I’m certain will help millions of people make better decisions.
d like asize that this podcast is separate from my teaching and research roles at Stanford.
t of my and effort to bring zero-cost to consumer information about science
tools general public.
t theme ‘s episode does include sponsors.
ussion . Keith Humphreys.
, welco
ndrew.
topic, hink for a lot of people it gets slotted into one small drawer.
ompare say, mental illness, many, many things, depression, manic bipolar, OCD, and on and on,
is thin we call addiction in thinking about how best to possibly treat addiction,
comes t g to treat addiction en masse at the level of policy, which we’ll also talk about today?
do you ddiction and how should people think about it?
ause it rd, unlike, say, you know, maybe it’s a little like schizophrenia,
ike, ah now, he’s a schizophrenic person.
mean is now, he’s a person with different moods and that sort of thing.
ore lik
ance.
w, I’m d to, you know, a TV show or I’m addicted to my phone or that sort of thing.
not ju f you do a lot, you know, which we sometimes, you know, colloquially call addiction.
e of do ething that is harmful.
ic anim y, you know, is, you know, James’ old study with rats done in the 50s showing that you could give a rat the opportunity to give itself brain stimulation, which they enjoy,
contin o that even as they were starving to death next to a pile of food pellets or run out of water while they were next to water.
.
the thi r and over or even being compulsive about things.
the poi estruction when you would normally, you know, any other behavior, you would think, well, you would just stop doing that.

qua non iction.
e a def 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.
t take once and then stop doing everything else.
ressive
be over

the de n.
rue.
r types ards, particularly natural rewards, start to fall away from the person’s life.
you kno elationship with my parents or my spouse or my friends.
o work you know, which would normally generate the things I needed to eat or I’ll give up my housing for the sake of this substance.
not on become more physically dependent on it, but essentially you’re psychologically dependent on it because it’s the one thing left that is still rewarding.
been s away.
asier t stand 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 moment when I take that hit.
e a lot ustries that are addiction for money, basically industries.
talk ab of them, nicotine, alcohol, cannabis, social media, all of these.
ing, do ink that there is truly something to the, quote unquote, genetic bias for becoming an addict?
tance o ior specific?
ybe alc or example.
t quest
just ge id of one myth where we say people are born addicted.
ad, you if mom was addicted to fentanyl, then the baby is born addicted.
e becau know, a fetus has no association between their behavior and the exposure to the drug.
ically nt, meaning they’ll go through withdrawal upon birth, but they’re not addicted.
sk from in your genes.
he esti of, you know, how much of that is shared, it’s actually quite a bit.
t studi e kids were adopted out of families with parents who, you know, were addicted to alcohol,
ood of ing an alcohol problem, even if they were raised by teetotalers, for example.

across now, studies.
bstance

ou know 0.4, 0.5 for most of them.
can ima at the same gene, some might be specific and some might be more general.
e of a c one.
o a gro Han Chinese are and you lack the enzyme or don’t have much of a particular enzyme that is used to metabolize alcohol,
njoyabl ience to drink.
break to acetyl aldehyde and acetic acid and all that sort of thing.
but th dn’t lower your risk for anything else, but at least specific for alcohol.
things mpulsivity, that would put you at risk for, you know, across substances.
king, y oing to try more drugs.
e likel you know, you’re going to get exposed to one.
e happe hich is really fascinating and poorly understood,
doing w o, lots of people are in recovery.
le and ple in my studies who have been, say, clean and sober in their, you know, sense for 20 years
udden t elop like a very strong sexual compulsion
nds bec ey’re just eating and eating and eating.
know, t rlying diathesis, whatever it is, has found a new phenotypic expression
r actua olved.
as the lar set of behaviors that went with the addictions they had.
recover
cohol, ard it said that there’s a subset of people with,
ey call ohol use disorder.
alcoho day?


ll lash t me if I call, refer to someone as an alcoholic.
riends alcoholics.
n them, way, who are recovered.
oke bec ey’re impressive recovery stories.
ay, jus it what it is, which is alcoholism.
h split names now.
you in tion of saying something that’s going to offend anyone.
at.
ng into
a much spectrum thing.
u diagn m with alcohol use disorder, it can be mild, moderate, or severe.
he mild veryone at AA would laugh at.
person casionally drinks too much, has some harms, but basically life is still put together.
uld be ou’ve got to be kidding me.
.
get up severe end where we see the things that looks like addiction.
ally th thing, addiction and use disorder.
ader.
sort o alcohol like other health behaviors that you might start addressing, particularly in like primary care.
like we like, you know, doctors to intervene when someone is 15 pounds overweight and has moderate high blood pressure
you kn er, you know, develop a more serious problem.

ou know er severity problem that a doctor might, while the person still has a fair amount of control, advise you,
ou coul cut back a bit now, you could avoid a lot of suffering later.
ame fro
talkin addiction.

meanin
the pub erstands.
to an ing, they go around the room saying, I’m so-and-so and I’m an alcoholic.
so-and I have alcohol use disorder.



have, w in recovery define at some level of their identity, not their total identity.

‘s actu important part of the 12-step recovery process, which we’ll talk about.
split ere, but I’m grateful that you’re willing to embrace that nomenclature.
ifying hy it was split.
hese cl and naming things are split because of, quote unquote, sensitivities.
fend, e a.
o offen

ard it at there’s a subset of people somewhere around 8% to 10% for whom they drink alcohol and they experience it very differently.
more as lack of a better term, kind of a dopaminergic, energizing experience.
te to t e, but that they have a very different experience subjectively of alcohol than most everybody else who can build up tolerance.
tolera
onger t nto the sedative effects, the depressive effects of alcohol.
aid tha 8% to 10% are particularly susceptible to becoming alcoholics because they drink and they feel spectacularly good.
rinking ay that many other people either pass out, blackout, crash their car, end up in jail or dead.
e, this 10% may be at greater risk than everyone else.
hat, wh uperb psychiatrist, was based in Southern California for most of his career, did some wonderful studies of male children of alcoholic fathers.
gs he s s that when given alcohol, their body sway is less at a level you can’t even perceive, but he could measure that, you know.

they m ke how hard the alcohol hit them.
hangove next day.
think, hat’s great.
that ha
can dri t.
e probl use someone else would get the signal of like, whoa, I, you know, I’m feeling kind of dizzy here.
much t .
they g nd go, oh, God, I’m never doing that again.
signal
s punis ore rewarding.
ross dr
surely .
e diffe ugs, you know, varies enormously.
out thi
an inj oke my ulna and, you know, I had to take Vicodin for the pain afterwards.
ds so u nt.
u know, ble, groggy that I just took one and said pain is better than this.
people lly 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.
to do nes.
t, ther learning history there, right?
ng, you I’m just wired differently for that particular drug than people who get in trouble with it is.
essaril groups.
know, ioids but, you know, love cannabis or love alcohol and that, of course, is going to change their risk.

ortant nd I didn’t realize that it extended to things outside of alcohol because oftentimes when a discussion starts to surface about addiction and whether or not zero is better than any,
gs can in moderation, I think this is actually a big unspoken point of friction.
really ink five or six drinks.

ay they work hammering away and they’re going to say, listen, my life’s going great.

r marke still within range.
decline now, they’ll get worse.
n becom difficult to have because it sounds like it’s highly individual how people will react.
ehavior cts.
I’ve h e statistic that one of the greatest risks for becoming an alcoholic is if your first drink is before the age of 14.
people you know, have their first drink, like you said, and it’s like a magic elixir for their physiology.
few thi t can get somebody like that to stop drinking except the risk of losing everything and sometimes even then.
.
l is th you know, template for talking about this because it’s socially acceptable in most places, for adults anyway.




e know or not they have a predisposition because those people might want to avoid using something because our colleague Anna Lemke has said that you can’t get addicted to something that you’ve never done or taken.

lpful a you know.
you if now, in this game of Russian roulette, the bullet will not be in your chamber for sure.
like y ess likely for this, more likely for that.
determ t a substance will not damage your life is to never use it in the first place.
g to be isk.
of work e kind of genotyping to try to figure out could I tell people, you know, what their genetic risk is for alcohol.
ood as ying, your parents, alcoholic?

hat’s l most useful bit of information.
does pr rinking run in your family?
de a qu as it is.
than an we have from SNPs or anything like that.

er has r who’s alcoholic, does it cross sex as readily as it goes from say father to son or mother to daughter?

ll risk for sure but the father to son link is the strongest one you see in genetic studies.
‘s, in it’s hard, right?
ore tha do.
re anyw
xcess m n women do anyway whether they’ve got an alcohol problem or not.
s is so of unfolding process, right, then men carrying risk would be more likely to have that risk realized through the behavior than a woman would.
a fair of women who don’t drink or drink or, you know, hardly any.
e the t you, you know, if you had all the genetic loading for cocaine in 1800, it didn’t matter.
e.
genetic g for alcohol and you’ve never drank, then it’s really irrelevant.
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more or ow?
y, you n the late 90s, early aughts, the alcohol industry figured out that women had more money, but they weren’t drinking the way men were.
a long- mpaign to try to increase women’s drinking.
know, ine juice and those mommy wine chats online and all that, that was really engineered by them.
es that rganic online were engineered by the industry.

nt up a
drink i for women for most things than it is for men, partly due to body size, but also partly probably due to some hormonal things.
ou know itation as I see it, you know, of women.
of youn now, like undergraduates I talk to, re-evaluating that, like looking at their mom’s experience and saying, you know, I don’t think I want to do that.
uraged .
control now, the decisions we make, but I don’t want them making them just because the industry slickly marketed to them, because the industry’s sole interest is always going to be to generate profit.
h addic cause, you know, something like, what, 10% of our country drinks about half the alcohol.
ou’re s
drinks e alcohol.
ight.

g the i , you want that group to be as big as possible.
ey off who have a, you know, half a bottle of wine on special occasions.
on the who drink the equivalent of multiple bottles of wine every single day.
ntally ndustries, the more addiction there is, the better off they do financially.

.
that dr is at an all-time low in the United States right now, at least.
ah.

have ch and this may have something to do with this new generation.
s risk r in lots of things on, you know, over the last 10 years.
you kn ting class, less chance of dropping out of high school, fewer unwanted pregnancies, all that stuff.
enerati probably be a drier generation than their parents were.
her in oup?
ust def , well, cannabis is up, so alcohol is down, implying that you have to do something, that people have to be using some sort of mind-altering substance.
ization nabis, we certainly have seen a lot more use and a lot stronger products, but youth use really has only changed pretty slightly.
eally b ng adults, including adults who probably stopped at some point and have now gone back in later life to using cannabis.
annabis want to parse the alcohol stats a bit more also as it relates to women.
ither p est 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.
, and w ed 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,
very sp about, you know, two per week, sort of the upper limit for adult non-alcoholics that don’t want to incur any additional health risk.
ry clea
leep, w obably cascades into other things, inflammation, et cetera, but is zero better than any,
-alcoho lts, because every week it seems I see a new article that says zero is better than any.
out the me benefit from two drinks per week, and I’m getting, frankly, I’m not tired of it, but it’s almost getting funny.

the, i ditional media, not to poke on them, but they just keep flip-flopping.
ons tha s come up are, well, did the alcohol industry sort of encourage this study?
onest, a lot of advertising of alcohol in traditional media outlets.

st inte ecause I like red wine, I would love to believe it is healthy.

about e 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?
60-minu y, I think it was in the 90s, it was about why do French people, why do Mediterranean, it’s the red wine.
explode know, this is so great.
argumen

uch tra nts that are just, like, ludicrous, you know, in a grape skin.
st spre it was just so great for the industry.
than n king.
‘s just ue.
n you l they would look at studies and say, well, look, you know, the non-drinking group have higher mortality than the low-drinking group.
y call J-shaped curve, you know, like that.
drinker de people who are, like, inalcoholics anonymous.
‘t drin
a wret perience with alcohol.
hey’ve ferent kinds of damage to their bodies.
isn’t a
o live .
hey wou etter off if they went back to drinking.
would g ll, basically, for them.
you kno eted and spread and it’s not true.
cardia it, okay, but, you know, we don’t get to, you know, live our lives as single organs.
y.
hat if true and it is wobbly.
it’s s than the cancer risk.
re not o get any mortality gain from, mortality reduction from drinking alcohol.
nks a w d by a drink, I mean like a 12-ounce beer, a one-ounce shot, or a glass of wine, a four-ounce glass of wine, you have slightly higher risk.
y, very
not th 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.
mall.
for you
has ov d, the industry message that this will extend your life and you’ll be more healthy if you drink than if you don’t.
an esta hat as being true.
early, going to 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.
a very nt way to view these stats.
did ab ohol had a lot of different responses.
select s in the responses.
drinki I later learned wanted to quit drinking.
.
cts of ruption to sleep from alcohol and so on, probably part of the effect.
ting as ates to women because 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 relax.
that ma n 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.
st canc and other hormone-related cancers and so forth, not always hormone-related.
the it ably best to avoid alcohol entirely conversation moved into women’s specific health, it had a very potent impact, which is interesting in its own right.
at’s pe equired to override some of the marketing because, let’s be fair, it’s nice to relax with friends.
relaxi 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.
lly get 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, it’s social, they stress less, and so on and so forth.
ioned, eone who drinks wine and I know that it is, you know, on average, you know, it’s not healthy.

cause i es other things, particularly with exactly that situation that, you know, getting together with friends is enjoyable, enriching, good food is enriching, good food and a good wine tastes good.
hings.
other d s we make like that where we endure some risk because we care about something else.
erous t know, for someone my age to, you know, hike up a mountainside probably.
spectac can say, oh, I’m going to accept that risk.
more p twist my ankle or something, but this is just really beautiful.

ace we alcohol that was bad was needing an explanation to stop.
ou ever o someone at a party or seen someone say at a party, why are you drinking?
at, but ertainly heard a million times, why aren’t you drinking?
at part you refuse an offer of alcohol, people think there’s something wrong with you.
to have lanation like, well, I got an exam tomorrow morning or I’ve got a cold or something.
dn’t ne xplanation.
that so essure.
ay heal rmation can work.
on just eforehand?
t have explanation that worked in their circle.
, well, ow, I see those data on, you know, ovarian cancer and, you know, I decided to quit drinking.
is, yo health is a reason people still accept, I think, is a legitimate for changing behavior.
you kno use, you know, cancer is scary.
people
g happe n, you know, first Surgeon General smoking, thinking about everybody smoked.
fit in .

out, th e a lot of people who just quit immediately.
apable ting, wanted to quit, but they needed some, to tell everybody, why are you not smoking anymore?
t you c garettes anymore?
you an
hy.
ople wh feel uncomfortable about people not drinking around them?
sk me i ted to drink and I’d say no, and they’d say, why?
.
th, whi ‘ll say anything that’s on my mind without drinking.
o drink e then I’ll tell you everything that’s on my mind.


l tell what I’m thinking.
ke, loo
in soci ings.
ocial a
people ave trouble with social anxiety.
little n Japan when I was a young man, and there’s this, you know, culture of getting, going out after work,
going , and someone getting really, really drunk, and everyone’s drinking, and you’re vulnerable with each other.
you kno I will, I will, it’s like a trust exercise, like that falling backwards thing, except it is that we’re all drunk.
n’t doi it’s like, why are you not undergoing any, so we’re all going to be vulnerable, and you’re not.
you go exploit us in some way, or I’m going to say, you know, I think I hate the boss, and then you’re going to repeat that at work, because, you know, you’re one person sober enough to remember I said that.
eal thi people have anxiety about.
ou know what if, you know, a man and woman are on a date, and the guy keeps giving drinks to the woman and doesn’t drink himself?
t is th al thing to think?
et me d
ke adva f me because, you know, you’re going to be with it, and I’m not, because I’m going to be drunk?
f fears in the soup, but I don’t think, you know, so 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.
non-is u know, of what do you want?
ant spa water, I just give you a glass of sparkling water and don’t say, why aren’t you drinking this intoxicating beverage?
dn’t ne xplain it to me.
super i ing.
lity pi
bout th they’re just editorial thoughts, so forgive me.
s I tho w crazy it was.
meetin doctors and scientists who ostensibly were working on issues related to health, and everyone would just get trashed at the bar.
hat, an n’t judgmental.
liked i se by the third day of the meeting, I’m cranking, and they’re all just, I can tell they’re all just bleary.
ing muc r than I am.
tenured as we would call it, or as I would call it.
ive yea like, what happened to you?

nded to a lot, both at meetings and outside meetings.
r often meeting fees.
you kno t a finger here.
he stuf happened at meetings that turned out cost people jobs was always alcohol related.
the man man on a date drinking or a group of people at work drinking together, in Japan it sounded like it was men getting drunk with other men.

e of th female dynamic in drinking, I’m going to simplify this.
akes he rable.
kes him tupid and impulsive.
where rinking and he’s not, you gave the example that perhaps, you know, he would take advantage of her.
it, ce there’s that picture and it’s mine.
home s
e can’t r home safely and he might say or do something really dumb.
atter h math is arranged, it always ends up, drinking ends up being kind of a bad idea.
ing to mental here.
‘t judg people do, do as you wish, but know what you’re doing is my philosophy.
e a wor e drinking with your coworkers or drinking on a date with somebody that you don’t know very well, male or female, right?
st like of safety all around.
a bad i
more pr ns, that may have changed that norm of, you know, everybody who’s out and gets drunk because the consequences aren’t the same.
ow a lo ou know, professional women and friends are like, I don’t want to do that, you know.
ant to nd the boss when he’s drunk, you know.
Christ ch together at work instead of, you know, drinks afterwards.
that.
ng, now urse, I haven’t thankfully had to worry about dating for 40 years.
st peop d say is just the anxiety, you know, is, you know, intense for some people and alcohol is anxiolytic, right?
y that ople are, you know, sort of feeling, you know, it’s just, you know, too nervous, you know.
ould or houldn’t, that’s just, I think, probably in the soup, one of those benefits people care about.
e, it h e said, who are more socially engaging when they’ve had a drink than when they haven’t because they’re kind of wound up people.
me othe comes out and they may seem more appealing.

a numb ays.
enough for people to be able to think about whether or not they have a genetic predisposition, understand that zero is better than any.
me card efit, to weigh that against the cancer risk and not just take it as an independent piece of information.
bout vu lities of other people’s actions and vulnerabilities of one’s own actions and words, if drinking.
make a med decision.
I feel t.
sh, but hat you’re doing is like the purpose here.
nnabis ecause eventually I’d like to weave back to how industries impact use and abuse.
s growi was illegal.
r it.
pot.

t was m s potent.
hat.
e indus

stry ha ibuted to this greatly because it bypasses the blowing of smoke, the smell, and a number of other things.
oughts annabis as something that can be used, quote, unquote, recreationally, medicinally, and its potential for abuse?
about se things have been amplified or reduced by the fact that it’s essentially legal or decriminalized.
oughts abis?

about i ke a distinction between sort of old and new cannabis.
u go ba he 80s and 90s when, as you mentioned, it was illegal everywhere, the THC content, that’s the principal intoxicant, would be, you know, 3%, 4%, 5%, something like that on average.
studies al sales show the average product is about 20%.
y stron
how peo it is different, perhaps related to that high potency.
lled to a lot of really interesting data that got a lot of play.
about 4 ink it’s 42% of people who use cannabis use it every day or almost every day.
ent.
n the p u know, the more modal user might have been once or twice a week.
ings to so you take somebody, you know, what was like an 80s pot smoke.
you kno smoke a joint at, you know, 5%.
every consuming 20%, you quickly realize like their brain exposure is dramatically higher, about 65 times higher between the modes of those two experiences.
so wha 65 times mean?
ally is he potency difference between a coca leaf and cocaine.
o.
rence.
u know, akes the poison.
lly dif drug than what was back there.
rd to g ss to parents because their view is like, ah, I smoked weed, you know, is, you know, who cares if my, you know, 15-year-old is using it.
‘s kind ing you drank low alcohol beer and you’re not concerned that your 15-year-old is guzzling vodka.
differe
ger dea it used to be.
away th that you have an industry really pushing it, just the drug is stronger, more addictive.
dical a ions?
know, t abinoid receptor system evolutionarily is, you know, one of the oldest in the history of Homo sapiens.
rain, b also in the body.
oing to e applications for pain.
any peo ld say they spontaneously get relief.
lways w t means because sometimes that’s just relief from withdrawal.
ably so of medical applications for pain will come out of this plant.
of the hich is the non-intoxicating part.
hat is seizure disorders in kids, you know.
other like that for sure.
easier dy this than it has ever been before.
0, Cong anged the way research works.
er to d
se thin
re dang rug than it was, you know, when I was a young person.
e podca s a cannabis researcher.
ab.
on beca ad released a solo episode about cannabis.
of the r psychosis in young men and made some points about, frankly, concerns about cannabis because of the high THC content.
th the I said.
on soci a.
s isn’t y to get invited on the podcast.
on.
a very l discussion where he clarified a few things for me.
gs that ims 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, are very good at gauging the kind of level of high.
go int oid modes.
the pla igh that would make them feel paranoid or put them into a psychotic episode.
take e because it’s harder to gauge where you’re at, if you can just swallow an edible or even nibble on an edible, often surpass the level at which they would be comfortable, meaning at which there’s a psychotic episode or there’s paranoia.
his kin ft argument for the fact that the elevated THC levels in cannabis are not such a problem because people are essentially taking less to offset the difference.
‘s no e for that at all.
risingl even experienced pot smokers, at judging in lab studies of like how strong different cannabis is.
that pa I do agree we should think about the edibles differently because of the onset is different through the gut, you know.
anythin know, you get that.
ciently now, to the brain.
mething now, it takes a while, you know, to have its effect.
y when roducts came out and a lot of people were new to them, they would, you know, bite down on, you know, one piece of the whatever, the bar, the cookie or whatever.
I feel me, take another bite, still feel the same, and then just eat the whole thing.
ll hit ke a train.
does h
t is tr hat a lot of these products are not well made or they’re not up to like the standards of like you would have a cookie.
n up a chocolate chip cookies in the United States and find all the chocolate chips at one end and just dough and the rest.
n with s products in legal markets.
bite o rong part, you’re getting the, you know, the whole enchilada, so to speak, because it’s not evenly blended through.
people e gotten into trouble on that as well.

hosis r

tical o literature for years.
scienc ad, but just like it seemed to me there were lots of ways to explain it.
skeptic candidly, because, you know, in the old studies, they would be those men who had used cannabis in teen years and then they would have higher rates of psychotic disorders in adult.
based o Swedish registries because everybody has to register for the military, you know, and they would track people and it’s quite amazing data.
ational

reason could come about, you know, could be a common factor.
hings, w, but the evidence has gotten stronger as the drug has gotten stronger.
t to re eople are using it much more intensely.
is ther much more plausible that it would be from a much stronger drug used, you know, every day could generate higher rates of psychosis.
his bec ‘s a rare, thankfully, condition, but I think there is, you know, probably something there.
ish it, there weren’t, but there probably is something there.
nabis i any first degree relatives with any, you know, schizophrenia, schizofoic personality, anything in the psych, bipolar disorder.
lly rec that for anybody.
ably, p quite risky.
iac ris ther health risks?
that t a direct risk of cannabis, even if it’s not smoked or vaped, on cardiac health.
t, of n ed cannabis in the heart.
ooked a literature, so I don’t, I don’t know the answer to that.
ome, on I should touch on that you also raised earlier about first drinking,
is dif when the brain is plastic and our brains are most highly plastic, you know, when we’re young.
se effe e worst things are going to be because people start when they’re in teen or, you know, late single digit.
ions ov ingly start, and that is where if there is a psychotic risk,
then, d hat period of brain development, before people get their first psychotic break,
round 1 20, 21.
less fo ing, you know, initiating a substance when you’re 50 is far less likely to end you up with an addiction
ble thi when you’re young.
nows at one person or has heard of one person who’s very productive in their life,
, et ce igh energy, who uses cannabis.
they ar are exception, and there are a lot of examples of people who use cannabis
anywhe ife.
gh the developmental progression of finding a job that can sustain them, right,
life, elationship life, their professional life.
re othe ts to life, but those are key ones, right?
ta on h or just frequency of cannabis use as it relates to life progression?
we call .

that y n that fail to launch.

ear, no olitical reasons, but I want to be clear when I say fail to launch,
very ki o go to college and, you know, be a, you know, a varsity athlete or any of this,
of one eventually, getting a regular job, keeping the job,
althy r ships of various kinds and being self-sustaining.
king ab
ue.
, I did lein’s show.
ry succ guy and he mentioned that he sometimes uses cannabis edibles.

g.
easing.

w, ther d, you know, there are very, very, very successful people who use cannabis for sure.
ean, I’ l a phrase from Jonathan Calkins.
, we ha ormance enhancement drugs.
ormance ing drug.
l.
of you being directly traced to it are extraordinarily low,
egular dermine certain things that you need to succeed in the modern world,
ory and tration and being able to keep track of details.
also, rmines their sort of motivation to do much of anything.
ock is thing.
milies Alto, where I’m from, very achievey place,
you kn traight A son, you know, doing everything, starring on a sports or whatever,
months as just smoking cannabis all day
in the e used to star on and the math he used to be great on.
etty fr ng.
s are n ucive to succeeding in, again, in a modern world.
agrari ety, it didn’t matter because we, you know, everything was on muscle power, right?
ucceed society, you have to be able to do those things.
etition now, if you want a job, you know, computer coding,
on not th the smartest kids in your neighborhood,
on with artest kids who are in Mumbai, you know, and in Tokyo.
cus or just slower and you can’t remember things
, like, sure you keep track of time,
t you a advantage.
that s pe of, you know, living in mom’s basement,
is true hunk of people who are heavy users of cannabis.
about s of so-and-so is very high achieving and they use cannabis.
ing up perately wanted to be a professional golf player
ll thes ssional golf players who were heavy drinkers.
ing goo e heavy drinking part, sadly.
is life at some point.
of peop can use very addictive substances
that an ery high achieving,
eal det to that messaging.
don’t ople to cloak their reality, but it’s complicated.
as poli s too.
hen you p the rules, you know, your laws and regulations to think,
accomp I’m able to use this, so that must mean it’s pretty safe.
doesn’ w logically.
ccasion ou know, take a snort of cocaine or whatever
state s that doesn’t prove that that would be safe for everyone.
now peo e different levels of risk.
social l.
incent their lives.
enerali a sort of a lucky life or a costed life.
o more than you can when, you know,
ou know sort of between the person and the, you know, and the ground.
at many have heard me say that I’ve been taking AG1 for more than a decade.
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talk t participated in with one of the members of the Kennedy family.

cuse me been very open about his own recovery.

t talk.
it, an touch on some of those things again,
import versation.
ame up discussion that many industries are industries of addiction,
gamblin
nking a at you guys were talking about,
ery dif to look at any industry and not see it that way at some level.
themsel t way.
t toget h app developers, they’ll say,
more a e, you know?
ood for ss.
r like cted customer.
‘s goin appealing if you’re trying to sell something.
n is he ddictions or adaptive addictions
outsid rogressive narrowing of the things that bring you pleasure.
ng, quo uote, addicted to a learning app,
nto a n f things, one hopes.

en soci a.
from Yo ideos.
d that video of you and Patrick, you know, on YouTube.
ble-edg e piece.
o alcoh cannabis, what you told us earlier,
to drin by making it seem like an important part of being a woman
s to dr at sounds diabolical.

hat can s going to make them more creative
as alc hat to me is very diabolical.
his, we s not as bad as alcohol argument
ooting f in the head is way worse than stabbing yourself in the head.
kills, w, about 150,000 Americans a year.
r, we s ave hand grenades in the drugstore.
d kill thousands, but not 150,000.
legali k driving because, you know, that only kills 10,000 people.
a craz to set as the, well, as long as it kills less than 150,000 people a year,
me.
ke any
like, cally, I am a capitalist.
mpanies
licon V
gs peop te there.
an imp part for society to work, to have a private sector.
e, you regulate addictive goods, temptation goods, very intelligently and tightly
ount on rt of rational consumer to protect themselves like you can when you’re dealing with cabbage or lettuce,
verdose
e burni their lives over all these drugs.
, you k protect those people but also to protect the rest of us from the consequences of that,
w, you ings like advertising restrictions.
which are, people, even heavy users, respond to price.
really nt tool to regulate them.
e with s, particularly, you know, just some of the promotion is so naked
in plac e kids are exposed, particularly.
een a l m fight.
with t cco industry.
ing you say about the tobacco industry turned out to be true.
hey did o make it more addictive.
at any health regulation.
to kid that stuff.
onomic ves.
ot be n you work in this space about what the financial incentives are
addict duct.
ood for ottom line.
side ha ay, all right, we’re going to put in laws and regulations
der to .
rid of it, but you can make it a lot, lot harder.
exampl
azed th ave just given up on any restrictions on gambling now.
a kid, se was not allowed to go into the Hall of Fame because he had once placed a better on his own team.
g anyth rupt, but he bet on his own team would win.
the Hal me.
a spor ent without having gambling ads shoved in your face.
mple of ing that should just not be the case.
r anyon trying to quit gambling.
lot of men particularly, but not just young men,
emselve mically over sports gambling.
his.
t.
s a rea rn.
his pod o’s a self-admitted gambling addict.
e who t ambling addicts said it’s among the worst of the addictions
ith the y, it’s true, that the next time really could change it all.
lly the ddicted to the shame of losing.
winning s a thing of the distant past.
crazy rest of us, but –

d distu
s will t every addiction is gambling.


s book, ion by Design.
going t onounce the name of the person who wrote it.
but I’ ure.
e, Addi y Design, about gambling.
ople wh video poker, many of whom work in the casino.
paid an they go pay the casino back by giving it away.
ll take hpick and bend it and force the bet button down and they won’t even touch it.
ere and in kind of a dissociative state as it just runs and runs and runs until their money is gone.
tion of tuff.
een per to be addicted.
s like ery couple of years.
or gamb ut I just enjoy the sort of pageantry and the food and all that.
ee deal tables anymore because dealers don’t give the perfect timing of reinforcement that machines can do.
don’t now, you have to wait, you know, for your reward and all that kind of thing.
you fin nd there’s a social component.
s down cess.
an give act timing between your press the button and then you get your reward or, you know, your win or your loss.
infini 4 hours a day, unlike a dealer, never gets tired.
nos are hopped up dealer’s tables and now you’re just playing with a machine.

ll off o many anecdotes on my side.
mething as shared by a previous guest on the podcast you may find interesting.
t a uni out in Las Vegas and he got access to one of these.
t Crisi getting outdoors, getting away from things and basically carrying weight on your back and walking as a therapy of sorts, an important one to do regularly.
o one o research casinos.
at slot es used to be a small fraction of the income of casinos.
e.
at came because a father who worked for the casino industry was at home watching his kids.

t the k en’t playing to win.
or the of what was on the next screen.
realiz but it became clear to him.
this w p people.
ing the o share this once again.
slot ma you think you’re trying to win.
ng, chi ng, ching, ching.
f and y
e dopam ard.
t that the old rotor machines where you have some cherries and bells and stuff,
andscap could have an infinite amount of novelty through novel combinations.
out th le will play to win 50 cents on the dollar.
ts, rig
rationa they could know that rationally.
e to pl l it’s all gone, as long as you give them novelty.
en real ing for the money anymore.
.
st bein lated with enough novel combinations that their bank account gets drained.
all.

it chan view of gambling.
ought i bout winning money and leaving.
about p and it’s more about the novelty that’s introduced in each, quote-unquote, hand or spin.
that c over certainly to sports and the excitement that you’re feeling about the potential that you could win.
el comb of things might prevent, hopefully, somebody from becoming a gambling addict
e reali what they’re addicted to, if not already shame, might actually just be the novelty.
‘re los their money.
dustry r that.

wins.
ut in a and you get 100 credits.
he thin t’s, you know, it does its thing.
ke, you you’ve matched this way.

you’ve d that way.




these e things.
ow, 30% t I put in.
win.
as you ople will keep playing even while objectively they’re just pouring money down a sewer.
addict ambling.
I coul
like t couldn’t be, I could see how I could be.
s just e to these kinds of things.
ircuits

g too, w, casinos are one of the few places where you can still smoke, you know, indoors.
inks.
like ab dense pack of addictions.
f peopl roblem gamers are problem drinkers and also are addicted to cigarettes.
the Lo s, it’s almost like an anthropology experience for me.
this an wow.
ry in S book, which I just found amazing, with a bunch of people playing, playing, playing, playing.
heart a t one of the machines, fell over on the floor in a group of them, and none of them even reacted.
ing as rson died.
societ
d if I’ going to Las Vegas, I’m going with you.

elf, bu eem like a safe person to go there with.
s.
five b d that’ll be the end of it.
drive t ff.
abis, i ng to be very interesting to see what happens with cannabis now and going forward.
in sta re it’s legalized or decriminalized that the state collects its taxes on it?

regime
y impor int to get into when you think about policy.
n is ab user.
look, w t going to punish you for using pot.
pretty r – it’s been a popular policy for a long time and doesn’t seem to really affect use that much, you know, maybe a little bit, but not a lot.
ing the tion, processing, marketing, and sale legal, bringing in a corporation.
ntally nt, 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.
know, I know the exact state count, but it’s most people in the United States, population-wise, have access at this point to a recreational cannabis.
state, eve, has something.
ional, dical.
– due , there was sort of a way – mistake they made in regulation.
ocess h t you can make these like Delta-8s and Delta-9s.
hat are ited, there’s quite a bit of like, you know, hemp-laced beverages, which are quite strong.
ay drug
hen we school.
are gat ugs.
that, w, cannabis had some unique role, you know, that was going to lead you to use heroin use.
ything, you know, if you’re a teenager and you start smoking or you start drinking or you start, you know, using cannabis or, you know, stealing prescription opioids from your parents or whatever,
your li d of progressing to other substances, you know, for multiple reasons.
might l
guess I of like a drug.
ers.
tworks nge.
her peo do this.
rtable em.
with y
re like ave something else you might want to try.
thing i uld be some brain sensitization, you know, going on that, you know, makes, you know, drugs more rewarding.
nterest k with, like, identical twins in different states, which seems to suggest that you could be starting some unfolding process when you expose a young brain to it.
ses is eways work.
was ju abis.
its wit eneral lie, I would say, is that alcohol is a drug and we pretend that it isn’t.
entione , people getting drunk at science conferences or health conferences.
nces, p l 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.
o to th nd get drunk as if they are not drug users.
t that 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 more likely a kid was going to get in trouble with alcohol than with cannabis.
a lot ussion about psychedelics, broad category of drugs, LSD, psilocybin, MDMA is an empathogen, not a psychedelic, but somehow it’s been lumped into it.
methyle xy, methamphetamine, MDMA, ecstasy, folks, it’s methamphetamine with some modification.
edelic, n empathogen, but it gets lumped with that, ketamine gets lumped with it, dissociative anesthetics, it’s not a psychedelic.
o have rsation about psychedelics, I want to be really clear, maybe we just put psilocybin and LSD on the table and then talk about the empathogens and ketamine and all the rest separately because so often these get lumped and it leads to a lot of confusion.
le who ey’ve benefited tremendously from doing clinical work, meaning with a guide in safe setting, etc., on high-dose psilocybin, maybe only two or three times total, and that’s it.
pressio times for alcohol issues and other issues.
ut micr , they do a high dose, so two to five grams.
o use o ings are interested in or currently using or considering using psilocybin, LSD less so, as a means to get over their addiction.
hts abo and your thoughts about these compounds specifically.
re exci part because we haven’t really made much progress in pharmacotherapy in the last 20 years, you know, for lots of things, for depression, for addiction, you know.
these ork, and I think they’re, other than the GLP-1s, you know, one of the, you know, probably say the second, I’d say my second bet on that, I put my first one on GLP-1 agonists.
ot of h t real things can be hyped, 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 medications.
mething you know, you could look at different pilot studies, you know, small trials, they are encouraging, and I’m glad that, you know, it’s a lot easier now to do these types of studies.
ad my f Dr. Todd Korthis down to Stanford, you know, and he’s from Oregon.
doing hings probably similar experience to what the, you know, your friend had, where you get, you know, you have preparation, you know, 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, it’s transformative for them.
le who ry bad experiences on them, too, though, it has to be said, and that’s why we don’t just say, all right, let’s just use this as our frontline.
psyche xperience and afterwards?
flashb ou know, you’re driving along, and then you have a flashback, you know, and, you know, that is both upsetting, depending on what you’re doing at the time, you know, could carry some risk to it.
well ho these, or exactly how these drugs work, you know, the sort of serotoninary kinds of drugs.
know, ough, keeping on the topic of addiction, is thankfully, you know, there’s no evidence that people get addicted to psilocybin or to LSD.
potenti s extremely, extremely slight.
ied abo far less as a class of drugs than I do things like stimulants, which I know, and, you know, and alcohol.
rature, is might have been updated since, is that there is zero evidence that microdosing psilocybin has any benefit.
that’s illy.
ence th 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,
ourney typically two guides for safety purposes.
how it’ explored.
d explo conditions, because there has been some exploitation, mainly in the MDMA trials, but, and then follow up, that it’s been somewhere between 60 and 70% of people who go into that sort of thing with major depression,
n’t bee ved by other approaches, get either significant relief or full remission after two full versions of what I just described at fairly high dosages.
the neg mpacts, certainly there’s the quote-unquote bad trip phenomenon.
quite a nd I hear from a lot of people in this psychedelic space, is that post-MDMA for trauma, post-psilocybin for major depression and addiction issues,
phoria, e feeling that something significant has changed in the weeks and months afterwards,
d of ti r, a significant sudden drop in mood that frightens them, and that they’re able to recover from, but that it’s a real thing, a real trough.
y, is s from the very well-known trough that comes two days after MDMA use.
that, get high and then there’s a low, you know, very well explained.

right.
psiloc treat addiction thing.
rious b of the lack of kind of standardization of how this would be done outside a clinical trial.

ou hear some, you hear a shaman, practitioner, guide, and there’s no, because it’s illegal, there’s no Yelp reviews for these people.
at’s ov g it.
regon.
t Todd senting at, which is, yeah, because you, it is legal.
t decri ed.

kland, nia, it’s decriminalized.
minaliz
h, yeah
erent.
ally, y licensed by the state to do this.

what w nd out.
is lik y, probably this is a case where it’s easy to be a scientist.
ying to cientist.


know if orks.
nt to f ut if it works.
method that.
dollars good people to do those studies.
ht of y know, National Institute on Drug, they are funding quite a few studies, you know, of this sort.
, which Alcohol Institute, is doing it also.
to me, ally, I think people get a little scared of these drugs and sort of like think, well, you know, you can’t use them in medicine.
u know, lots of things in medicine that are a lot riskier than this, right?
n of wh he effect on the patient?
?
tment.

xyConti know, there’s all kinds of things, right?
out by g really good research.
s area
etting estment.
amount lanthropic investment too.
hing is he people doing the studies are at equipoise.
‘s been ad work, 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, you know, about, you know, what the evidence said.
er-clai t they found because they believed in themselves, you know, maybe because they’d had very positive experiences themselves.
is not long run a good way to do science.
y want who design a good study and then let the chips fall where they may and then tell us all.
ide.
y’re no know, shouldn’t be a spin doctor.


te abou cybin.
why th o few studies about LSD.
mine wh in this space, he runs clinical trials at UCSF, said, oh, it’s very straightforward.
on LSD cal trials that is, are done in Switzerland because the LSD trip can last up to 13 hours and they’ll work very long, hard hours.
s, it’s o get the staff to come in two hours before a four to eight hour psilocybin session.
that th n is okay enough and taken care of enough to go.
ng we e ork hours any more than we already have.
teresti I mention it because sometimes practical issues drive the science.
as tha
also a care system.
long to e odds that this would ever be scaled up in the health system are pretty low, right?
easons you can do something in less time, you do it.
ment no ing a solid effort in laboratories to figure out whether or not they’re non-hallucinogenic, non-psychedelic experience-related compounds within these compounds.
elic ex e may not actually be critical to the antidepressant effect.

f the i ing things about ketamine.
, you k r late great friend Nolan Williams, you know, was looking at like if you could block, like say with some kind of naltrexone molecule, block the, you know, the blink of lights and the visions and all that stuff, would it still have the same effect?
stion, w, for science to figure out.
y, but that part.
t a lot ple find that actually pretty upsetting.
hey cou ketamine and not have that kind of vivid dissociation stuff and they were depressed and help them, that would be a good medicine to have, right?
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rotonin ke inhibitors, and all the other antidepressants have gotten kind of a bad rap in recent years.
at all ool shooters were on SSRIs, whether or not that can be separated from the data on how many kids are on SSRIs, you’ll tell us.
, and o escription antidepressants, psilocybin, and any psychedelic for the treatment of depression, and on and on, all funnel into brain plasticity.
fice an l you what’s bothering me and you give me insights and over time I work with that, and I get better, it’s the consequence of brain plasticity.
f these , whether or not pharmacologic or talk therapy or a combination.

l magne mulation.

t rewir in circuits.
ut the elic experience.
ted is ople say, oh, you know, these things open plasticity.
oh, my mebody who studied plasticity, David Hubel and Torrenson Weasel, who essentially got the Nobel Prize for it, were my scientific great-grandparents.
, I thi enson’s still alive, but David would be rolling over in his grave or, you know, like, no.
t to op ticity because it can go in any direction.
lastici
herapy er, while TMS might be slower, I mean, plasticity needs to be funneled.
et’s ju plasticity.
are ver gued by the idea of just opening plasticity as if that’s going to solve the issue.
e have ly the most when we’re young, is absolutely a two-edged sword.
u try t , you know, French at my age, it’s just really, really hard, you know, to pick up that new habit.
know, speaking it or you try to learn it as a psychedelic teenager, you’re going to have much more capacity to get it and retain it.

if you smoking cigarettes in my age, you probably will not get addicted.
oking c es when you’re 13, you almost certainly will.




ns star people are young.
an, I m u can think of this as a learned, you know, it is a, you know, it’s maladaptive learning.
you kn t you, you know, you acquire those things and you stay all the way through.
someti er people, I can remember getting mad, like shows they like got canceled and people were watching them.
becaus rents watched it.
Woman.

watched
‘t want for old people.
t young .


e habit people are young is how you get them to do it for 50 years.
rsuade ople my age to start eating Cheerios or Frosted Flakes or whatever.
en peop young.
scores nt you’re making of like, plasticity isn’t good or bad.
the bra and it can be used in very different ways.
hy for, e some minimal effort, I can’t get addicted to TikTok.
rsive t hank goodness.
started ou were 13, it didn’t exist then.
t did, ht have.
d it fa engaging and picked up that habit.
, based t I observe and knowing myself.
ine.
resting
c, diss e anesthetic, has some proven benefit for depression, although maybe transient.

e poten
eles, n 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.
, yeah.
you ca articles, but we did a review, Todd, of course, and some other colleagues, of the potential therapeutic effect of this whole drug.
ketami struck me, yes, it is FDA approved for treatment-resistant depression, so it is approved.
gative for depression.
like, v er the, you know, efficacy thing.

tive tr
w a cou people who I, judgment I trust, said it was very, very valuable to them in a deep depression.
t as qu knockout I thought it was going to be before I read all these studies.
e that .

have a people getting addicted.
ladder, ow, damage you get from it.
oung pe th, you know, sort of, you know, 60-year-old bladders from ketamine.
you kn t urologists have seen this now.
omeone oming in with this?
heir bl as been damaged by ketamine.
icant, w, side effects.
the thi uld jump to if I had treatment-resistant depression, which has got to be said,
know, c ing, you know, condition to deal with.
ely to y do the SAINT protocol that Nolene Williams developed with RTMS
of tha reatment-resistant depression are so much clearer in my view.
re, as I can see, virtually nil.
it up
agnetic ation, is a non-invasive brain stimulation that can either activate
activit ecific brain areas.

his.
be avai o folks in all parts of the country and the world?
ean, RT depression is approved, you know, and so you can get it, you know,
e this ogy.
nsive m , so I’m sure there’s lots of places where they’re not local.
, it’s .
tually it.
the spe rotocol that Nolene did, I’m honestly not sure, you know,
lower ty one and Nolene’s, you know, genius was to compress this treatment.
e in, y , five days in a row and have 10 minutes on, 50 minutes off.
e thing ate.
days.
seen s ple’s lives just absolutely changed by that.
trial, it’s a trial.

elics, lly can fool people that they’re getting RTMS.
ys toug terpret psychedelic religion because everybody knows when they’ve gotten a psychedelic drug.
ontrol ent know they’re in the control experiment.

S.
oils on ad.
it and ls like something’s happening and it’s just a sham.
ople in d, guess which condition they’re in, they can’t guess.
ome goo ce.
would g if I were, I would look at it.
he name
‘t know can put it.
.
any pap y outlets.
om a lo ople with depression issues.
very wa SRIs because of the side effect profiles,
se of w y’ve heard.
t SSRIs een very, very helpful to the community of people who suffer from true OCD.
re so O
ilitati ls of obsessions, excuse me, and compulsions.
demoniz ompound.
that.
ple who t from SSRIs.
.
be som to, where people would want to explore.
e on SS SSRIs make people shoot other people or themselves?

t the m oting thing.
fit the here mass shootings are.
ust a m oting in Australia.
rare th see these in developed countries other than the United States.
t mass g in 30 years.
eople t Is in Australia.
ass sho
take S
level shootings.
at is t anatory variable.
explan ariable is that it’s extremely easy to get high-powered weaponry in our country,
tty muc e rest of the developed world.
r sake ing back, but I’ve seen data.
lid the re, that something like 70-plus percent of the prescription drugs for depression are consumed by the United States,
e perce of the population, maybe that’s a better way to frame it,
h, much in the United States than it is, say, in Northern Europe or in Australia.
SSRIs, a much lower frequency.
not go rs without a mass shooting in a country of Australia.
25, 30 people in it?
ven at rate, the disparity is so huge in where mass shootings occur
t going the likely explanatory variable.
?
about ence on SSRIs.
lly har t, you know, debated issue for years.
use dep , of course, raises suicide risk, right?
finitio omeone’s getting an SSRI, they already have some risk present.
e legit orry with teenagers.
n-zero.
t’s not tely in my wheelhouse, so I’m just going to leave it at that.
o’ve wo this much more deeply than I can.
uld say are many teenagers on these medications who benefit from them.
ubt abo .
are in d in this, I’m working on an episode with a guest about
term ef f SSRIs that some people seem to experience.
f peopl here.
great t bout the Internet, who have rallied together and saying,
ave the onstellation of symptoms.
ias aga e medical industry, but we were prescribed SSRIs in our teen years
there’s tellation of mainly sexual side effects and mood-related side effects
resolve fter coming off.
th fina , which was used to treat baldness,
Mike Le g, came on here and said, look, the data aren’t really there,
ot of y ys who are given these anti-hair loss drugs,
he drug they’re still experiencing debilitating sexual side effects.
hat the l profession sometimes takes 10, 20 years to catch up
are ex ing.
o make -SSRI statement here,
re peop ing around out there that are convinced one way or the other
m up pr d, and they have loud voices.
‘s wher oncern comes from.

ow, you what the evidence is in that particular case.
ething neral about medications, how we approve them.
short- ials.
at lik ypical trial for opioids and pain, you know, it’s like 9 weeks or 12 weeks.
medica you know, and opioids are a good example,
arily m t taking them for a year gives you the same effects
for exa ou become tolerant to them or you might become addicted to them and all that.
al just nge of how we regulate these medications.
eting s you know, that are done.
someth a complicated and rare from a widely used medication,
that o
l make that get, you know, aggregated up, but that’s hard to figure out.
om the ion about psychedelics,
great ue, Nolan Williams, sadly he passed a few months ago.
hat lat be not.
t a lin s information because he’s a critical figure in this general space
t of de n because of his work on TMS, the Saint Protocol, as it’s referred to,
, which ery unusual psychedelic,
trials rans mainly, taking Ibogaine out of country, illegal in the United States,
out of .
psyche xperience.
t rate ed.
creatio nd nobody should do it recreationally.
llowed DMT, sometimes no, but from my last discussion about Nolan before he passed,
data we encouraging such that people, veterans who had PTSD and or addiction issues
nce und intense supervision, sometimes followed by DMT
e a tot ssion of everything bad, frankly.
e.
triking ast the way it was being described,
as anti g that Ibogaine would be the first FDA-approved psychedelic,
s not t of thing you can just do hanging around with your friends,
nt to.
f scary ences in there that one works through.
hts abo Ibogaine work
otentia through the legal door of psychedelics?
I were neighbors and I really liked him.

of the sychiatrists of his generation.
spect f as a person and as a scientist.
y day w alk by his office.
with I was really fascinating,
did, th tant thing, he imaged people,
before erwards,
see a l hese changes.
atter?
people, ow, there’s certain experiences
escribe enthusiastically
eally d t, but they aren’t in fact different,
uments ‘s different.
nk that ally groundbreaking,
ot goin t to continue that work.
ay is t s is an open-label trial with no control group.
ave so
to do r trial, you know, and see.
a lot a sort of ceremony around this.
of lik colleague might describe it,
missio he soldiers.
Mexico do this.
marader
her goo packed around it.
at part therapeutic experience
you kno emical experience?
u would ut in a trial.
have s you know, you do all that other stuff,
ve the e at the end.
lutely tudying.
r hands ave to pick this up,
eople w

to whe work is going to go now
as Nola heading that work.
e who a ing hard to keep it, you know, going forward.

e user.

ce is i high.
teased ine.
‘s true
y of ca

a kid, t a photograph of me drinking yerba mate.
ne.
h is ra imulatory, although nice, even, flat ride.
ell I l mulants, by the way.

four y d, 800 milligrams of caffeine, no big deal.
caffei y, that’s kind of like where I’m nearing my limit.
e all d .
. so I ep well.

world u feine.
ffeine.
king th my own reasons, is caffeine addictive?
ddictiv
oductiv
eine.
ithout e if I have a flu or cold.
interes finding out what life without caffeine is like.
rst per answer this because I love coffee.
y, I do e a problem with coffee.
between and my children, I can make that decision.

miss th
okay jo ay because my sons laughed when I told it to them.
timulan
nd it i tially addictive.
hat wou see if someone were addicted?
d says, inking so much, I’m retching.
w, shoo omach pains.

ng to s
‘ve act ever met them.
ople sa I can’t seem to stop using it.
hat wou ddictive.
a true consider a coffee addict person because it’s not that intense of a stimulant.
things, ow, you can GI symptoms, things like that, that would be the main thing.
eepless
y who e ces those seems to quit.
ryone I seems to quit.
timulan ave to say this is the biggest disappointment of my career in the addiction field.
in the 0s and going into the Lower East Side of Detroit, which was very rough.
verywhe
ffering ple who were addicted to crack cocaine then in the late 80s is not very different from what it is today.

er.
at all.
e of an that works in pharmacotherapy.
apies t ‘t really seem to work very well, you know, and, you know, groups and stuff like that, you know, which have sort of like very most modest effects.
herapy
develo
e tried
ed all f, you know, medications for stimulants and just not been able to succeed.
seems is contingency management, which are these things where you, Steve Higgins, I think, was the first person to do this, where he showed against the idea that people have no control on addiction, which is, in fact, rare.
control ot no control.
nting w ple who were addicted to cocaine saying, well, you’re coming into treatment.
we’ll d nalysis when you come in and, you know, and if it’s a negative urinalysis, the first day we’ll give you $2 and the day after we’ll give you $4 and the day after we’ll give you $8 and the day after we’ll give you $16.
ople st
ed thos ds.
a cont .
change ant users’ behavior.
gs, you like, you know, well, if you come in, there’s some kind of reward.
a job a ion, there’s some kind of reward.
ing tha y looks good for stimulant use disorder.
behavio hnology.
s been d a lot.
, you k ‘s covered by insurance now in most places.
pointin that if you, you know, took Keith 2025 back to late 80s and, like, talked to those same people I was meeting coming into treatment,
t new t appen for people like me over the next, you know, in the 40 years, a new man for the future.
rry, ba nothing.
disappo
prescri timulants, Adderall, Vyvanse?
hat tho ‘t exist when I was in high school and college and graduate school.
cause I affeine enough that I worry that I might have liked them.
y of th s I just mentioned.

hedra a drine pills and things like that that were sold over the counter.
too st ry.
ay, yes ast half of my friends with male children, those children are on amphetamines for the treatment of ADHD.
young n they call me because I have a network, not because I can treat, but not a clinician.
me beca y’re worried about the growth stunting effects.
ir kids going to achieve maximum height.
d that ids aren’t sleeping or eating.
symptom imulant addiction and general sets of issues.
oughts dderall, Vyvanse and similar?
ls for .
e lives ansformed positively by Ritalin, you know, who cannot sit still, cannot do their homework, you know, and it is transformative.
time, say, over-prescribed.
ug that mes is both under-prescribed and over-prescribed.
ople wh benefit or not getting them.
f peopl re getting them that, you know, I think there’s just less tolerance for some variations in how all our brains work in medicalizing everything.
lot, w kes parents anxious, you know, your kid has this 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.
about st very generally.
can’t b nymore.
the spe you know, or, you know, and carry a diagnostic label.
, you k lot of that going on, unfortunately.
th the .
of the se I know those calls are really, really tough to make.
now, I me kids whose lives are meaningfully transformed by them.
‘s toug

gree wi and forgive me for citing previous guests, but because I’m not an expert, but I hosted a psychiatrist on here who’s expert in ADHD.
at non- ADHD poses a much greater risk for addiction than treating ADHD with substances that in non-ADHD folks are addictive.
a kid o has ADHD and doesn’t medicate, they’re at much greater risk of abusing drugs.
they’r ch lower risk because it lowers the impulsivity.
ll be t
ea, but it could well be true.
h rate among people, you know, in adulthood you see are alcohol addicted, which doesn’t seem to be, you know, a coincidence, you know.
at coul could well be true.
t on th cape of like energy drinks and nicotine has made a big comeback.


nt beca s both a stimulant, but it also relaxes you to some extent.

t, the
tolera m very sensitive to drugs.
o milli f nicotine gum.
t gave ms in my throat when I wasn’t taking it.
‘s beca , the muscarinic acetylcholine stimulation.
throat spasming, then you feel like you need it.
sical s n.

h folks e that it’s bad for gum disease and the skin folks, this,
pically but here in LA, men and women, it definitely ages skin
he vaso ction in the skin.
k older though you’re not smoking it, the oral nicotine.
ve to p ith what I’ve heard.
ze winn league.

t Colum told me long ago and many times, nicotine is protective
and Al ‘s, which is why he chews or did chew tons of Nicorette


it has enefits.
ook old
to tak r care of your teeth.
ut high t forming and addictive.
on nic s an industry and as a substance?

on.
umed al icotine in a carton of cigarettes, it would kill you.
hat’s a able that it is so popular because of that.
eason y it’s both.
then I, I feel, I feel relaxed at the same time.
ople wh t are mistaking the treatment of withdrawal for a drug benefit.
n that?

y you s en you sleep, obviously you’re not smoking and the nicotine
wn and e up, feel jittery and jangrily and all that and you have
e, it f eat because you’re, you’re, you’re, it, but that doesn’t
es are good for you.
g, you ally good.
s just hdrawal that makes you agitated and angry and annoying
ttribut well, you know, it’s the use of the nicotine, but, you
be you pendent on this drug and what you actually need to do
the, yo the days where you will feel cognitively sludgy and
keyed u ll that.
once y hrough the withdrawal, you won’t need it to get to that

ot of p ike that.
nabis a o.
ople sa n’t sleep without it.
ll, whe sign of cannabis withdrawal is sleeplessness.
t you’v ike a sleep disorder that you’re treating and not that you
trapped ycle of withdrawal and medicating withdrawal?
oids to other example.
n’s com k and it’s like my injury.
could it could also be you’re dependent on opioids.
to thos e to ride it out?
s that e, you know, withdrawal easier from different types of drugs.
f you c past that point, you could be free of using it at all.
e nice
th runn experiment.
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f peopl uding me, are interested in how to avoid getting addicted
o get o iction to different things.
s as to r or not the field of addiction treatment has started
dle sta kind of late stage addiction or whether or not it’s
addict
ber of now are suspecting that they might be addicted to social media
exting thing, something electronic.
that t ht be too dependent on food.
ted to nd Z.
present reat success of you and your colleagues and people like Anna
ing pub ocates about what addiction is and isn’t.
like i ent of the substance or the behavior, if somebody is early in the
ng like e weighed down by something and it’s hurting them in
ry diff han somebody who’s like raising a hand, hopefully, or thinking,
t takin own life because they’re so hopelessly addicted to alcohol

hing.
what’s proach if somebody says, hey, I think I might have a

d say, m so glad you told me.
hat ten llions of people experience and many of them stay silent
ore peo l.
at you ange or this is shameful or, you know, or an odd experience
n extre mmon experience.
hat so son doesn’t feel embarrassed and they feel comfortable,
bout it
you con imism.
probab know, surveys give something like 24 million Americans are

e them someone in recovery looks like anybody else.
they’r ely addicted, but not when they’re in recovery because they
d they ok like, oh, that’s just a school teacher.
t.
icer or er, but that there’s a lot of reason for rational hope.
ar case talking about, when someone’s just starting to worry
e, the at they will recover are dramatically higher.
much, m ier to sort of pull out before you’ve burned your life

real, i gh when people come in and you say, all right, well,
support
sn’t ta e anymore.
t least place to live?
you kn eping on a couch right now.
work, o know, I lost my job.
ugh for rson to rebuild everything.
ve thos rces, there’s still people who love you and your life.
aningfu where you’re contributing and you also have some accountability.
p you m t behavior change, whatever it is.
out any or change, not just one connected to substances.
do whe rk with people?
nk abou ation.

ge, but e says, I want to quit smoking.
ll say, uld you want to do that?
l, that .
h, good , good.
you do t to do it, it doesn’t matter what I think, right?
there’s a few people, if you push on it, they actually become less likely to do it.
them to o tell me, why would you want to, what do you want to get out of this?

o work u, but, you know, what is it?
es?
w, refl on that, like, well, here’s the thing.
thes st I hate the way it’s, so you would, you would, you would enjoy and help them elaborate.
get up ur clothes would smell really good and you’d feel good about something.

, and I ding a lot of money.
spendi know, whatever, 2,000 bucks a year?
bucks you hadn’t smoked in a year, what would you buy for yourself?
hing yo lly enjoy?

them b , you know, in their own mind, because, again, this is about them, not you.

ng to b and maybe I want to do it today, but in three days I’m going to be in withdrawal
el like to go back and I need to think about, wait a minute, you know,
moking you know, that $2,000 trip to Cancun I’ve always wanted to take.
helps m them.
then we o do some, like, sort of behavioral analysis of where do you use,
, what use, are there cues to use?
le ther you know, and also to non-use.
ere you never use?
you kno ver at my mom’s house.
ood to
it your re often.
er smok holy day whenever my religion is.
talk ab t.
ugh tha
ques yo there that we could try on other days?
he thin get you in trouble, you know, like I’m trying to quit drinking.
t into use and opened up the cabinet, what would it be?
ike, yo 20 different types.
mewhere
away s it’s behaviorally harder for you to, you know, get this?
wn the and go to a liquor store, that kind of thing.
ff like
there’ practical skills in learning that.
e a soc eraction without alcohol, for example?
fun?
k like
t with nd who loves to drink and explain to him why I can’t drink anymore?
gs as w
therap s.
t’s rea ortant is that like any other, anytime you’re making a behavior change,
like in y simple, almost dumb advice,
ther pe o are trying to make the same change.
ogging?
p.
to stop ng?
just go into an AA meeting or one of the other fellowships we have,
or Smar ery.
on the ourney is good for us.
shows t matter what you’re doing, I’m losing weight, I’m exercising,
I’m qu smoking, because it gives you two things.
t, but gives you some accountability.
were g gging, I mean, Tuesday, you weren’t there.

part o group or not?
for pe he combination of the two.
we enc people to do.
hear s crete questions that one would ask,
ple hav of, you know, just quit.
ople wh t familiar with addiction as a chemical brain circuit,
, full ssue, but mostly a brain circuit issue.
t makes ugh.
eone’s o say, my God, why didn’t I think of that before?

rette a out.

sed to ed at as a character defect.
ts have ter defects, but I would argue at no greater rate than non-addicts.
cter de
cter de exactly.
son I t was viewed as a character defect is that,
and sus lity to them varies.
y for m it drinking alcohol and I wasn’t aware of what addiction is,
ebody w ving a hard time quitting drinking
l, just

ind of nd just swap whatever substance or behavior for alcohol there.
e other is that oftentimes, sadly,
around n their addiction.

they lo y that wasn’t theirs.
s or ot ychologically or physically.
drug ad hat it had to come down to their kid getting into their drugs
fore th lly quit.
me, the concerned that they might not be able to quit,
ore the dren and life.
erson i sober some years later.
can ima the outside,
h some good character defect arguments when you observe that kind of thing.
le get it’s spectacular how the real person seems to emerge,
fact t addiction masks something about who they truly are,
round.

right t ot of the explanations from addiction come from people who are hurt and angry,
reason
an addi rent and that was hard for them
s disin ng and so they’re mad
g to ha rtain amount of venom in how they explain this,
ndersta
ou know e do things they would not otherwise do.
saying now, lying about lots of things that there’s no,
n’t lie
l show he baseball game and what you play your game.
I’m go save up some money and we’re going to get that,
ing fix I’m actually spending it on drugs, those types of things.
hurts
tant to ledge that because sometimes the language about,
metimes ment, public health people have given about addiction
scoldi eople who have been harmed by addicted people.
u know, ‘t feel sorry for you.
his per

almost ow dare you be angry at your mother?

.
hurts.
t, you f someone who has dementia, you know,
nt and lot of nasty things, it still hurts.

a disea n’t change your experience, you know, as a person.
rying i c messaging to acknowledge that the pain is enormous.
o live addicted person.

problem public health and just psychologically.
e wake ow of the Robert Reiner and his wife being killed by
seems nally violent and horrible by their son, it seems he’s been
was an .
im that ing up make him look quite angry and deranged, frankly.
teresti ee how that shapes people’s views of addicts and addiction.
e was s d by his parents for a long time in that addiction.
vie tog which wasn’t a very good movie and everyone knew it.
, it fe a desperate attempt to rescue his son through his profession.
ed as t ly as it possibly could.
is home uote unquote, homeless problem, which is perhaps also an addiction

ng that s are in pain, but the people around them are in a lot of pain

n the f ddiction could be framed as like a context as opposed to

parate avior from the person.

an add arent as a kid, you know, you won’t understand all that

you’re love and attention and you’re not getting it.
ommon e ce to grow up with an addicted parent.
te life gative feelings about it to people.
derstan you know, even if you do eventually come to the view that,
had a or mom had a disease, you still didn’t get what you

you kn ef and sadness about that.
ould yo to quit?

ting qu
n’t it?

for a m bout the carrots and the sticks.
of obv most cases.
moking, dn’t have to pay for cigarettes.
d.
much.
en a li re cryptic and probably harder for people to think about,
hink ab they’re very far into their addiction.
rved so tacularly enormous, frankly, weight loss achievements
le.
r Jelly forgive me, that’s his name.
hat.
me.
ant man
o in ex like 400 pounds or something, lost over 300 pounds.
med hum g.
out wha doing, he’s running 5Ks and half marathons.
letely nt person.
dy who’ stuck in the very large body, they can’t imagine those
y’ve ne lly lived in them.
ake a c otivation, a positive motivation,
ient in that it can really pull them forward as opposed to just all the stuff that they’re not going to feel?
be pre se to losing it all for the sticks to really matter.

ome ext u 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.
hey do more.
ion, if k people about what, you know, what about something, would you take, you know, $5 today or $20 tomorrow?
ke to s ight now.
omorrow t exist.
proble ou can’t really say to people, you know, if you get in recovery after like five years, you’re probably going to, I bet you’ll meet a nice person and you’ll get married and settle down and then you’ll go back to school and get a job.
ll like now, fantasy camp kinds of stuff, right?
s okay those long-term goals.
very m ng.
us on t hat are immediate because that’s the world they’re living in, a world of immediacy that, you know, you know, for example, you will have more money every day.
not, if using an illegal drug, your risk of arrest will drop to zero immediately once you stop engaging in these transactions.
cally b you know, very, very quickly than you feel right now.
al rein nt really matters too.
geniuse e people who developed the 12-step fellowships, the fact that you get literal status by how many days you have not, or years you have not used the substance and you get, you know, respect.
are abo e things for very good reasons.
l to th val of the species.
it was of AA to have the one day at a time concept.
be seem hokey, like a slogan.
nly qui ing for the rest of your life.
right?
inconc .
nk toda
go to ng and get some reward for that?
bly do
every then you will have 30 years eventually.
to wait l those rewards because it’s very, very, very few people can do that.
really hey’re probably not very prone to addiction.
at far ll the time and have extremely high self-control say they’d be less likely.
addicti re people either believe or it’s actually true that it helps them be more functional in other areas of their life?
with t hree drinks.

escript mulant and get your work done.
ADHD, u know, not revealing anything, you know, that isn’t already known.
raise l f alertness.
equisit ocus and you’re out the gate, whether it’s caffeine or people who are taking,
our de ford campus, I would bet that there are students who are not prescribed Adderall, Vyvanse,
s that em in order to get work done.
tive pl they’re driven and no one wants to feel tired when you got work to do.
t of wh look at motivation.
k what is you say, drugs are bad, look at all these things, it’s ruining you, you know,
hurting is way, that way, this way.
ind of the person they’re an idiot, right, if you actually do that.
articul
ike som s about it.

table.
s just friendship group has always drunk and I would just love those hunting trips.
w, shit together.

one thi get.


ing thi struggle between you as the punishing force that’s going to deny that this person has enjoyed something about this
t of it ly.
s is wh his is what we need to decide.
and th the benefits.
mine.
nt to g his or not?
the gr those things.
, I use so much closer to my college buddies and now I had to skip our annual trip for the first time because I was afraid I would relapse.
a real
be gri
are ma gs like that.
relatio where one person nagged the other to quit drinking and then when the person got sober, left them.
d a lot s that they didn’t like and it turned out there were certain aspects of the person, you know, their drinking problem that worked for that other person.
l, I ha control over the checkbook because you were always drunk and I got to make my spending decisions by myself.
n’t hav find now that we’re talking more, I realize I don’t like a lot of things you say, you know, before.
at’s al
of thi pen.
n some ense, you know, I don’t mean necessarily beneficial, but they have some function, right?
re that cause that will change if the drug use changes.
xample resting because there’s this whole notion of codependence teaming up with or partnering up with addicts.
like Co nce Anonymous and…
s a bit ated, honestly.


nterest dies was done by Ruth Conkite.
for a nd it was women who were married to alcoholic men and did, you know, all the things that fit the codependent thing.
en got nd they went back and studied them a year later, the women looked exactly like women of men who had never been alcoholic.
ngs tha ttributed to the personality of the codependent person is actually reaction to addiction.
yper-re le.
ause th age won’t get paid.
lacatin
be beca y’ve got this volatile person, potentially dangerous person.
of that from.
a bit u
there a le who have bad tastes in partners.
out tha
air to reciate a lot of things families do are more reactive than something that was preexistent and fit with an addiction.
ortant ecause I think most people think the addict codependent pairing is almost like a prerequisite.
inds me s whole literature, which I think is an important literature that became popular about, you know, avoidant attachment versus anxious attachment and this idea that people always pair up along these dimensions.
t have rried out subsequent to those naming categories is that put each of those people in a different context and they behave very differently.
can – s more plastic in our psychologies, in our romantic pairings than perhaps we assume.
that, y , there are people who 10 years into addiction find they’re not married to the person they married, you know, because that person has changed an awful lot.
they w ginally pretty social, pretty competent, pretty honest, and then after 10 years of heroin use or whatever, they are none of those things.
eels li he marriage person, like this is just not the person I married in the first place.
match, cause I picked the wrong person, but that person changed.
t and t inal question, which was different stages of addiction perhaps requiring different approaches, there’s this idea perhaps – I’m trying to remove my neuroscientist lens here – but I believe – I’ll just be open about this.
hat at int if you use certain substances long enough, the brain has 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.
-heroin s, they’re different.
rent ev gh they’re sober.

ect exp because there was time, et cetera.
rtain d tually kill neurons.

e the r ircuitry.
ifferen
t they ‘t quit.

imagine g 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.
could w his circumstance.
‘s the
hey’re .
beast.

mental understanding of the disorder that is a change in the brain.
ow, you ll it disease, you can call it disorder.
as dee adaptive learning.
that ra eally, really believes the most important next thing for me to do is to consume this powder.
ng all ngs that I’m evolved to do instead.
true.
es and observe them in the brain.

t thing the person can’t even report on.
k, myse udia Padula, Brian Knudson, Kelly McNiven up at the VA in Menlo Park of people who were in a residential program addicted to methamphetamine.
hamphet hile they’re in the residential thing.
m, imag m and showing them cues of meth-associated things like the pipe or the powder and all that.
w much like that?
wards t
f that, s also nucleus accumbens activation that you can see.
who rel
but wh e was going on in their brain.
cessari it.
us accu s 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.


eport, d, nucleus accumbens, let’s just put in dopamine activation as a proxy.

ine act , so to speak, we’re being neurosciency here, not technically precise.
activat dicted whether or not the person would relapse better than their own self-report of the subjective feeling of whether or not they would relapse.



n why, w, addicted people sometimes get unfair rap in terms of, well, they, you know, they lie about what their desires are.
nt to s ng.
ould as they’re in a residential program for 28 days, they do, in fact, want to stop using, but they don’t have complete insight to what’s going on on the inside of the brain like anyone else is.
ose two would both say, I really, really want to do this.
d relap the other doesn’t.
ily mea ne who relapsed lied.
idn’t r how deeply my brain has been changed.
d for m n, you know, the neighborhood I live in, to walk around and see no one using drugs ever, to see no allusions to drugs in TVs or movies, to see no pipes, to see no powders.
lapse b I have rewired my reward system.
n they out your addict brain or one’s addict brain, that’s my addict brain, that’s your addict brain talking, that’s not you.
that yo red to, I think, pinpointed the addict brain is, at least in part, nucleus accumbens, dopamine reward, circuitry activation.


anticip predicts the use.

icularl you get into legal products, that is a hugely important thing.
n, it’s ard to watch TV and not see an ad for beer, for example.

yes.

where , around cigarettes, you know, this is very driven by class, but there’s still a lot of neighborhoods where quite a few people smoke.
d to ge gh the day without being exposed to the Q, the smell of tobacco smoke, or the smell of cannabis smoke, for that matter.
you kn ving is going to be a driver of relapse.
someth t you were not born with.
hat you through a repeated exposure of your brain to, you know, pretty powerful drug.
ing who p 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.
what yo inting to really represents the divide between that inner voice that we think of as us telling us, like, why am I doing this?
be doin but I feel like I’m compelled to do it, almost in a kind of automaton kind of way.
common nce just in life, right?
shouldn that, ho, ho, I’ve been trying to lose weight, but I’m tired today and I’m going to have it.
that w a contradiction between our idealized self and our own head and our behavior, that’s probably just being a person.
the po t 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, then you start to worry, right?
going t mage to yourself for the purpose of consuming this brain candy, you know, which has no nutritive value at all, but is clearly seductive.
these d t if I were to go back into the lab, I’d want to team up with clinicians like you and some of our engineering, bioengineering friends and develop something, which would be similar to what Nolan and company developed for depression, right?
ion, br mulation, not just willy-nilly, but of particular brain areas and circuits to try and undo major depression.
erful i was a brain stimulation device that could tweak the reward circuitry in the presence of a cue that predicted methamphetamine for the amphetamine addict or alcohol for whatever, process, behavioral addictions,
ate the y to experience reward, but would eliminate essentially the bad addiction or tamp it down, tamp down the rewarding properties of the bad addiction.
e, do a iment, a parallel experiment where you ramp up the reward circuitry in the presence of a, something that cued for positive behavior.
nk you t tamp down reward circuitry.
challen ave with the, you know, okay, obviously abstinence is going to be critical, but for somebody that has a nucleus accumbens, and we all do, it’s going to want to latch on to something.
ny addi ot to the next thing.
althy t
are add
e that
2-step , and this is somewhat cultural also, but you can’t go to a 12-step meeting and not see people with lots and lots of tattoos if they have issues with, and I’m not demonizing tattoos, but if they have issues with drugs or alcohol, typically smoking will pop up in its place.
.

d be, y , school and family and connection and community and public service.
uld, yo but a device that could help tune the specificity of reward, I don’t think is outside the realm of possible.
Stanfo now.
everyt

OCD.
depres
PTSD.
so man s.
it’s pl y that we’re after.
e right ne of the challenges is, you know, addiction is, it’s not like it’s introduced something new into the body.
very s e use to negotiate life.
use for now, learning, you know, acquisition of knowledge, acquisition of skills.
we jus t have that, we would be better off.
er off.
withou
ry pati at West Virginia University, you know, who had a very uncontrollable addiction and got, I’m not going to take sure of the nature of the implant.
ng impl at’s happened once.

about
friend at Washington Post, interviewed that patient and the team.
likely e will see something like that.
ee more you know, transmignetic stimulation, because it’s not so invasive, not so expensive, and not so risky.
t, led Salem, who’s a really good psychiatrist, a multi-site study with RTMS to the dorsolateral prefrontal cortex for people who are cannabis use disorder, addicted to cannabis.
eople w on these protocols for alcohol, for cocaine.
ork.
lmost..
almost aying we put them on pills because there’s, you know, what brain region, at what intensity, all that kind of stuff.
know, t vene far more directly, you know, to the brain than talk therapy, for example.
nk that tainly possible.
ossible
e was s who was very, very, very…
g on ea still couldn’t stop.
even wi implant, still needs medications, goes to lots of 12-step meetings.
it dis
an, we talked about GLP-1 agonist.
n that, s maybe something that would have the lasting effect on changing what one wanted.
o talk LP-1s.
we piv e…

the, qu uote, homeless problem…

a, you ut see this.
t least ll me where my numbers are off, 50% an addiction problem, either first or also.
ah.

aren’t to go to 12-step meetings.


em to.
y door alk to some of them and they’re not going to 12-step meetings.

e…
ry is a
d befor
eless p
en know eless is the right word.
o the u thing.
ess.

es, you
ed to s irs with the naming.
erious ce abuse issues.

h issue may have stemmed from that.

to solv hole problem here in, you know, five minutes or less.
e wrap es around the legislature?
involve ings related to this.
get som n the street to understand what’s going on and rescue themselves?

, it is high rate of substance use and mental illness.
other p because unemployment is low.
economy lly terrible, there are a lot more people who don’t have anywhere to live who are, you know, just need a job, basically.
ot…
t of, y , housing or a family.
t they rk.
, unemp is historically quite low now, so who’s left are the people who cannot, even when we’re near, you know, full employment, cannot find a shelter.
e peopl ave problems like mental illness, like addiction.
ngs, an was good evidence you can do some things by combining housing, you know, nice housing that people would want with recovery culture.
‘s a mo led Oxford House, which is run by the people who live there, and they all contribute a bit to the rent, and they have a culture which is basically you can’t fight, you can’t be violent, and you can’t use substances or bring them in, but otherwise that’s it.
of reco mmunities, like 10,000 of those things.
s have good evidence of benefit.
, for t ave, you know, the streets and live there and make that trade.
drugs a
more.
ast hav e, clean place with nice people who like you and will support you.
e.
opinion to – it will be a court-mandated thing, and there’s two mechanisms for that.
paired ey are a gravely disabled and imminent threat to themselves or others,
e civil ment process, make them go to treatment.
itted a and many people do, like, you know, grab someone’s iPhone, knock them over, and run away, and get caught,
type o age we can do through things like drug court where you say,
shoved erson, you assaulted them, you stole their phone.
o jail s, but we don’t want to send you to jail.
if you mply with this treatment regimen, you will not have to serve the penalty for that,
your r t the end.
gs are o be necessary for some people.
people e uncomfortable with that.
to use re to put someone into treatment?
nethica
th Alzh disease wanders away from a nursing home, we go find them,
ack, wh hey want to or not,
hat the e is affecting their judgment.
hey can e out there, they’re wrong, and so we take them back, whether they want to or not.
g is tr olutely true, of addiction.
nges ou ent, impairs our judgment, and without pressure, many people will not stop using.
ike to y Doug Polson and colleagues of people seeking help for alcohol treatment.
ood one ause alcohol is legal, right?
r on al ade them go.

them, one leaned on you, basically, to quit drinking in the past year?
d yes.
moving h the kids if this continues.
show up one more time, you’re fired.
s is yo d drunk driving arrest.
treatm the judge might take some mercy on you.
in a wa on’t have to press people to seek care for, say, chronic pain.
ain suc
to leav ic pain.
valent iving up substances because, again, it’s rewarding.
o it.
is nece
to hav that with the sort of criminally involved homeless addicted population.
to get table with protections for sure, protections for civil rights, need to give them quality care.
to trea here they can regain their reason and then make better decisions for themselves.
involve gislature.
e when I can say you did that under a Republican administration and a Democrat, a Democratic administration.
o get i tisan politics here.
opposi s of the aisle.
to get legislature as it relates to addiction and treatment of addiction.



?

to the moment has been the best addiction treatment policy we’ve had as a country.
e 2008 parity legislation came in.
e Cross and all those.
ff, the to cover mental health and addiction too at a comparable level.
expand over more and more people on the private side.
side, t nsion particularly of Medicaid has become the backbone of a substance use treatment system.
e I’m f st Virginia, I have to know it’s the biggest spender, you know, of the addiction treatment system.

ment in quality, easier to access.
d is a eam healthcare player, it helps integrate addiction care better into the rest of the healthcare system.
nterrup ut 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.
nce, th go to a treatment center and it will mostly or completely be covered by insurance.
lan.
mise an particular, but here’s what used to be legal.
n could ur copayment for an outpatient visit is five bucks unless it’s mental health or substance use.
25 buck u’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.
gs whic very skimpy benefits are now illegal in almost all plans.

m or da you open up the plan today that whatever you got through your work or wherever will give your kids something that they need is just way, way higher than it’s ever been before.
advoca changing the law and changing the regulations because obviously covering care costs money.
to, yo cover care.
y have they also don’t want to.
eeping ssure on, they have to follow the law.
e’re in er place on the private side.
e publi will be the contraction of Medicaid.
udget b t was passed this last year takes about a trillion dollars roughly out of Medicaid over the coming years.
mber of on Medicaid have substance use problems.
t subst e care and other care that they need is not entirely clear.
d about pact of that, especially on low-income Americans who are dealing with addiction.
s for p ithout insurance and or who don’t want to go to a treatment facility?
about
?
n 12-st rams?
grams h s phenomenal aspect to them, which is they’re happening every day and night, online and in person.

the wo
ing, yo like it, you leave, you find a different meeting.
ay for
upport.
t so ma gs about 12-step that make it arguably the most accessible addiction treatment program ever.
‘s grow ht now.
houghts



?
t that rograms were designed by people who have the problem and therefore understood what it is, what you need when you’ve got that problem.
is like I am in Palo Alto.
neer wa in Palo Alto on a Saturday morning with, you know, his 20th or 30th or 40th beastly hangover of the year.
what a ng?
a great now, I’ve got this great life.
ow, $20 on one-bedroom condo that I really like.
messing life alcohol.
Psychi partment.
t some
d on th nd.
t a mes
day you ll back and then you’ll get on a waiting list and eventually you might get in.
charact by ambivalence and impulsiveness, I want to quit now, two hours later I don’t.
althcar m is the worst possible design.
esign?
o go to
A websi k in the area, oh my God, there’s like 15 meetings today.
ere 15 s, but there’s like a woman’s meeting, a men’s meeting, you know, a spiritual focus meeting, you know, a LGBT meeting.
.
have, moment I want to change, you can just, you know, follow through.
t immed ward, social reward for taking positive steps towards it.
ment sy ll never be that good at sort of, you know, being that accessible.
ealth i e, no paperwork, no pre-approval.

rk when get there?
eer, I really know anything about addiction in my first job.
was li 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.
into t ction field and that’s the truth.
ything t and I met, while I was on this job, I met some people who said they were in AA and 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.
it to m talked to my mentors about it and my mentors were professors in medicine and they were very dismissive.
ike, we they don’t have doctors, they don’t have medications, it’s kind of folk medicine, you know, a bit of professional snobbery there.
along ducation that I was incapable of learning.
will y me?

ell, yo go to a closed meeting, but there are these openings.
t to se
sed wit the authenticity and the caring and the warmth and the wisdom.
ade me aybe there is something here.
rted do earch on it as a number of other people were at that time.
ust kee ng out really, really good in studies, you know.
ew year me, John Kelly and Marika Ferry did what’s called a Cochran Collaboration Review.
e la cr t rigorous review of evidence in medicine as a method.
hese st f Alcoholics Anonymous done by different people with different viewpoints
and di countries even.
remely lative to very good therapies like the one I was trained to do,
vioral , motivational enhancement therapy.
mes, if k, like, do people stop entirely,
facili kinds of counseling to help people get into AA was winning, you know,
routin that.
ooked a outcomes, like did the person at least cut their drinking
e of dr or less dependent or better family, you know, functioning, whatever,

‘s amaz something that’s free, you know.
left s A doesn’t work, they really…
ink the evidence.
idence.
trials r, there are quasi-experimental studies,
e utili studies.

to any hether it’s a patient or just a person I care about,
nt to s nking, that’d be a place to try.
eally n to it, right?
to a b e, you’re out in the evening and 15 bucks.
, meani know, you’re just out in the evening.
h-risk r to just give it a go.
alterna oo, by the way.
but if e in an area like San Francisco Bay Area where there’s more choices,
lso lik Recovery and Women for Sobriety and I’m forgetting some of the other names.
don’t l articular AA model.
of mut port, people are on the same journey with me.
ng the urney and they’re doing well.

eful in on.
ly pote that’s why it’s survived and thrived as an organization.
someth e AA in it.
ion if are interested in AA, and this is, it’s not like I’ve been sent here to advocate for AA,
h menti pen meetings.
know, meeting is one that anyone can go to,
an add you’re just curious or you have a different addiction and you want to go to an AA meeting
ings te e more established and they’re more of them than the other letter anonymous meetings,
ing and sorts of addiction.
eetings
by how do what it does.
ust a s example of human self-organizing into something that keeps going,
with a .
.


y out o ics.

ple tha n’t get sober any other way that did it.
e data the other addictions that are treated through the 12-step model.
ous, Ov s Anonymous, Gamblers Anonymous.
them no

aren’t y studies, but the model is pretty much the same.
y hold
ed in t stion for the drug groups.
on gam nd sexual addicts, those things.
ol of d have to the extent we have when it’s on the NAC,
Narcoti ymous.
of thi t were interesting.
to get into those groups.
at stud re there was what’s called 12-step facilitation counseling.
there, got somebody who knows the program,
to it, ging you to go,
out, yo how did the meeting go,
ponsor, l that kind of stuff.
much lo
n an al rogram, you know, you get these, you know,
g of th of patients going into AA,
much, m ller with the illicit drugs
tend CA
hy, but n’t as easy to get people in.
e were tions pretty consistently that people who were going,
re doin r.
sn’t qu strong from a, you know, external validity view,
validi t of view.
y’re no ame kind of trials, you know, randomized trials
e, you hen we draw inferences.
he evid 12-step groups for drugs as positive, encouraging.
ry it, w, so I’m not harmful.
ong.
l kind ng AI no positively has a causal effect on alcohol.
ut it.
bout th ther that’s true for the trial.
st of c ut on average, it was harder to demonstrate that effect.
t facet en I asked whether you think AA is a cult.
ons why mes people will call it a cult is,
e very ere, is that often, not always, but often enough,
e who g AA, discover sobriety in the AA community
mmuniti talk a lot about it and how much it’s changed their life.
ew set le they hang out with and in the name of sobriety.
that ca f it’s not handled correctly,
omewhat eparator by people around them.

e insta ere certain groups are not in a healthy dynamic.
of the it seems to be healthy dynamics.
her pie I think sometimes gets tucked away and no one wants to talk about,
tical c t of 12-step is that the addict acknowledge that they’re not in control of everything.
t contr r people, but perhaps they can’t even control their own mind.
ve a hi wer in notion.
ople in this to think that one has to suddenly become formally religious.

just, elieve in God as an entity.
g is th tep, well, I know because I’ve been to a lot of meetings,
he ackn ment of some sort of higher power,
-assign hat higher power is.
.
us Chri
y natur
univer
y the c ve.
ot disc ften enough.
l say, don’t want to go 12-step because, like,
bunch o know, Jesus freaks coming at me,
ve to d ch of other things, and, you know, what’s happening?

ere in uestions.
g, well ldn’t call it a cult.
that A ‘t do.
verybod ey.
let you hem money.
g they’ ived the organization.
er off ey.
hould l at.
randios
now, an re perpetually broke by design.
gh to k ng.
t.
want t t.

ou are ked down upon.

literat u know, so they don’t do that.
they do p anybody from leaving.

n liter and up and say, I’m going to go get drunk.

s diffe an a cult.
up dru


it drin the other behavior or substance and you can’t show up

hey wil ly let people sit as long as they don’t, as long as they’re
unk rat n throw them out.
ng and then that’s a different thing.
ll.
pse is l part of recovery and nobody knows that better than

iate th know, they don’t want to hear from a drunk person, obviously.
ous thi
word Go , right?
ople wh have had bad experiences, you know, and just that word
hem.
t reall sense, it doesn’t even matter how, if they know how
fines i just like, look, I was, you know, I went to Catholic school,
hool, I I hate religion, and this sounds like religion, so I don’t

e might pier than in programs like Smart Recovery, which doesn’t
to it.
redibly le, you know, in terms of how it’s, that’s why it’s really
ligious zation.
u know, t says in the texts, the 12 steps are but suggestions.

t in a an church saying, you know, Jesus was the son of God,
who kn ‘s really up to you, right?
at, in ion, no, he was, period, that’s not a negotiable point.
egotiab r than what you believe, it’s like, it’s like, it’s what
ou go t ngs, stay sober.
are.
sen, wh d away too young, unfortunately, was an addiction psychiatrist,
to peop k, the God in AA can be anything.
it cou esus, it could be your group, it could be the doorknob,
u, you istic SOB.
y were concerned about with the people who found it, is that it was
of, I ontrol, and I don’t need any help.
ally.
elief, ke, no, you’re whipped.
lost yo rol out of the subject.
is the l point, how you end up explaining the spiritual part is
ut that s not negotiable.
be ther
I can ontrol my drinking, they would say, well, then you shouldn’t
we can’ ‘s why we’re here.
ounders good psychologists.
juxtap of the narcissism and the shame that is addiction.
hey wer were really great Americans.
d, they d the country.
om this , if you’re curious, you can go to an open AA meeting if
nterest
ound th and people say, I’m so-and-so, I’m an alcoholic, some
and-so, m their first name only, of course, and they’re an
re a vi you just say, you could say nothing, you’d say pass,
ch mind or you could say your name and just say, I’m just

a numbe mes, and it’s usually family members of addicts or
want s in their family or a friend to go to 12-step.
resting trick tool.
er to g one to go to 12-step if you yourself have gone, and if
t and y someone to go saying, I went, and I’ll go with you,

unds ve of hokey on the one hand, but I’ve seen the incredible
can do


comple ee, accessible all the time?
wild i n.
y John my friend who did the review said, it is the closest thing
unch in health.
let’s t ut GLPs.

any peo e lost a lot of weight who couldn’t lose weight previously.
thrill so relieved that I don’t have to look at these stupid arguments
t wheth ot obesity was the consequence of some other thing besides
calorie ive to caloric expenditure.
o blame t statement, but it, like, people are going back and forth
and th of thermodynamics apply.
to GLP ou eat less than you burn, you lose weight.
for pe o are very overweight to eat less and burn more.
all th tionarily, you know, hardwired circuitry of desiring overconsumption.

time w ere are these peptides that people can take to lose significant

eptides ing down now through the compounding pharmacies, and people
es.
people aring their GLPs.
g them.
that.

tion.
low a GLP is required for people to get the desired effect,
ing up .
compani this, but people are getting them through compounding

heir do
ir…
escript ut they’re doing it, and people are just losing weight easily.
cle, an one gets, you know, inflamed about that, but you can do
ining t t that, and they’re awesome weight loss drugs.
ng, and .
the wa I would take them if I needed them.
have ot efits, too.
t fully d out.
ely int in their effects on substance use.
friend n addiction psychiatrist.
atients is they want not to want.
ent tha , I want to conquer my desire.
didn’t this drug as much as I do.
s somet friend of mine said to me over lunch, a friend of mine
ost a l eight, and I said, wow, you’ve lost a lot of weight.
on GLPs
to spe day not eating, and now I don’t think about it.
l day l
t, don’ don’t eat.
is just
ould do or, say, cocaine or alcohol?
sort of same kind of family of behaviors.
interes udies.
here ar studies that are negative.
you kn hing ever works out perfectly for everybody.
ough an udies, small trials, and opportunistic epidemiological studies,
throug ospital, you know, here’s 10,000 people who, you know,
cocaine sorder, and let’s see if the ones on GLPs went to the emergency room list,
.
know, t vulnerable to different kinds of selection effects.
is patt ticularly with semaglutide,
at is i V and Ozempic and alcohol, drops in alcohol use.
er thin nk is perhaps important,
now wi VA and Novo and a philanthropist to do something like this,
the mos eating of drug behaviors, right?
ese dru te a sense of satiety and fullness, right?
ore lik change, you know, swallowing something, a drink,
ing mys snorting a powder.
, you k ting-like behavior.
was op c.
re I wa tart.
ould be tic.
u know, have a drinking problem,
re like lso be overweight.
lready overweight.
wo-for of this, you know, for, you know, transforming people’s lives.
ounds a your drinking problem.
mention ear friend Anna Lemke and my colleague,
eat is re patients, I don’t really want to stop drinking,
st love weight.
se I’ve verweight my whole life.
the Oze re in the addiction clinic,
t motiv r the addiction part,
omes wi other thing I really value, then I’m going to do it.
he bene
, their ng cuts back.
lling.
is thes ld drugs.
, like, rs.
e that.
d milli people have taken them.
ss like there’s some awful side effect, you know,
p for 1 to them.
ot of p l upside here.
t coupl of science in this area are going to be super exciting.
hol cra sugar craving?
much.

he lure u know, when you’re hungry, you know,
ely to ?
AAP wou this, you know, hungry, angry, lonely, tired, you know.
l that ke, if they…
someti l this way about carbs, you know,
, are s carbs, they want a beer.
hing in
hat’s t amental thing that is the driver.
he subj effect of consuming.
toward g advertisements for pharmaceuticals on television, online.
on.
elevisi ore?
ion.

ffect i ng to have now that so few people watch television.
houghts t?
se, the medications for hives and allergies and all these things.
egory.
y think things that have an addictive potential.
on on a rd-Lancet Commission that I led, you know,
en Lanc the medical school,
points e is that there’s only two countries on earth
n ads a time, which is us and New Zealand.
New Zea ut it’s just…
m other ies come here, that’s always a jolt to them.
go to per Bowl party and like,
for ask octor about this, ask your doctor about this,
ut this
te, and t prove this,
create that everything is perfectible
our doc ugh and, you know, and that is just not the truth.
ide, I to worry about them, particularly for, you know,
don’t h ankfully, OxyContin ads on television,
shot c als.
mean th one actually in the Super Bowl of,
duced c tion.
know, for?
y of br up the subject of, you know,
w, opio killers.
have t d I think that’s good.
pioids, y, and we, and, you know, they’re, I’ve worked in hospice for 10 years.
l me ho dibly valuable they are.
e, you verpromotion was clearly part of what triggered the opioid crisis.
an TV, everything.
know, g d, you know, other types of promotions,
at were arated enough from the industry.
highli n the Lancet Commission.
bably d have its own 12-step yet.
on.
e to st

en disc in the past about television is ruining society,
staring ox in the evening.
pened m times throughout history.
social addicts or video game or YouTube addicts?
like i tion working?
like g at it’s not quite like eating,
eat at oint?
person older person,
person you can’t ever be on social media isn’t reasonable.
u’re no to talk to your friends
ding ri front of you, and it’s not going to work.
ercepti ford freshman who said to me,
.
r my me alth, but I have to be on it because everybody else is.
tragic, think lots of people are in there.
story o lane coming here of how much would you have to,
demand had to leave social media?
a cert ey, you know.
rybody re leaving it, the same people would say,
o be on em.
gs like stralian social media ban are going to be really interesting
ally an dual punishment.
iled fr party.
s going pen in person for teenagers.
hat wil that real life more appealing than being online.
nated.
ow what g to happen, but really fascinated to see what happens.
s the c more people coming in with these types of problems, you know,
hey can looking at their phone or games or pornography is a really big one,
throug media.
re are bling apps you can use on your phone and that kind of thing
remely lt lives.
have b bsolutely consuming for them.
hat the l course is of this, you know, because it’s new.
e five- urse of social media?
ally im e to answer at this moment.
people evelopmental thing that they will get out of?
go int lege campus, you will see a lot of people drinking at levels
them fo level of alcohol use disorder.
f them ars later will be married and have a job and drink very little.
hose ki maturing out effects.
out ef social media or not?
t was e ..
of X an I stopped or just do a teeny bit.
cularly but of course, I had 40 years of my brain not touching it.
y for w the most popular thing of kids,
Instagr omething?
g that, thinking in that plastic, you know, neuroplasticity
ere 8, 11, 12, is it developmental?
l you b ing your kids?
e kids you don’t have sex because you don’t have a date
ll day at the phone?
t cours
yet.
f adult ted to social media.
addict

m not, ds like an addict, right?
o say I think so.
enefit ng an old phone when I upgraded my phone,
seldom, finally upgraded my phone
hone an X and Instagram on that phone
of the n a Supermax prison lockbox
out of
day or now, 19 hours or something.
t open t wouldn’t even work.
ul beca e it’s locked away
rtunity k at it,
hings, open it on my other phone
pick it blocked.

and it t require, I mean, the box costs 30 bucks.
d more at in work output and recreation output
t with friend and not looking at my phone.
people done things like that
a dumb
nstant tification, da-da-da-da.
tware y get that like, you know,
of tha
ally go enter a code and say,

those a know, useful things.
ight,
a lot al norms about it.
k of so like drinking before noon, right?
nst dri efore noon
er of p bide that norm, right?
h, well not noon, you know, da-da-da.
ime evo e kinds of things about social media,
now, li know,
find se
l media dinner table would be, I think, a good one.
media i taurant or whatever.
‘ll do that
olve th lem just through individual clinical medicine.

o be so
lt a lo rms around alcohol, we’ve built norms.
nk and
t peopl roadly find believable.
social I think,
of the f, you know,
t has g with them.
real-li ples of young guys whose parents I know
tacted use different situation for each,
ibe the p.
s looki a failure to launch.
high s
vated t f to college
y colle stopped doing that,
ost the
a care that was going to sustain them independently.
ame ent s, to say the least.
ced the DHD, all medicated.
o say,
on of r ircuitry and Ana’s book,
ook, Do Nation,
y hard their part is really what did it.
n highe tion situations,
off me n,
t video or YouTube
eriod o
attent apabilities.
y,
se that ave agency in the world,
things for themselves.


s are r ly high achieving
ve patt addiction
dicted this.
o escap ortex of this stuff.
se stor ause I think,
stories m proud of those guys.
multif l.

tion or
ion did cue them
e or, o video games.
patter ogressive languishing
context ia.
g to me porn,
that wa e backdrop
ses.
butt r w,
n healt tionships,
ng out,
most i t thing.
cannabi
rink,
rink, i , without any issues.
k about hey have to deal with
had to th growing up
really tand what addiction was,
y more coming at them

nshackl selves
fferent nd chains.

ake, to
ny path t of this.
here,
to rec
le who,
ear fri mine,
d to qu ing
s and y d years
felt to efeated by it
by, you
father

around s beautiful being

hanges sort of homoracial system
nges th ve another friend,
it was o prison,
a terri ng.
d anybo fit from being in prison?
needed you know,
y month f methamphetamine
l.
zed, wo was really crazy.
he didn any treatment.
way fro rug for an extended period.
nite nu stories like that
onditio know,
of mil f people, right?
be lot ots of pathways out.
by the rprises a lot of people.
substa blem
ell in resentative surveys,
tually see anybody
iatry.
pathway
tion tr .
l kinds s
asons.
am memb e has been open about this,
le sayi
alcohol
lifelo hol and cannabis addiction.
gs, but he decision
weight
r produ
ing wel h
rced th
ed of, w,
d, as t .
switch day,
.
ng him y,
id you eetings?
nt to t
ent beh

he othe s he was doing.
take t s out of his mouth,
few pod
elation th his kids,
sly pro ally,
p to hi

mily li lcoholism.
t’s wha imes people forget
ak the n one generation,
ctacula
k.
.
ortant.
om, you
ns wort
hat you is necessarily going to come out that way.
another too,
iful fo of people about recovery
cquirin reasons not to use
e at th t you started
those r ships out
ed them
en livi our mom’s basement,
d being all day.
to get ow,
I’m res and I feel important is nice.
e.
u know,
ou know
the ti ice.
kes it month by month,

st of y e that way.
n that t to ask earlier.

of a t ubject.

‘ve hea sometimes the smarter the person is
ctual t d to be

orks fo
just ki o,
d, carr .

llow st follow step three.
uncomf and do that.

han the ones.
of do i
k it.
quite a
get in ons of IQ.
ome peo e this prefrontal cortex
five di strategies simultaneously.
ke more nd chug.
er or w
.
that f le who just kind of like ratchet into the work
it, wh is about?


his one ce, like, will I ever drink it?
out it h.
eps and e out.
s.
xpress
ng got e?
keep i e.
e to, y , do a philosophical critique of the 12 steps.
on’t dr to meetings.
meeting
, and i action program.
fferent t sense from a lot of psychotherapy styles,
, more ctual and analytical, you know,
you’re ly going to do certain behaviors.
ke that I can see why AA would bother you.
AA is, st not one thing.
m sure, a few miles of where we are sitting,
meeting gas station with guys who are smoking tobacco
tattoos e talking about the steps.
eetings rofessionals who will talk about, you know, angst and things like that.
d your ple.
very i tual people, like professors,
ting wi r people like that.
orking ps and all that, but they are also, you know,
lk abou egaard.
, and a ike AA is like, fine, you talk about Kierkegaard.
t drink meetings, talk about whatever you want.
d your
I, whe e are thinking of going, I say, think of this like dating.
wouldn n one date and say, I didn’t like that person.
o be al rest of my life.
f dates ?
ent mee t different times of day and different places,
fferent
the on felt like home.
, you k ere’s no wisdom like the kind of wisdom
really are from someone at an AA meeting
en they up and started their share
g in co th this person.
fferent ses.
re’s so el of truth for you
ou disa th, and therefore you have insight.
thing,
hey wer conscious about that.
you kno called the big book.
, it wa d the big book because it was printed on cheap paper,
at and
e Depre right?
his boo stly stories, and we tell stories
omethin em will catch you and say, gosh, that life is like mine.
r she i
there.
of like d they got to that good spot.
that go .
ious an I think, clever organizational strategy
know, a place for you here.
you he
bout de

ce.

not co le talking about death.
fear, b ink there’s a lot to learn about it
someone been close to it a lot.
very lo out losing someone,
to go lly, and that’s, you know, hard truth.
into ho and then what did you learn about in hospice
our sen ife and death?

hospice lor.
10 year
beauti ngs about it.
ell peo ey go, oh, God, that must be really depressing.
the mos t people I’ve ever worked with.
ionate, verything.
ld sort erstand it because, you know,
erson’s to die.
worst uld happen, right?
think h, if I say the wrong thing,
our se you know,
three to develop more trust.
oing to ve that long.
pted th , right?
just do nd help this person have a good death
ly have death and work, you know,
experi
very u
d it de g at all.
ause I fted to doing more research
aking c patients.
nt to, w, the obvious thing would have been,
just do ddiction thing?
ll just ething different.
was I w ed of death and I don’t like being afraid.
person
I’m af being afraid.
look b
ow abou a, like the most basic thing is exposure,
ear and y.
hings m em scarier.
all rig scared.
.
hat pro
as much round death as I can.
imate e ce.
people s.
they’re g in your office, but, you know,
bedroo have like, you know, what is that?
u know, a high school baseball player.
w, the ls and, you know, or, or what’s that?
icture.
I 40 ye .
intima sweet.
friend y ever makes is an incredible honor.
hat whe to say goodbye, I had been honored by them in that way,
y made.
it prof a moving experience.
at fear
to hel people get free of that fear.
been a t for a while and then the family, you know,
e scare aybe sometimes doctors are scared of death,
on who his is what’s going on.
om, you your uncle’s going through.
to hap ely.
s likel ve.
oing fo
them b you, you are radiating that acceptance
ome to, is hard.
glad I at.
ld reco hat to anybody who wants to like give back community,
to a pl peace with, with dying.
is to, e with the dying, not to run from them.


we both olan.
I was eling your, feeling your feelings.
like he way you describe it is like heavy
ightnes ere, which clearly I’m not a hospice worker.
ve that onship to death, but thank you for sharing that.
a unive perience and, um, being in there with people alongside them.
ng that k many people, young and old run from it’s, it’s like, uh,


here.
societ know, I’ve, I’ve done work in developing countries.
eath.
w, ever eople die in the street literally.
s, oddl h, there is more death and less fear than there is in
logical y where death is hidden and, and, and denied.
are mu terrified of it than, you know, people I met in Iraq, for

why you have to make an effort, you know, cause you’re, you know,
st thos and those structures if you want to be in, in companion
eople w dying.
asking ‘m about to ask, but it’s been on my mind a very long

elated two major topics we’ve covered, which are addiction and

aid by ing addict that all addiction is gambling of some sort.
g to ge le this time?
I goin t fired this time?
I’ve th lot about addiction and I’ve wondered if all addiction
cape ou of death.
an att get philosophical or, or, um, deeply psychological, but, um, I
thing.
other s think, but it’s a weird thing that the portions of our
hink in future and plan and build technologies and it made us the
th and e the house cats or the elephants or something, um, can
we’re o die someday.
y drop at feeling for most people, it is scary.
nd real
any of pped really deeply into that and we’ve created any sort
ything ne, it’s deeply terrifying.
say ab iction is that, um, the states of being high, whatever the
erson, y have a timelessness to them.
eal wor e you’re operating in the real world as if you had superpowers.
one’s m
ther or e fear of death, uh, is something that addicts in particular

the qu is embracing death as a very real thing, overcoming that
obia, u ou think that perhaps could be used to help treat addiction

ly inte idea.
think v adly speaking, a lot of heavy substance use is some desire
uh, to y from unpleasant truths.
k I, on ose is death and suffering, but I think it’s broader than

I just be in this, uh, PTSD anymore, or I can’t, um, you know,
ed as a and I, I just need to stamp out those visions and those memories
u know, nd step outside them.
disint and I’m miserable and, uh, my spouse and I hate each other.
moment I am above that or unconcerned about that, that oftentimes
g awful h, uh, that and frightening or, or humiliating, uh, or,
that t the escape from.
they do e that, you know, at least in the short term, the high,
, are h t in the short term, you know, everything could be falling

on a st , you can still feel, you know, euphoria, at least for

gh abou ery is when you stop using, those things are not gone.
to die.
bad, y riage is bad.
you we l abused.
to pers me people never to stop because it’s a lot harder to actually
ngs, um on, uh, than, than avoiding them through, uh, intoxication.
or this sion.
h light stances, routes to sobriety, uh, stages of addiction, um, very
the GL 12 step, we’ll provide links to all these resources and papers.
ng, bef walked in here, I solicited, um, acts of all places, uh, for
iction.
u, most questions that were asked, um, are already answered material
, but t re three that I think are worth touching in on, uh, that

s, uh, getting addicted to things more than women or are they
help m en?
consum addictive, uh, substances in every culture on earth and
, uh, i he major addictions, you know, opioids, probably for a man to every
hol, pr about 60, 40, um, you know, used to be higher, but, uh,
rinking
ee in c that is close, the one is a prescription medication that those
ttle cl 50, 50, but otherwise it’s predominantly male.
p betwe ction and lying and not just lying about the addiction?
collea talked about this before.
g circu ere?
o.
you end these situations that are possible to cover over without lying.
, where now, you, you were supposed to, you know, dad, you were
up aft ol.

drunk,
say th
ou know ar, I had car trouble, you know, I couldn’t do it.
w, the hat happened to the, you know, money for the, oh, yeah,
ax bill e I’m not going to say I stole it.
is why
course metimes we make, uh, addicted people lie.
out to nts that, um, if you watch how doctors sometimes ask people
ce use, bsolutely clear the correct answer.
drink, ?
ugs, do
o, and u’re addicted, you get very good at, at reading people.
person o say if I tell them that I use methamphetamine?
they li because they want to, but because they know they’ll get
from t on asking them.
was abo pse.
that re an occur just as easily when things are going well, as
y’re go rly?
your cl

pse, uh th ways.
friend e in college, I remember his dad, after years and years of
ober an miraculously got an extremely high paying, respected job,
ly erra k history and, uh, immediately relapsed, went out and
on a h and, and, uh, killed himself.
, how c ou know, everything was going right, but you see that a lot.
you kno t money in my pocket and I’m happy.
.
d me.
do wha ays did and then be shocked that I got the same result


ough, r is most likely in times of, you know, stress, you know, whether
nsitory , like, uh, you know, spat with the spouse or, uh, with
st real know, I was exhausted, um, you know, didn’t sleep well
in a ro kind of thing, or something bigger like, uh, uh, you know,
addicte and I’m dealing with that and that makes me more likely to relapse.
om me.

dad of lege age boys.
you gi or do you give them about addiction?
at they ticularly prone, but just they’re in life and to be in
you’re to addiction period.
ling th s, even from Southern California, um, because, uh, they,
e, oh, , another talk about addiction, you know?
them a out fentanyl because I’ve known so many families where kids
, say l u know, nice, nice family, middle-class kid have died from
took as n the form, uh, that it looked like something else.
this ha in college campuses, happening in high schools, you know,
d pills ook exactly like an Ativan or an Adderall.
o try t you don’t realize you’re taking fentanyl and you die.
ed them that, like never to take anything, you know, you, you can’t

nally a it, you can’t know what it is.
thing I hem is, you know, the, the point that you’re going to
decisio self, but the only thing I can tell you is you will never
ething u choose never to, to use.
l point trol.
ter tha , what you started using is something I can’t know.
omethin an’t know.

phreys, ank you so much for coming here today.

e discu
s to ev that you have immense knowledge about this area and the
not jus edge, but that your clinician and you help people get
covery y sober in all these different dimensions is itself amazing.
m certa not alone in saying that what’s so awesome about the work
hat it, at became evident today is that you combine incredible expertise
compass people.
n’t hav y it.
aspect what you shared.
t’s an o have you here.
collea d to meet you finally.
just gr that we were able to create a environment where you could
e and y passion.
t it’s o help a lot of people understand themselves, understand
and ho take action if they need to.
h.

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