How Alcohol Rewires Your Brain and Increases Cancer Risk by 40%! The Alcohol Doctor, Dr. Sarah Wakeman
Guests: Dr. Sarah Wakeman
Full transcript · Read the full conversation in order, with its original context.
§01Transcript — part 1
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The amount of alcohol it takes to begin to cause health-related problems is much lower than you think.
If I have this glass of wine every day?
You’d be in what we call moderate risk, which is associated with pretty much every form of cancer.
So say that I’m drinking two glasses...
If you’re drinking two of those glasses, we’re talking about a 40% increase. But even drinking that amount, your risk of breast cancer would increase by about 5%.
This amount?
Mm-hmm. Which for many people is very normal. So there’s a lot of misinformation out there about how much you should drink, which I think people don’t know. But I can take you through everything.
Dr. Sarah Wakeman is a Harvard Professor and addiction expert, leading the charge against one of the biggest public health crises of our time: addiction. Bringing facts, empathy, and hard-earned truth.
One in three people may have a problem with alcohol at some point in their life. And globally, 2.6 million people every year die from alcohol-related causes because pretty much every organ in the body is impacted by it. You can see here, this is a 43-year-old person where their brain looks the way a 90-year-old with dementia would look because of that brain damage over time from alcohol. [00:1:26] **Dr. Sarah Wakeman:** What drives people to use substances is probably the most important question. And if we look at studies, one is about 40 to 60% genetics. And then the other half of the equation is trauma. And so when we hear someone talk about alcohol gives them pain relief, whether that’s emotional or physical, that’s a very real thing. That’s because your natural painkiller system is activated by drinking. It’s an anti-anxiety and a pain medication sort of all in one.
When you think about how we treat addiction, where are we going wrong?
The biggest problem is that people haven’t been given the evidence and tools to understand addiction. But also, many rehabs don’t offer the things that we know are actually effective.
And what is it that people need?
Great question. One of the most effective tools we teach people is something called CRAFT. And they found that people drank much less after it.
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The show gets bigger, which means we can expand the production, bring in all the guests you want to see, and continue to do this thing we love. If you could do me that small favor and hit the follow button wherever you’re listening to this, that would mean the world to me. That is the only favor I will ever ask you. Thank you so much for your time.
Dr. Sarah Wakeman, with all the work that you do, what is the mission that you are on?
My mission is really to change the way people think about and understand alcohol and drug problems, and also to give people the evidence and the facts both to understand addiction, which are problems related to alcohol and drug use, but also to just understand the science around, for example, how much should you drink? Is drinking healthy? Is it not healthy? There’s a lot of misinformation out there, and I want to give people the tools to make the right decision for them in their lives.
And who are you, and what is your body of experience and education?
I’m a medicine doctor by training. So I still do some general medicine, like in the hospital taking care of pneumonia and heart failure, and in the outpatient setting taking care of people’s diabetes and depression. But I trained specially in addiction medicine, so I’m board certified in addiction medicine. And that’s been kind of my life’s work.
I work in a big academic medical center in Boston, Massachusetts, where I would say my focus professionally has been thinking about how do we bring addiction care back into the medical system so that it’s not this separate and unequal and often very poorly done, sort of siloed system, but actually just a part of the healthcare that people get. And then I train people. I’m the program director of our fellowship program, so I train doctors who want to be specialists in addiction medicine.
When you think about how we treat addiction in the modern world, what are some of your gripes? Where are we going wrong?
How much time do we have? I think we have enough. Where do we begin? I think at its core, the biggest problem is that we’ve all been taught and sort of infused in this idea that addiction is an issue of behaving badly, that it’s an issue of morality, that people really need to knock it off and pull themselves up by their bootstraps, and that this is like a criminal legal issue, that it’s an issue of willpower.
If you believe those things, then why would you think that someone should get medical care? Or why would you treat them with compassion and kindness if you think that they’re doing something wrong? And so really reframing how we think about addiction based on all of the science we have and what effective treatment looks like, which often is very different than what people may have experienced if they were trying to access care for themselves or a loved one.
And what is an addiction? What falls into the bucket of addiction? You know, because I use my iPad a lot, I use my phone a lot. Is that an addiction?
It’s a great question because we use that term colloquially a lot. You know, "I’m addicted to Netflix" or whatever. So addiction is really defined by use despite consequences. So continuing to do something in your life despite bad things happening to you because of it.
We talk about addiction, we talk about the "Four Cs" as a way to remember it. So one "C" is loss of control, meaning you’ve tried to change and you haven’t been able to, so you’ve tried to cut back or you’ve tried to stop and you couldn’t. The other is compulsive use, so your use is like spiraling out of control, that you’re kind of using in a way that isn’t really attached to your rational thinking.
The next is consequence—continued use despite negative consequences either in your life, your job, your relationships, your health. And then the last "C" is craving, which is this sort of strong psychological urge to want to use, like you can’t get the idea of having a drink out of your mind. And so it’s really those Four Cs that we think about.
Then we make the definition based on how many criteria people meet out of this 11-list of different criteria. Based on that, people can have a mild use disorder, moderate, or severe. And so moderate-severe is really what we think of as addiction, but it’s that use despite bad things happening to you.
And what things are capable of being addictive in this world?
Lots of things. I focus mostly on alcohol and drugs. So alcohol, obviously, probably most common. We’ll talk about that a lot today, which I’m excited about. Certainly when we look worldwide, 400 million people have an alcohol use disorder, meaning addiction to alcohol. That’s a lot of people.
The other are drugs. That can be opioids like heroin or pain pills or fentanyl. It can be cocaine or stimulants like methamphetamine or prescription stimulants. Sedatives that people might take for anxiety like benzodiazepines, cannabis. So there’s a whole sort of range of substances that can be addictive.
How addictive a substance is is really related to how much dopamine is released in the brain. I know you’ve had a wonderful episode with Dr. Lembke about dopamine, so you’ve talked about that a bit. And there are different addictive indices of different substances. Cannabis is less addictive than methamphetamine, for example, but all of those substances can cause addiction in people.
Even beyond that, I wonder sometimes in my life if I’m addicted to other things, like I drink coffee every day. I certainly get a craving to drink it now.
There are a couple of important pieces there. Is your coffee drinking causing harm in your life in any way?
No, I think it helps.
It may be helping you, right? Okay, so it’s not addiction. There is a difference between physiologic dependence, meaning if you don't drink your cup of coffee you're going to get a headache, and addiction, meaning that you’re spending all your day and all your money buying more and more coffee despite your girlfriend nagging you about it and you're late to work because you're purchasing coffee. We don't really see this so much with coffee, but that would be sort of addiction.
How big is the problem? Why should we care? Why should the person listening to this care? Because I imagine it’s the case that many people here don’t have an addiction that fits into the category of having severe consequence for their life. I also imagine some people are under the impression that addiction is something that happens to other people.
Can you frame the situation for me and explain to me why we should all care about this and the scale of the impact it’s having?
I guarantee you that many people listening have been touched by addiction, either personally or in their lives. Because of stigma, we tend not to talk about that, but the scale is huge. Globally, 2.6 million people every year die from alcohol-related causes. So that’s 7,000 people today will die from an alcohol-related death.
Another 600,000 people die from drug-related deaths annually, so that’s like 1,600 deaths today from drug-related causes. And then when we look at the criteria for a substance use disorder or addiction, it’s about 400 million people worldwide for alcohol and 80 million people for drug use. So it’s incredibly common.
If you think about alcohol, some studies estimate that the lifetime prevalence, meaning over the course of your life, how likely are you to at some point develop alcohol addiction? Somewhere between 15 and 30% in some studies. So one in three people may have a problem with alcohol at some point in their life. This touches all of us. We just don’t talk about it because of stigma and because of these mental images of kind of "othering"—that it’s only those people who are injecting heroin who have addiction, or that person who has the shakes every morning and is drinking as soon as they wake up who has a problem with alcohol.
Which direction are we going in as a society? Are we getting better, or are we getting more addicted?
Great question. The pandemic was not kind to addiction. We saw rates of alcohol and drug use and deaths related to those increase significantly after the onset of the COVID pandemic. That has started to level out. For drug use-related deaths, we’re now back at the pre-pandemic levels, but there was a very significant increase during the time of the pandemic. That’s really not surprising when we think about what are the things that drive people to use alcohol or drugs in a problematic way.
I was looking at some of the life expectancy graphs, and this one in particular I found quite shocking. It shows that there was a drop in life expectancy during the pandemic, but even when you compare it to other countries, it’s not as significant. I’m wondering why, in your view, there was such a significant decline in life expectancy during the pandemic?
Obviously COVID was one driver. One of the main other drivers was substance-related deaths. Actually, immediately following the onset of the pandemic, beginning March-April of 2020, we saw a 23% increase in alcohol-related mortality, and we saw the highest rates ever we’ve seen of drug-related overdose deaths. That actually impacted US life expectancy up until this year. This is the first year that we’ve seen that change.
At the essence of what’s actually going on there, because addiction is downstream from something else, what is actually going on?
That’s a really great question—what drives people to use substances? It’s actually probably the most important question even in my work. If you don’t understand what someone’s substance use is about or related to, how are you ever going to address it or help them address it?
Trauma is probably the single biggest driver. You often hear things like "cannabis is a gateway drug." I would say trauma is the gateway drug. If we look at many, many studies, there are kind of two different things that drive someone’s risk of addiction. One is genetics. It’s about 40 to 60% genetics, similar to diabetes in terms of someone’s risk. That’s not a done deal, obviously. There are people with strong genetic risk who never develop addiction, and people without that who do.
The other half of the equation is based on kind of your exposures and your experiences. One of the number one drivers is what we call adverse childhood experiences. There’s this famous study called the ACEs study, which stands for Adverse Childhood Experience. It’s been replicated—there was a recent one done actually in Europe as well—that looks at the number of adverse childhood experiences you have, and it’s a linear track increase in terms of your risk of substance use disorder.
If you think about what’s happening in the brain with substances, when we use alcohol or drugs, all sorts of feel-good hormones are released: dopamine, your endogenous opioid system (which is literally your natural pain reliever). If you take someone who’s experienced trauma, there’s great relief that they can find in substance use.
We saw that in the pandemic. What was going on in the pandemic? People were scared, they were bored, they were lonely. They were stuck at home, they didn’t have their usual routine. Some people were losing people that they loved. And so we saw all of this escalating substance use. It was actually most pronounced in people who were frontline workers—that could be a healthcare provider, but also someone working in a grocery store or convenience store who had to work through the scariest times of the pandemic—and also people who were caregivers. Those are kind of the two groups that had the biggest increase in their substance use during the pandemic.
What is going on in the brain? You referenced it a little bit there; you referenced that dopamine makes you feel good. So, very naively, I would assume if you feel bad, dopamine makes you feel good, you want more dopamine. But is it more complicated and nuanced than that?
Alcohol is a really complicated one because alcohol has lots of different effects on the brain. Any drug or substance that can cause addiction is going to release dopamine. That’s sort of a primary driver of many things that we find rewarding, whether it’s sex or food or alcohol or drugs.
But alcohol also binds to the part of our brain system called GABA, which is sort of our anti-anxiety system. It’s the same system that anxiety medications like people may have heard of, Ativan or Lorazepam or Xanax—these medications that are kind of sedatives and anti-anxiety meds—alcohol acts on that part of the brain.
It actually then causes a release of your endogenous opioids in your brain, like your brain’s natural painkiller. That’s actually why one of the medications that’s effective in helping people stop drinking actually just blocks the opioid response in the brain, which doesn’t make sense when you first hear about it until you understand these neural mechanisms. Actually, your sort of natural painkiller system is activated by drinking.
When you hear someone talk about alcohol gives them pain relief—whether that’s emotional or physical—that’s a very real thing. That’s a powerful system in our brain that gets activated when you’re drinking.
Okay, so if I’m having a stressful time at work and work is making me anxious and it’s crippling me, then I’m more likely to want to have a big blowout on the weekend because that’s effectively a pain medication.
Totally. It’s an anti-anxiety and a pain medication sort of all in one. I think often this is part of the area where I think just getting more awareness and education about alcohol is so important because we see that as a way of like treating ourselves, right? And it’s very easy to have that get out of control. Especially if in your head you think, "as long as I’m not drinking in the morning, or missing work because of drinking, or having problems in my relationships, I’m fine." But actually, there’s so many health problems and even life problems related to alcohol that people may make different decisions for themselves if they had that awareness earlier on.
I was thinking about a friend of mine who is fairly well known, who passed away from issues related to his addiction. He had a lot of pressure on him when he was fairly young. He wasn’t necessarily a young child when he had a lot of pressure put on him, but he was young. I was wondering, as you said "childhood experiences," what age that is?
Is there like a certain age where those experiences become... you know, if you experience a certain level of trauma at a certain age, it’s harder to recover from that and you’re more likely to be addicted?
It’s a great question. Trauma at any time can put you at risk for addiction. The earlier that happens, the more sort of long-lasting the impact can be. When we think about the brain, your brain doesn’t really fully form until your early to mid-20s. Both in terms of trauma but also in terms of early substance exposure, you’re at much greater risk when you’re younger.
That doesn’t mean that trauma in later life doesn’t put you at risk for developing substance use as well. I’ve seen people whose first trauma was in their 20s or 30s or 40s and they can still develop a substance use disorder; it’s just the risk is even greater when you experience those adversities as a child.
The interesting thing is trauma is not so much about the experience; it’s about often being left alone to grapple with that experience by yourself. What’s traumatizing to one person may not be traumatizing to someone else. Take the pandemic, for example. I’ve talked to people where being stuck at home and alone and bored was deeply traumatic. Other people were fine—they were in their living room doing whatever and found ways to connect and to live their lives and did okay. It was the same experience, but it was experienced very differently by different people.
So it’s less about the actual experience and more about the impact on that human, how they’re left feeling. Often it’s about feeling disconnected. We often talk about the opposite of addiction is not sobriety; it’s actually connection. It’s how do you build that connection with other people again.
My friend that I was referencing is Liam Payne, who was from One Direction, the boy band, who passed away. He was on my podcast a few years before he passed away. On the show, he said that much of what made his early life so difficult as a teenager was he was obviously thrust onto this big show.
The way it worked was he got all this public spotlight. They’d put him up on a stage and he’d be in front of 100,000 people in Dubai, and then after that experience, he was then driven back to a hotel room and locked in a hotel room because obviously you can’t go out because you’re so famous that if you walk out on the street, crowds are going to emerge. So he was then locked in that hotel room.
On the show, he said, "I was locked in there with the minibar, which is full of alcohol. So I would drink, and that cycle would repeat itself." He’d be like stage, car, hotel, locked, drink, stage, car. That cycle repeated itself. When you were talking about isolation and loneliness as well, I never really considered the fact that connection and social relationships could play a role in creating an addiction in someone. But it tracks.
Totally. I mean, it makes me think about a patient I saw this week who really wants to stop drinking and is able to go for a few weeks, but his life is pretty empty. Like, he’s not working right now, he doesn’t have a lot of relationships. So when he’s not drinking, he’s sitting at home watching TV by himself. It doesn’t take very long for him to think that the thing that’s going to give me relief is having a drink.
Then the question becomes less about the molecule of alcohol and more about how do we fill up people’s lives? How do we form connection and build community and build a sense of identity and purpose and engagement outside of the relief of substance use?
You’re clearly extremely smart. When I meet people like you, I always think to myself, "You could have committed your life to anything. You could have worked in pretty much any field and you would have been a success because you have what it takes to be successful." So why do you care so much about this?
I think like many people, I had kind of a personal thread. I had a family member who was impacted by addiction who actually died when I was in medical school. So that was a pivotal moment. Coming at the same time that I was learning all of this science, I was realizing, "Wow, I wish I’d known this when I was younger and dealing with family members and friends who are affected by this." And that we’ve gotten it so wrong. Most people don’t have the kind of tools and knowledge to do things differently. And so, you know, there’s that saying "when you know better, you do better," and I think I kind of wanted to put out into the world what I wished was there for other people.
An immediate family member?
Mm-hmm.
And what age were you when you lost that person?
Probably 24 or so.
From addiction?
Yep.
When you’re dealing with a family member or someone close to you that has an addiction—so many people listening will be able to relate to that feeling—can you describe what they feel? In an attempt to make them feel seen, because sometimes, especially in hindsight, if you end up losing that person, you can be filled with lots of feelings of guilt or misunderstanding, especially thinking about how society’s moved on since. So how do you put into words how it feels to be a family member with someone dealing with addiction?
I think you feel powerless. You feel like you want to do something and you either don’t know what to do or feel like everything you’ve tried hasn’t worked. I think again, because people have been exposed to this idea that it’s an issue of willpower or choice, which really implies that if people wanted it bad enough, they could just stop.
If you’re a family member, then that’s easy to feel like, "Oh, they don’t love me enough. They’re not choosing me over this substance." And so I think often people feel deeply hurt. They’ve been through experiences that have created trauma for themselves. There’s a lot of trauma within families who are experiencing this.
And then they’re sometimes given really bad advice, like that you have to kick someone out, or this whole concept of kind of "tough love" and that people need to hit bottom. And so sometimes people either do that and then wrestle with the guilt of "was that the right thing or not," or they feel bad even like being kind or loving to their family member.
So I think there’s a whole mix of feelings. And of course, if you lose someone, you always wonder "what if?" Could I have done something differently? Could something else have changed? I think people can feel angry and sad and guilty and be left with that.
What did those people in your life need that you lost, that they didn’t get?
I think they needed science-based treatment, and compassion, and empathy. I think they needed a world where addiction was not seen as something to be ashamed of or something that we judge, but rather something that is a problem. The shift from "you are the problem" to "you have a problem and we can help you with this." I think too often we have approached it as if you, the person, are the problem.
Do you sometimes think back and think, "If I’d done something differently..." whether it was you or someone else around you, or the system around that individual, they would still be here today? Because I think that was the first thing that sprang to mind. I played back all the decisions that I made, and I thought, "Okay, maybe that was bad advice that I was given. Maybe I should have been here. Maybe I could have called more. Maybe I could have intervened here. Maybe there's something else I could have done."
Absolutely. I mean, I think about that all the time. I think of a friend I lost to overdose, I think of the family member I lost to alcohol. Not only things that I could have done differently, but also, those people—they saw their doctor, they were in the hospital, they had all these touchpoints, all of these like reachable moments where someone could have engaged with them and offered them kindness and actual effective care that’s backed by science, and they weren’t. And so there are all of these like missed moments and missed opportunities.
But the other thing I think about is how much time I lost with them. Because I think often in this model of like tough love and kicking people out or thinking like "I’m not going to see you until you stop using or stop drinking because I think that’s going to help make them make that change," you lose out on all of these moments of time with people that you love and you can’t get those back.
And so there is this problem, I think, in that binary model of like you’re either sober and in recovery or you’re actively using and this is good and that is bad, is that we lose the fact that people who are struggling with addiction are amazing, funny, loving people who have a problem that they’re dealing with. But if someone was dealing with cancer, you wouldn’t like not want to spend time with them. You know, you miss all of that time, and in both cases that I’m thinking about, like I’ll never get that back.
There’s a phrase I heard many years ago which I’m now reconsidering, which is "change happens when the pain of staying the same becomes greater than the pain of making a change." And that kind of dovetails into this idea that someone needs to hit their own rock bottom for them to change.
I think part of the reason why that idea prevails is because we hear so many stories—I hear them on this podcast—of someone’s family rejecting them, throwing them out on the street, and then them having that eureka moment of "I need to change my life." People always reference that rock bottom moment where they took action because they were at the very bottom of the world. How does that phrase sit with you: "Change happens when the pain of making a change becomes greater than the pain of staying the same"?
I think that there are those times for sure. Not to discount that, and I hear those stories too. But I think from evidence, what we know, there are probably more times where people just endure the pain again and again and again until they never change.
And I think the part that we don’t see are the folks who change happens when they begin to get enough hope that things could be better for them. That someone loves them, someone cares enough that they’re reaching out a hand in the darkness, that there actually is a path forward. I think people stay stuck when they feel hopeless, when they feel like nothing could ever... that they’re never going to get this, they’re never going to be able to change, their life would never get better.
Take the example: I’ll often hear from family members when their loved one is in jail, that they’re like, "Thank heavens, they’re in a safe place at least." There’s actually this sense of relief. There’s even a term for it called "arrest-cued" that people feel. I think it just goes to the desperation that families are dealing with. But this idea that that’s a safe intervention... And you hear these stories, right, of someone who they get locked up and that’s their eureka moment.
And yet, if imprisonment were an effective intervention for addiction, for example, we wouldn’t see that actually the time after getting released from prison, there’s 130 times increased risk of dying from a drug-related cause after people leave prison. And that your risk of dying ever from addiction is much, much higher if you’ve ever been imprisoned.
And so I think there are those stories, but we tend to elevate those amazing narratives and we miss the fact that so many other people are going to die in pain and alone and isolated because they have no hope. And so it’s not to discount those moments, and some people are incredibly resilient and against all odds, even with the most trauma, they can make it through, and that’s incredible. But that doesn’t mean that we should create a system that makes it as hard as possible on people.
So, would you say that if we are trying to help someone change, really it’s about hope? It’s about the strength of their "why," and it’s about love and empathy and connection? Is there anything else missing?
And it’s about effective treatment.
And treatment. Okay. Which is subjective, right? Which could be depending on the situation they’re in?
It depends on the type of addiction and their situation. But in most cases, it’s some combination of psychotherapy and medication.
Alcohol. Yes. It’s been on a journey. It’s been on a journey in terms of society’s opinion about it. Can you take me on that journey and tell me where we are now? And when I’m saying that, I’m talking about society’s opinion on its health benefits, what it is, and then also what we’re getting wrong now about alcohol.
The journey of alcohol is fascinating. First, I think we think of this as a relatively modern thing, but archaeologists have discovered beer-making equipment in hunter-gatherers' cave dwellings from 13,000 years ago. 13,000 years of people figuring out how to make beer. You look at China 9,000 years ago. It was really about a spiritual journey or a social thing. It was never really about health.
At some point, we started talking about this as something that is good for your health. Like, "Drink red wine; it’s going to improve your health." And that’s where I think we got wrong. And the reason why was actually from how we were looking at the data.
First, if you look at only one health condition, there are some health conditions where a moderate amount of alcohol actually improves your health. But it was also how people were conducting the studies. In most of those studies, what people do is they take a massive population—tens of thousands of people—where we have some data where they’re reporting how much alcohol they used. And then we look at health risks over time. And scientists would lump people into non-drinkers versus light drinkers, moderate drinkers, or heavy drinkers.
What they were finding is that people who were drinking in the moderate level were actually doing better than the people who weren’t drinking at all. And so that was where that concept that drinking is good for your health came from. People talk about this "J-shaped curve," meaning that moderate drinkers actually have lower risks of health problems, and then it’s really only when you start drinking very high levels that you start having more risk of health problems than people who don’t drink at all.
What they realized was wrong with that is that in the people who don’t drink at all, many of those people are not drinking because they’re actually really unhealthy for another reason. Like, they might have heart failure and they don't want to drink because they don't want it to mix with their medication. Or they might have had a history of alcohol use disorder and they’re actually in recovery, so they’ve already had some damage from alcohol and they are not drinking because of that.
When you change the reference group—you actually make the group that you compare people to people who very rarely drink—so it's not that they're not drinkers at all, but they drink very, very light levels—then you start to see that those health benefits of alcohol go away, especially if you look across all conditions.
Are you telling me that there’s no healthy level of alcohol consumption?
Yes. I would never say drinking alcohol is good for your health. That doesn’t mean that drinking at what we call low-risk levels can’t be a part of a healthy lifestyle. So it’s a slight shift that don’t fool yourself into thinking that drinking that glass of wine is like going to exercise for 30 minutes. It’s not something that’s going to promote your health. I think of it more like having dessert, eating bacon, going out in the sun. There are risks associated with all of those activities. It doesn’t mean that I would say you can never do any of that, but you need to understand what the risks are and then make choices for yourself.
So I look at this glass of wine here and this pint of beer. If I drank one of these a day—not a huge amount—I think what people tend to think is, "Well, it’s only one, so my body will just flush it out and there’ll be no adverse health consequences." Is that true?
Well, part of the challenge is what we think of as one drink. I think much like if you learned to read the serving size on a food, you realize that a serving of ice cream is like half a scoop. It’s not like a giant ice cream sundae. The same is true with alcohol. In the UK, the low-risk drinking limits talk about units of alcohol, which is the equivalent of 8 grams of alcohol. How much of a drink has 8 grams of alcohol? To be in that low-risk category, you have to be below 14 units.
The problem is that glass of wine, just eyeballing it, has several units of alcohol. So it is not a single... even though we think of it as a single drink, it’s probably like three units of alcohol.
So if I have a glass of wine every day, I’d be over that limit then?
You’d be right at that limit. The problem is most people don’t drink just one glass. If you have two glasses one day, and then one glass one day, and then three glasses one day because you’re at a social function, all of a sudden you’re actually quite a lot over that limit.
So if you said that this is roughly three units roughly, and you get 14 a week... so 3 times 7 is 21.
Yeah. So yes, you’re over if you’re drinking that size.
Okay, so if I have this glass of wine every day, then I’d be over the UK limit of low-risk drinking. So I’d be medium-risk drinking.
You’d be in what we call moderate risk, which is associated with pretty much every form of cancer. Which I think people don’t know.
Okay, because I was wondering why cancer has been increasing. A variety of different forms of cancer have been increasing, especially breast cancer is one of the ones we always hear about that’s increasing. So you’re saying what is the data in terms of low or moderate risk of drinking and cancer?
The data is growing and really worrisome. For breast cancer, there’s really a few cancers that even at low-risk limits, you see the risk begin to increase. So where we would say there’s kind of no healthy or no even low-risk amount. Breast and esophageal cancer are two examples of that.
Breast cancer, if you were to drink below those low-risk limits—so in the US that would be fewer than seven drinks, but a drink in the US is five ounces of wine which is smaller than that, or in the UK is below that 14 units, so it would be fewer than seven of that size glass of wine—we still see a slight increase in the risk of breast cancer. It’s about a 5% increase.
So that means your risk of breast cancer would increase by about 5%. That’s not huge, so I think percent increase is kind of hard to do the math on, but if you think in the US, for example, the average woman has a 13% likelihood of getting breast cancer in her lifespan.
13% likelihood. Wow. Really high.
Really high. So a 5% increase would increase that to like 13.6% or so.
So that means if there’s nine women in this room, one of them is going to get breast cancer probabilistically in their life. Damn. Why is it increasing?
The reasons for that are likely environmental because your genes don’t change over that time period. So the risk factors, if we think about breast cancer, it’s alcohol, it’s obesity, it’s age at when you have children or don’t have children because it’s a really hormonally driven cancer.
Same thing if you think about colon cancer. That’s a really scary one where we’re seeing more and more cases in younger people. Some of the drivers of that? Eating meat, so processed meats increase your risk of colon cancer. There’s probably other environmental things, honestly, that we’re not yet measuring or able to measure, just given the rate of acceleration when I talk to my colleagues who are oncologists. Things like plastics or other things that we don’t yet know. There’s clearly something in the environment that is driving these increased cancer risks.
So even at this sort of level, if I’m drinking that—might be one unit, right?
Yes, that would be one unit. So that would be fewer than 14 of that. You could see like if you had double that, it would be a decent pour of wine. You could not have more than seven of those in a week to be in low risk. But even drinking that amount, your risk of breast cancer would go up a little bit.
Even this amount?
Mm-hmm. There’s really sort of no safe amount of alcohol when it comes to breast cancer.
Is it just breast cancer?
That low-risk category, so when these big cancer studies categorize people as sort of low risk or light drinkers, moderate or heavy. For pretty much every cancer, once you get to the moderate category, we start seeing increases. And there’s what we call a dose-response relationship—so the more you drink, the higher your risk of cancer. There’s only a few cancers that the risk seems to increase even at that very low level, and breast cancer is one of those, and then esophageal cancer is one of those. So there are certain cancers where even a small amount of alcohol will increase your risk.
Does it have an impact on thinking about cancers that are prominent in men?
So colon cancer, we’re seeing that in a lot of young men. Liver cancer. Prostate cancer, which is obviously a male cancer, we don’t think of as being sort of an alcohol-sensitive cancer. But most cancers, because the way alcohol impacts your risk of cancer is not really on a specific organ outside of the liver—it’s really about how it changes our DNA. So it’s about inflammation and what are called reactive oxygen species that sort of change our cells and increase the risk over time of the mutations that lead to cancer.
So if I’m a heavy drinker—so say that I’m drinking, let’s say I’m drinking two glasses of wine a day consistently.
If you drink two of those glasses, yeah, you’d be in the heavy category.
So two of those a day puts me in a heavy drinker category? Which would surprise most people, right? Like that for many people is very normal.
It is very normal. I think it’s somewhat more difficult for younger people to understand because younger people drink less. But if I think about the generation above me, having two glasses of wine a day is quite normal after work, on the weekends, with every meal that you have. So that would make me a heavy drinker. And then what are the stats saying in terms of my cancer risk profile?
It varies by cancer, but roughly we’re talking about like a 40% increase in cancer depending on the cancer type. And the more you drink, the more that’s going to go up. So these are scientific studies where it’s not precise to you as an individual; they’re based on large populations. But definitely, the more you drink, the greater the risk.
And then if I have other—do they call them comorbidities?
Exactly.
So other illnesses, other diseases in my body, my probability’s going to go up further if I’m obese, if I’m overweight.
Exactly. If you smoke. So one of the main drivers of alcohol too and cancer is that it actually makes you more susceptible to the cancer-causing effects of tobacco. So if you drink and smoke, your risk of cancer is going to be even higher.
How does that work?
The thought is like if you take esophageal cancer at like the cellular level, it makes you more susceptible to the carcinogens, which are kind of the cancer-causing compounds in tobacco. And so rather than just seeing like an additive risk, you actually almost get a multiplied risk in terms of the risk of cancer. So smoking and then obesity is the other big one. A lot of cancers, your risk goes up if you have an increase in your body mass.
What’s going on in the body then if I drink alcohol? How is that leading to cancer? You referenced it slightly there, but I want to make sure I’m super clear in my brain as to the knock-on effects and how that ends up as cancer.
I mean, there’s lots of different mechanisms. So maybe starting just with what does alcohol do in your body? You ingest alcohol, the fancy name for that is ethanol. It’s a molecule. And it basically gets absorbed pretty quickly from your stomach and so it hits your bloodstream usually within 10 minutes or so of having a drink.
How much it hits your bloodstream depends on how much water you have in your body, so alcohol doesn’t penetrate into your fat. It just kind of diffuses into the water parts of your body. That’s actually why for many women, they will get more sort of drunk or more of an effect from alcohol at a lower level than men because women have more body fat than men. But that’s going to depend on you as an individual; if you have more body fat, you’re going to have a different impact.
So alcohol gets in your bloodstream. Alcohol can instantly cross across what we call your blood-brain barrier, so it impacts your brain instantly. And that’s where you feel the initially pleasurable effects for many people: of feeling a little relaxed, feeling more social, feeling a little bit less anxiety. If you keep drinking and that level keeps going up, then you start having impaired judgment, you may have motor—lack of motor coordination. So we’ve all seen this, and many people have probably experienced it: you may be stumbling, not able to drive safely. You’re not going to make the same decisions you would make if you weren’t drinking. And then if you keep drinking, then you get—you can actually lose consciousness, so pass out, and people have experienced that.
Your body is going to try to break down alcohol as quickly as it’s able to. Like anything, we want to kind of excrete any abnormality and get back to our normal functioning. And so that process happens mostly in your liver, which is why the liver is so sensitive to alcohol.
Because your body sees ethanol as poison?
Yes. I mean, you know I think you talked about this with Dr. Lembke, but your body always wants to restore what’s called homeostasis. So your body’s always going to fight to get back to what it feels its normal is. And so ethanol is not something that belongs in your bloodstream; your body’s going to try to excrete it as fast as it can. And then it converts it into something called acetate and then you can pee that out and breathe that out and get rid of it.
So to eliminate the alcohol in your body, you have to go through this process, and part of that process includes this toxic molecule that’s going to be floating around and causing damage to your cells. So that’s one way that alcohol can cause cancer. The other is just general sort of inflammation. People have probably heard that inflammation is just not good for the body and increases the risk of cancer. And alcohol generates a lot of that inflammation in the process of getting eliminated. And so it can actually change your cells so that over time that can lead to cancer.
So I also found this graph, which shows—for anyone that can’t see what we’re describing at the moment—it shows the acceleration in liver disease death rates and general liver disease compared to other parts of the body, other organs in the body I believe it shows. What impact does alcohol have on the liver? And we have our little mannequin here of the human body. Where is the liver?
Great question. So here’s our little mannequin. So just to orient people to the body, so we’re looking at the inside of the body. So like the ribs are gone, the outside of the skin is gone. These two pink things are the lungs. They kind of encase the heart. You can see the heart behind the lungs pumping your blood. The liver is this brownish organ. It’s on the right side of your body right under your ribs.
It’s big.
It’s an amazing organ. It is quite big. It processes much of what any kind of toxins that we take in, things that we eat, your glucose, alcohol—90% of it is metabolized by the liver. So the liver is sort of the clearinghouse getting rid of byproducts in your body. The other are the kidneys, but the liver plays a huge role especially in alcohol. So it sits right here.
It almost looks like it’s as big as the lung. As one lung.
Yeah, it is.
Really?
Yeah, it’s a giant organ. And it’s an amazing organ. So you could actually cut out 80% of the liver and it would regrow itself. So kind of like those lizards that you cut off their tail and they regenerate a tail. The liver is fascinating. It’s why we can do living liver transplant. So I could take half of your liver and give it to someone who needed a liver. You would still be able to live and they would get a second chance at life from that part of your liver. So it’s this really cool organ that can regenerate.
But it can only regenerate up to a point. So once you get to a level where you have a lot of scar tissue in your liver, we call that cirrhosis. You sort of reach a point of no return where at that point the liver can’t heal itself.
So I sort of think of it like—to use a baking analogy—if you’re making muffins or a cake. You’re going along, you’re mixing all your ingredients, and you realize before you put things in the oven like, "Oh, I forgot the eggs." You can still add the eggs in and like whisk it all together and it’s going to be okay. If the muffins are baking in the oven and you forgot the eggs, you can’t like pour the eggs on top and make the batter the same.
And the liver’s sort of like that. That up to a certain degree, you can actually completely repair the effects of things like alcohol or obesity, other things. But once you pass that point into scar tissue, the liver can’t regenerate anymore. And so when you think about that graph or just the rising rates of liver disease, the main drivers of liver disease are one, obesity, and two is alcohol. And so those are the leading causes of liver transplant.
And the thing that is so sad is—I mean, I see this all the time working in the hospital—is first of all we’re seeing younger and younger people coming in in liver failure. So people in their 20s coming in in fulminant liver failure from alcohol and then dying in the hospital. And the terrible thing is that they often didn’t even know that this was causing a problem in their health and by the time they get to the hospital they’re so sick it’s too late. And yet all of that could have been prevented or even repaired if it was caught sooner. And so that’s where I think this education of understanding what really are the health harms of alcohol, and that we have normalized binge drinking in many cases, especially in young people, as being totally normal, and yet there are very serious health consequences.
So I’ve got a bunch of questions around the liver. Does that mean that my liver can take a bit of a beating before there’s any real problems? Should I—you know, as someone like me, I don’t drink alcohol, I’m not engaging in anything too bad—but sometimes I do wonder if I could have like a blowout weekend and then my liver would just recover to normal again and I’d be fine.
I mean, so first every person is different. One blowout weekend, you probably would be fine; anyone probably would be fine. The challenge is one blowout weekend then leads to like multiple blowout weekends, and then over time that can actually accelerate the damage to your liver.
You said that my liver regenerates though, so I’m thinking this thing will just pop back to normal again.
As long as you haven’t gotten to that scarring phase. So once you get too far down that path, even if you were to stop drinking, your liver won’t recover. The hard thing is that we don’t totally understand who and why that happens so young to. So this is an active area investigation because there are people who’ve been drinking for 60 years and their livers don’t show signs of scarring, and then we’re seeing these young people at 25 who come in and die in the hospital.
And so there are individual factors that you don’t have any way of knowing that are going to impact your risk of developing liver inflammation and scar tissue. And so the safest way to prevent that is to not drink in these really high ways that we know are going to lead to harm. The other way is to get medical care, because often we do detect these through blood tests and we can do ultrasounds. And when we see those early phases—so what happens first is you actually get fat deposition in your liver, that’s the first step. And then we see inflammation and fatty liver. And if you don’t stop the thing that’s driving those changes, over time we see the development of what’s called fibrosis, which is like scar tissue. And then that scar tissue gets more and more advanced to the point that your liver stops functioning and you either die or you need a liver transplant.
What activities outside of alcohol cause great stress on our liver that we might not see as obvious?
So obesity. Food does. Yeah, food. So your liver is very involved in glucose metabolism. So our diet and our body weight impact our liver health. The other are medications. So acetaminophen or Tylenol, which is a very common over-the-counter pain reliever, above a certain threshold can cause serious liver damage. So sometimes we’ll see cases where someone didn’t realize that like their cold medicine plus the Tylenol they were taking both had that ingredient and then they go out and drink heavily and that kind of combination effect can cause liver damage.
How much alcohol is going to cause liver damage?
So again, it varies person to person. For liver damage, it does tend to be the moderate to higher amounts that cause damage. One thing is that you know having these big surges—like these massive binge episodes—is probably more harmful than drinking like at a moderate level for a long period of time. Those like big surges cause a big buildup of that toxic byproduct that your body has to clear. And so you know if you have several years of binge drinking heavily, that actually probably is going to cause more damage than a longer period of time of just drinking above the risk limits. So really trying to minimize and avoid those very heavy drinking episodes is incredibly important. And then keeping it to those low-risk guidelines, which we just learned are kind of eye-opening and how low-risk they are, is going to reduce the risk of liver damage.
And does alcohol just impact the liver?
No, I mean alcohol has effects across our body. So many parts of the body can be affected by alcohol. So kind of starting from the top, your brain. And we can look at this with pictures like an MRI. I’ve got one actually. This is by the way shocking for me.
Yes. So when we do an MRI of someone’s brain, we basically—this is like a cross-slice. So it’s almost like you’re facing me and I’m cutting your face off and looking at your brain onward. Healthy brain tissue is the gray and white matter, and you want it to be as plump and like taking up as much space as possible, because that’s where all of your brain activity is.
When people get really old or have dementia, one thing we see is more and more of the black space is essentially water. So we see the brain start shrinking and shrinking and there’s more water and less active healthy brain tissue. That process is accelerated with heavy alcohol use. And so you can see here, this is a 43-year-old person with severe alcohol use disorder where their brain looks the way, you know, a 90-year-old with dementia would look because of that brain damage over time from alcohol use. And so we can actually a form of dementia is related to alcohol use, and so your brain can be hugely impacted with alcohol.
What is going on there? What’s causing the brain to deteriorate in such a way because of alcohol?
Well, remember I said ethanol, which is the molecule, crosses the blood-brain barrier. And so especially when you’re having these high levels of blood alcohol, that ethanol is sort of bathing your brain. And if you think about what we talked about—inflammation and changes to cells and to DNA and proteins—that is happening at the brain level.
The other thing that can cause—accelerate the brain damage we see with alcohol—is actually nutritional deficiencies. So people may be drinking a lot and they’re actually not getting really crucial nutrients in their diet, and that can accelerate the process of brain damage. We can even see a very like sudden onset amnesia from heavy alcohol use in the setting of not getting enough nutrients in your diet.
Okay, so that’s the brain.
That’s the brain, for sure. The next is the mouth and your esophagus. So obviously you’re drinking alcohol; it’s bathing your mouth, it’s bathing your esophagus and your stomach. So we do see an increase in cancer like we talked about, and that’s accelerated by smoking.
But we also see like benign but annoying and problematic health conditions, most notably acid reflux, so heartburn. So if you notice like "Oh, I'm like always having heartburn, I'm having to pop all these like antacids and take this medicine," you might want to think like "how much am I drinking?" Is that contributing to my heartburn? So that’s a very common thing.
The heart is affected by alcohol. You know, the heart is an organ where at low-risk levels there doesn’t seem to be harm from alcohol, but once you get into the moderate and high, we see harms. And the harms can be a couple fold. One is something called atrial fibrillation, which is basically where your heart starts beating really irregularly.
So in your heart there’s four chambers. The two chambers at the top—so this is really showing the ventricles and the atrium. So there’s two chambers that blood flows through. And in a normal heart your electrical activity comes from the top of your heart, goes down to the bottom of your heart, and tells the heart to pump. And so you get a single impulse that goes to the bottom of the heart says "pump" and that pumps blood out to your brain and your body and your organs and your liver.
In atrial fibrillation, the top of the heart is just kind of quivering with this abnormal electrical activity, and so the heart can’t pump in a normal way. We actually there’s a term in medicine called "holiday heart" because we see sometimes people drink a ton over the holidays and will end up in this abnormal rhythm just from that binge drinking pattern.
And then over time if you’re drinking at high levels, your heart actually dilates and you can end up with congestive heart failure from a cardiomyopathy, which means the heart muscle gets kind of weak and thin and floppy and can’t pump the way that it needs to.
Sometimes we think that if we’re good at handling our beer or our alcohol, then it’s having less harm on us. For whatever reason, I’ve always been good at drinking quite a lot—when I used to drink, I don't drink anymore—but when I used to drink, and being less affected than my friend who was a little bit bigger than me, had a little bit more body fat, which is really interesting because you pointed out an association there that I was never aware of. Just to pause on that for a second. You’re saying that if someone has more body fat, they’re more likely to get drunk?
Yeah, because they have less body water. And alcohol doesn’t go in your body fat. So essentially it’s like if you took a glass of water and you dropped red dye in it, you’re going to diffuse into that water. So the more water you have, the more diffuse it’ll be and the lower your blood alcohol content. So if you have very low body fat, you probably have more body water. And so two drinks for you is going to diffuse into a larger amount of water.
Ah, that explains a lot. Because I always wondered, he was so much bigger than me at the time, he had much more body fat, and he would get drunk very, very quickly. And you always think, "Oh, big guy, they can handle their beer or whatever." But he would get drunk very quickly. So I used to wonder, I used to think, "Well, alcohol isn’t harming me as much because I’m not as drunk as he is." But but that’s not true.
No. I mean, so first I think the interesting story there one is not just the body fat, but also that people metabolize alcohol at different rates. You probably—I don’t know if you found this to be true—you probably had fewer hangovers than your friend. Because a hangover does seem to be related to the amount, how high that your blood alcohol level gets. So people who don’t metabolize alcohol as quickly tend to have worse hangovers. So that may have been something you experienced. But it doesn’t protect you from the other health harms of alcohol like liver damage, like cancer, like over time, you know, heart problems or esophageal problems.
What is a hangover?
Hangover is a fascinating thing that people are—you know, there’s a lot of emerging evidence about it and trying to understand what happens. It seems to be most related to how high the ethanol concentration in your brain gets. Because they’ve actually done a ton of studies with mice and with people. It was initially thought to be due to the byproducts of alcohol, like that acetaldehyde molecule we talked about, but it doesn’t seem to be related to that. It seems to be related to ethanol.
But essentially it’s this syndrome where after you drink, once your blood alcohol content comes down to zero, you feel sort of apathetic, you’re tired, you have a headache, you often feel nauseous. And so it’s sort of that sequelae of your brain essentially being bathed in this ethanol and then as it leaves, you just feel totally crappy.
Could people think of it sometimes as just being dehydrated?
It is not just being dehydrated. There’s actually sort of effects of ethanol on your brain that lead to the hangover. I think if you are drinking at an amount that you’re getting a hangover, it is a good sign that you are drinking above a limit that would be considered okay for your body.
Because I remember back in the day, if I had a big glass of water before I went to bed if I’d been drinking, I felt better in the morning.
There is some element of dehydration, don’t get me wrong. And that’s partly because, right, if you think again alcohol is diffused in water. So if your total body water is contracted because you’re dehydrated, your ethanol level’s going to be higher. So drinking is going to help you sort of flush it out and feel better—I mean drinking water—but it’s not only because of dehydration.
§02Transcript — part 2
There’ll be people listening to this now—I doubt they would have got this far, but because if they did they probably wouldn’t think this—but there’ll be some people who would have gotten this far in the conversation and be thinking, "Yes, but alcohol helps me socialize, and socializing’s really important, and I can’t socialize very easily because of the design of the modern world without having a drink. Or I have great times when I drink, so I don’t want to quit my alcohol use." And you know, in some cases they will be high and medium consumption alcohol drinkers. What do you say to those people?
Well first, like, there’s no judgment here. So a molecule of ethanol is not more moral or immoral than a molecule of glucose. You could say the same thing about diet: we have lots of awareness now about processed foods and white flour and white sugar. That doesn’t mean that everyone’s going to live this like ascetic lifestyle where they never eat dessert.
So I think it really is like you need to go in with eyes wide open and understand what are the risks, what matters to you, and how do you make that calculus? If you decide it’s a choice you want to make, you want to set yourself up for success. So if you decide like, "I want to cut back on how much I’m drinking, but I’m going to go to happy hour every night with my friends and just try to like not drink while I’m there," you’re probably not going to be very successful because you’re going to be in a situation that’s constantly like reminding you of alcohol use and everyone around you is using alcohol.
So try to make some different sort of structural changes in how you set up your life and your week and your day, and you may find that actually you don’t miss it that much. That you could cut out three or four days of drinking and still get that social pleasure two days out of the week and your overall health risk is going to go down significantly.
In terms of treating someone with alcohol abuse disorder, rehab is often the most widely known form of treatment. One of my friends who struggled with addiction really, really badly with alcohol addiction but also drug addiction said to me multiple times, he said, "I’ve been to rehab three or four times now and it’s just not working." And I think when the most popular or the most well-known treatment doesn’t work for you, you kind of develop an even greater sense of hopelessness. Are you a fan of rehab?
Generally no. So rehab is this idea that you go away somewhere for a week, a couple weeks, and then you’re kind of cured, right? It’s almost like people have thought of addiction as an infection where you need like two weeks of antibiotics and then you’re done.
What we really understand is that for many people, addiction is more like a chronic illness, or even like cancer, where you need a lot of treatment upfront for the first few years, and then over time you get into stability and remission and you’re almost like a cancer survivor—you’re in long-term recovery. And so this idea that you go somewhere for a couple weeks and then you come out and you’re all better really doesn’t match what we know of addiction.
The other problem is that much of what happens in rehab is not all that therapeutic most of the time. So the things that we know are most effective for addiction: one are medications, which there’s a lot of stigma and misunderstanding about. And then two are like evidence-based psychotherapy, so things like cognitive behavioral therapy, motivational enhancement therapy, you know, working on your underlying trauma.
Often in rehabs, the model is really built around this idea of like you remove yourself from this environment, you do some groups while you're there. Sometimes often they're based on more of like a peer support model. Sometimes the therapies that are offered are frankly not very evidence-based, like we actually did this study—it was a secret shopper study where we called rehab programs across the country to like ask about what they offered. And many of them offered things like, you know, horse therapy or like dolphin-assisted therapy, which like I’m sure it’s very nice to swim with dolphins and to work with horses, but it’s not something that’s been like studied and effective.
And many places don’t offer the things that we know are actually effective, which are, you know, trained clinicians doing evidence-based treatments or medication treatments. So it’s a combination of like this short-term fix for a long-term problem and not actually getting the treatment that you need.
What does work?
Like for alcohol use disorder, most people don’t know we have very effective medications that can help you, even if you just want to stop drinking as much. So there’s this medication I mentioned at the beginning that actually blocks your opioid receptors. Which seems kind of funny that it works on alcohol, but the reason it does is that for people who—part of the thing that drives them to drink is that they drink, they feel this like pain relief pleasure sensation from the release of opioids in their brain and that makes them want to drink more—that if you block that, people don’t get sick if they drink, but they just don’t find it as rewarding.
And so someone named Sinclair actually in Europe did some fascinating experiments of even just using it as needed. So rather than taking it as an everyday medication, if you know that when you go to like a holiday event you’re going to drink way more than you want to drink, you take it like 30 minutes before you go. And then what people find is they have like one drink and they’re like, "Ah, I’m good. I don’t have that same urge to want to drink more and more because I didn’t get the same sort of tickle of feeling better and feeling relief."
What do you think about psychedelics as a way to counteract addictive behaviors like the ones we’ve described?
One of the most like groundbreaking trials in the last couple years for alcohol use disorder was psilocybin. So there’s a big study of psilocybin-assisted psychotherapy for alcohol use disorder which showed really remarkable effects. So people took psilocybin—they actually compared it, folks came in and they either got a big dose of Benadryl or psilocybin, and then they sat with a therapist for like eight hours for this guided psilocybin journey—and they found that people drank much less after it.
So it does seem to have some effect. And the thought is that part of the way psychedelics work is they increase neuroplasticity, meaning the ability for the brain to form new pathways and kind of retrain itself. And so it does seem to be a potential therapeutic for alcohol use disorder.
Psilocybin is the active compound in magic mushrooms. Have you heard of ibogaine?
I have, yeah.
Which is often associated—which is another psychedelic often associated with addiction.
People have looked at ibogaine for opioid use disorder. Those studies have been less promising than psilocybin, although it hasn’t been tested in the same kind of rigorous ways recently. Partly for opioid use disorder, we have really effective medications that have been shown to improve recovery and reduce death, and so it’s sort of hard to be better than that.
One really interesting like new whole class of medications for alcohol is medications that are being used for weight loss, so people have probably heard of like Wegovy, Ozempic. That whole class of GLP-1 medications seems to also reduce alcohol use, which is kind of interesting.
Really? Has that been studied?
So they—well first of all there are whole like Reddit threads and online communities about this where people were prescribed it for diabetes or for weight loss and they all of a sudden were like, "I don’t really want to smoke or drink. Like that kind of urge has gone away entirely." And for some people, they really describe it as being like miraculous. They’ve been trying to stop drinking for years and years and for the first time they don’t feel that sense of like craving and urge.
And there recently have been some actual clinical trials where they’ve done, you know, placebo-controlled blinded studies and have shown that it does reduce drinking. And so it’s a really interesting area where it seems like those medications kind of reset craving and appetite more globally and not just for food.
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One of the ways that many of us understand addiction if we haven’t experienced it directly in our own lives is we look up at role models on TV and in sort of celebrity pop culture. And we see these role models who, you know, we see on stages, start to deteriorate and deteriorate in the public eye. And ultimately, it seems often like it’s inevitable that someday the TMZ headline’s going to ring out and say that this person has passed away. And that happens all too often.
We think about Whitney Houston, or I guess Michael Jackson’s even been associated with dying from an addiction to I think it was painkillers or something. Prince, Elvis Presley, Mac Miller (who a lot of people will know as well), Anna Nicole Smith. And even now in the public eye, there are certain individuals where we’re starting to see this sort of erratic behavior: they’re posting on their Instagrams, they’re showing up in society in a slightly different way.
When you see that, in the line of work that you operate in, what is your natural reaction? How does it make you feel when—you know, because there’s a couple of people I’m thinking about at the moment who the world are talking about that we think they have an addiction, we think they need help. What is your natural reaction to that, and what is it that those people need?
When I read the headlines of someone dying, I mean to me it’s gutting and heartbreaking. One, because obviously it’s a human life that was someone’s mother and sister or brother, and people cared about a public figure that people looked up to and cared about. But mostly that it was a totally preventable death.
Like really, no one should die from a substance-related death. We have tools to treat addiction, we know how to prevent the harms of, you know, drug overdose, for example. And so the fact that someone can die—especially someone that everyone has watched for so long—is I think just like a tragic example of how what the mismatch is between what we do around addiction and what science says is actually helpful.
I think, you know, when I see someone who actively is showing signs, like it’s just sad to see that happen so publicly without people being able to support that person. And it’s not a magic fix. It’s not going to be like a—you know, you have an intervention, the person goes to treatment, gets better forever—that I think is often in people’s minds. It is a process, a journey, like any change.
And so really it is around where we began: that idea of how do you begin to understand with this person how is their substance use getting in the way of what they want for themselves, and how might their life be better for them based on whatever they believe better is if they were to make changes to their substance use?
I remember I had this one particular friend who had an addiction, and I remember always the life of the party. And I remember this one day he came up to me at an event and he’d sat down in front of me and said to me, he whispered to me, "I’m in so much pain."
And he told me about rehab and how it had failed him, etc. But it just—it almost sounded unbelievable that someone with such a big smile on their face would whisper to me, especially a man because men don’t really talk much about their emotions, "I’m in so much pain." And then finally, I then see how the world treats that individual. After him having whispered that to me one day, the world—how the world responds to his behavior and attacks him and criticizes him, but I was privy to the whisper. And that one whisper helped me to kind of reframe how to treat that person, but also really what was at the heart of what was going on.
Probably gave you so much empathy.
A huge amount of empathy. Because I would have been like the rest of the world—I would have just thought, "Oh, what an idiot, what a dickhead, why’s he doing that? That’s strange behavior." You know?
And you said something really important that was a slight shift in words: you didn’t say he failed treatment; you said the treatment failed him. And that matters so much. Because I think too often we’ve made it seem as if people are failing—like if they go to rehab and they don’t get well, eh, it’s their problem. And actually, the treatment wasn’t right for them.
If someone had cancer and their cancer came back or didn’t get treated by chemotherapy, we wouldn’t say like, "Oh, they failed." We would say, "Oh, what’s the next treatment? How do we get them to the right doctor?" And so there is this like personal blaming, and that gets at stigma, which is one of the main reasons that people don’t share that they’re struggling with substances, that they don’t seek treatment. We have tremendous stigma towards drug and alcohol addiction. It’s one of the most stigmatized kind of social conditions globally.
And so of course, then if you’re a person who starts to think like, "Oh, maybe I do have a problem, like maybe my alcohol use is getting in the way of things," it’s really hard to then say anything because you worry that you’re going to be judged, you’re going to be labeled, you’re going to be misunderstood. In some cases, terrible things could happen to you—you might get your children taken away by child welfare, you could lose your housing or lose your job. And so that stigma has like played into this terrible cycle where people, you know, have to whisper it to someone. It shows how much he trusted you to even be able to say honestly what he was going through, because there’s so much stigma about the condition itself.
You must have had many cases that broke your heart. Can you tell me about one that changed you?
Oh goodness, so many. One gentleman in particular, he was struggling with heroin addiction for a long time. And had been, like we talked about, had been kind of a chronic illness for him. He’d had periods where he’d done really well, he’d had periods where he had struggled and had always stayed safe through all of that.
And he actually—his like one really meaningful relationship in his life that kind of kept him together—was a relationship with his mom, and he lived with her. And they lived in public housing, they were dealing with economic insecurity like many people. And someone found out that he was staying with her and it would have put her at risk for her housing, and so he didn’t want her to lose her housing, so he left.
But he was newly homeless. And all of a sudden, because of just social barriers, was dealing with the stress of homelessness and being alone. And even with kind of all of the connection he’d had with his mom and with treatment, he was found dead between two parked cars, overdosed, alone in the street.
And you knew him?
Oh yeah. The cascading effects that it didn’t have to be that way. And I think there are so many deaths like that where I just think it doesn’t have to be like this. Really, no one should die like this. And there are so many things that, you know, in the moment feel so out of our control. And I think that’s part of what generates my passion for this work: I can’t always save the person in front of me or change issues around homelessness or housing policy, but I can try to work on a broader scale to make things different for the next person. I think that kind of counteracts some of the distress of losing people that I care about.
If you were President of the United States, for example—let's just use this country as an example—and you had to make upstream changes to the way society was designed in order to mitigate the downstream symptom of addiction and addictive behaviors, etc., what are those things that you would change about the way that our society is designed? You could change anything.
I mean, starting upstream, the biggest thing would be building resilience and building connection early on. You know, I think these things that feel so not related to addiction per se are actually deeply related when we think about adverse childhood experiences. So we think about prevention for children. You know, often people have looked at like education—like telling people, telling kids that drugs are bad. That doesn’t work.
What does work is actually building resilience in young people. So building resilience, building connection. So what does that look like? That looks like affordable housing. That looks like parks where people can get outside and play sports and exercise and build relationships. That looks like supporting families so that families can stay together and so those early relationships and attachment can be well-formed. That’s like the true prevention work is trying to break the cycles of intergenerational trauma, poverty, substance use, and actually supporting families, communities at the very start.
It reminds me of Rat Park.
Yes. Rat Park is a great example of that.
What is Rat Park for those that don’t know?
So Rat Park was a series of experiments that were done where essentially they were trying to understand kind of drivers of addiction using rat models. And so they took rats and they had one model where rats were isolated in their own cage with nothing to do and no human connection—no other rat connection—and they had access to a substance like morphine or cocaine where they could push a lever and get more of it. And those animals when they were deprived of connection and isolation, anything to do, used more of the drug. It gave them relief; it gave them pleasure.
They took those same animals and they put them in this amazing cage with, you know, areas to play and like wheels to climb on and lots of friends and other rats. And all of a sudden they saw the same animals were no longer kind of pushing the lever and trying to get more of the drug.
So it’s a somewhat simplified model—there’s lots of... it’s probably oversimplified—but it demonstrates that so much of addiction really is around this idea of connection, restoring sort of the world around us, the community, the interrelatedness that we all have, the opportunities and purpose and meaning and hope. So I think that’s the real prevention.
And then there’s how do we actually address folks who are having a problem? And I think what I would do there is first make addiction treatment widely available immediately when people need it. So the minute you walk into your general practitioner’s office or an emergency room, you get treated with compassion, with science, with people asking you what can they do to help and offering you effective care the same way they would if you had a new cancer diagnosis or a new diagnosis of a heart problem. And that we really reframe treatment entirely to look like the way it looks for any other health condition. And that we stop punishing people who use substances, where you know a lot of times people are still sent to jail for substance use, which you know is a confusing mixed message if we’re saying this is a health problem on the one hand but we’re going to put you in prison or jail at the same time. Those two things don’t necessarily align.
Many of us are living in the first model of Rat Park. We’re living alone, we’re living in these big cities, we’re more sedentary than ever before. Maybe we’ve moved to a big city because we don’t have our family around. We might be doing a job that’s incredibly challenging. So it’s no wonder when we think about addiction and alcohol and some of these other behaviors.
But more broadly, beyond alcohol as a substance, other addictive behaviors: whether it’s social media, or it’s what we eat, or pornography, or in the inverse, the good habits—the healthy food, the working out, the exercise, the productive behaviors—why we’re struggling so much. And I’ve often wondered if we should all just go to like communes and live, you know what I mean, in groups.
I mean, I don’t think human beings were meant to live this way. And it’s a relatively new thing, right? We often lived in a village or a community, we lived in these multi-generational households. I mean, I have little kids and I think having kids was such an eye-opener of that, like, "Well, that makes sense why people live with their parents and their grandparents and have these big families to create, you know, community and an extended family around you." And we have lost that in a lot of ways.
And I think the ways that we used to get that, like religion, maybe that still resonates for some people but for others it may not. And so finding other ways of engagement, of meaning, of purpose—that can be through lots of different things. You know, I think people are finding creative ways of doing that. It can be through like, you know, finding a volunteer activity, finding some other type of social group. Some people do it through sports—they find connection and engagement with people they don’t really know over this shared love around an activity or a team. But really sort of seeing that as a priority the same way you’d prioritize other things in your life and your health.
And are you a fan of therapy as an approach to aim at the early childhood trauma?
Absolutely. Yeah. I mean, I think one of the problems is that too often therapy has been like forced on people. I think that I’m much more of the approach of like we need to make treatment available and welcoming and high quality so that people get value out of it. And therapy is a huge part of that. You know, it’s about a lot of things: it’s about connection, it’s about figuring out those reasons why people are using in the first place, addressing and healing those traumas.
It also matters that we have good, well-trained, empathetic therapists. There’s been a lot of interesting studies looking at actually how empathetic your therapist is is probably the strongest predictor of whether you make changes to your alcohol or drug use.
Really?
Which is so interesting because we often think like, you know, you’ve probably heard someone say like "I don’t really like my therapist," and I think sometimes the reaction to that is like "Oh, well you’re not that into therapy." But they’ve actually done a lot of studies showing that a therapist who is less empathetic, their client is more likely to use more substances at the end of that course of treatment. So actually having a really well-trained, compassionate, evidence-based workforce is hugely important too.
And I guess the same applies for family and friends?
Yeah, I think empathy is really powerful. Those kind of things that we think of as soft skills actually matter tremendously.
Is it possible to prop somebody up? I mean, I was talking to—I think it was talking to Dr. Anna Lembke about this, about the idea that you can play a role in someone’s addiction. I.e., I want to help my friend who’s addicted and so I’m there for them, I’m comforting them, but I’m actually in some way reinforcing that addictive behavior because I’m positively reinforcing it because I’m supporting them so much and I’m loving them so much and I’m showing them so much empathetic attention that actually I’m playing a role in continuing that addiction. Is that possible?
Yeah, I mean this is this concept of like "enabling," which I think is nuanced. I would say at its core it’s really deeply problematic that for the most part love and support are never going to be harmful. And when I talk to patients, often the thing that caused them to ultimately engage in treatment was not some terrible consequence; it was the idea that someone cared enough about them in a moment where they didn’t love themselves very much and felt hopeless, that someone was willing to sort of lift them up and believe in them.
It’s these small moments of kindness. Like I’ll tell you a story of a patient that we took care of in the hospital who was there for a really life-threatening infection related to their drug use. And a year to the day after he was hospitalized, he wrote a letter to our team and he said, "You know, I’ll never forget the moments you guys came in and just sat with me and talked to me."
And he now sends an email every single year on the anniversary of when he got out of the hospital. And it’s those moments of humanity, of connection—again, that connection idea—that often are the catalyst for change. The kind of hope and belief that your life could be better somehow, as opposed to this idea of like increasing someone’s pain and suffering.
That plays out in different ways. So in families, one of the most effective tools we teach people is something called CRAFT, which stands for Community Reinforcement and Family Training. And it’s very different than the like people may have seen like shows where you’re supposed to like stage an intervention and, you know, tell someone all or nothing.
But CRAFT is very different. It teaches people first: how do you understand the science of addiction, family members? Second: how do you get support for yourself? Because it’s really tough to deal with addiction in a family. And then: how do you start to learn about consequences in a different way?
That, you know, if you’re a parent and your kid is missing school because they’re using, you don’t want to cover for them and sort of reinforce their pattern. But you also don’t need to kick them out of your house. That there are sort of gradations of consequence that can actually help people change. And one of the biggest sort of motivators for change is actually positive reinforcement of the behaviors you want to see.
So that’s been called "contingency management" in the kind of treatment world. And you know health insurance companies, lots of companies have figured this out, right? So if you get money back because you joined a gym, or you get those reimbursements for doing something that people want to see, people do more of it. It’s true in human behavior; it’s very true with addiction. But we often do the opposite—we try to punish people into getting well instead of reinforcing kind of the healthy behavior that we want to see more of, if that makes sense.
Yeah. I’m guessing—I’m trying to represent the audience member that’s listening to this right now that knows someone in their life that was addictive and they tried to be empathetic. They tried to offer support. They tried to give the person help and still nothing changed. In that situation—maybe the person that was struggling with the addiction didn’t accept the support. Didn’t go to the meetings. Didn’t speak to the therapist. In such a situation where you’re offering help to someone and they’re not taking it, they’re not willing to investigate different medical treatments, they’re living at your house, they’re in your business, whatever. Is there a point where you say "enough is enough"?
Yeah. Well first, like, it is just so hard to be there as a family member or friend. So for anyone listening, I’ve been there; it’s incredibly impossible. So have grace with yourself. I think that’s a different decision you’re talking about—at some point do you have to make a decision to protect yourself?
So let’s say you have someone in your home who’s dealing with addiction who, you know, gets aggressive or is stealing money or is, you know, causing trauma to the people living in the house. At some point you may need to decide that for my well-being, for the rest of the family’s well-being, I can’t have this in my life right now. That’s very different than saying kicking them out is going to make them better.
So the distinction there is that it’s okay to protect ourselves—sometimes we have to do that—and sometimes there’s only so much you can do. But to not sort of fool yourself into thinking that the action is to help the other person. And that’s okay. I think the other piece is—you know, at the end of the day, first of all it’s easier to be a treater. So I’ve been a family member, I’ve been a clinician.
As a clinician, I can truly be unconditional. So I’m going to be someone’s doctor whether they continue to use heroin or continue to drink or don’t. And there’s something really beautiful in that—like my engagement with someone is not premised on whether they make changes or not.
As a family member, that’s harder, especially if you’re a kid dependent on someone or you’re in a marriage or relationship. So you may have to make different choices. But I think at the end of the day, people don’t change because of why we think they should change. They change because they think their life is going to get better in some way. So the key then becomes figuring out: why might this person’s life get better if they were to make changes to their alcohol or drug use?
So it’s a shift where you become sort of on their team instead of trying to drag them towards water—drag the horse towards water. And there’s this fascinating kind of human instinct that none of us like being told what to do. There’s something called the "writing reflex," which is—it’s really hard for caregivers, it’s hard for parents—because we love to tell people our great advice and why what they’re doing is wrong and they should take our like brilliant doctor advice.
This can be like telling someone like, "Don’t you see what you’re doing is causing harm? You should make changes." It can also be subtler—it can be like lecturing someone or trying to educate them. But when someone shoves something down your throat, your instinct is to resist. It’s just like natural human behavior. Even if it’s a great idea, if someone’s like shoving an ice cream cone in your face and like "Eat!" even if you like ice cream, you might be like, "Wait, wait, I don’t know if I want this ice cream."
And so the key then is not to sort of tell someone what to do, it’s to understand why might they want to make changes. And so once you do that, then you all of a sudden realize like it just feels better. You’re not trying to drag someone towards something; you don’t have like personal skin in the game about what choice they make, but you’re really a partner with them in figuring out: how is this thing causing problems to you, and why might your life get better if you were to make changes to your alcohol use or your drinking or your substance use?
What’s the difference in delivery there, in terms of delivering that message? Because they’re both ultimately getting to the same outcome, but it sounds like the language might be slightly different.
Yeah, very different. So in kind of medical speak and therapy speak, we talk about something called "motivational interviewing," which is—it becomes almost like a mind trick thing, but it is basically a way of trying to identify from the person their reasons for change and reflecting it back to them. So it’s not you telling them you think they should change, but you are trying to elicit their motivation and amplify it, and then at the end of the day you’re turning over the power back to them. So that might look like something someone says...
I’ll be your patient.
Okay.
So yeah, I do drink a lot. I drink a couple of times a day, especially in the mornings. But it’s fine, you know. I’m still managing to get to work every day. Obviously I have a couple of misconduct issues at work, but other than that, you know, and my partner’s left me. But other than that, everything else is fine and I can manage this.
It sounds like your alcohol use is causing some problems at work and in your relationships.
It is, yeah. Yeah, I lost my partner and I keep getting these misconduct notifications at work and disciplinaries because I sometimes get there late and when I’m there sometimes I fall asleep, etc. And obviously I work with big machinery so there’s a little bit of a risk there, but otherwise it’s okay.
It sounds like you’re worried about your safety at work and also how your drinking is starting to affect your job and your relationships.
That’s true, yeah. I am. You know, I’ve been on the crane in particular—being intoxicated on the crane in particular has caused a few incidents, and you know, I sometimes do worry that one day it’ll—it’ll go a little bit too far, yeah.
Yeah, it sounds like that’s really scary—that you’re really worried your alcohol use could cause even like a serious or life-threatening accident at work.
Yeah, and then—what am I going to do for work? You know, because if you get something like that on your file, then I’m never going to be able to be a machine operator ever again, so...
Yeah, and your job sounds really important to you, and alcohol’s starting to get in the way of that.
Yeah, 100%.
And so what are your goals looking forward around your job or your relationship?
Well, I know I really should—I really should fix this alcohol issue that I have. And I would love to find a partner. I’d really—that’s really important to me because I want to have a family. So, you know, obviously prerequisite of having a family is finding a partner really, so yeah.
Yeah, it sounds like you’re really committed to thinking about making a change to your drinking and that you’re looking forward to finding a partner and family, and you’re worried that alcohol might get in the way of that.
So what you’re doing there is you’re not leading me, you’re kind of pushing me, if that makes sense.
Yeah. There’s like a little bit of like a Jedi mind trick thing where you’re—essentially it’s actually really... it’s a little tricky when you’re first learning how to do it because what I’m trying to do is I’m listening for what’s called "change talk." So any little nugget you’re giving me about making a change. So you’re saying like, "Oh, I’m starting to get this misconduct," "I’m worried about this thing with safety at work," "I want a partner." Those are like—it’s a gold mine of little kernels of change talk.
And I’m ignoring all of your "sustain talk." So anything where you’re arguing for the status quo—"It’s not a big deal," "Drinking’s not that big a deal," "I can’t make a change"—I don’t even acknowledge it or address it. And that’s actually hard because I think most of us pay attention to the negative stuff. So if you think about like a performance review at work or someone telling you any kind of feedback, we tend to amplify and remember like the one bad thing that someone said to us and forget the millions of good things.
So you have to change—you have to like train yourself to do the opposite, to hear those little kernels of change talk. And then I’m basically being a mirror but I’m amplifying it. So I’m taking these little kernels of change talk, I’m reflecting back to you your own words. So I’m not telling you that you should stop drinking because it’s unsafe at work; I’m reflecting to you like, "You’re starting to get worried that you might have an accident at work, and that’s really serious." And that’s kind of guiding the conversation forward.
The other key is that if you meet a point of resistance, you want to pivot. Because once you start arguing—whether it’s about politics or anything—people dig in. So if you start arguing with someone, you gotta find another way—you just gotta pivot and roll to a different tactic. Because the more you argue, the more people dig in on their point of view, and it’s more about like winning the argument than it is about moving forward.
What if you want to change yourself? Is there a process, a system, a methodology to help you discover what your ideal behaviors are, what your "why" is, and to implement change?
That’s what I say all the time: what’s your "why"? I think that’s so exciting. Like, we all want to live our best lives, whatever that means to us. And so having a purpose, having a goal is probably the most important thing.
Motivation is important—we talk a lot about motivation—but motivation is fleeting. It can slip and slide over the course of one day. So you may—you know, take kind of a mundane example: you want to get in shape. And you’re feeling super motivated one day. And then the next morning your alarm clock goes off at like 5 in the morning and you’re tired and it’s cozy in your bed and maybe you stayed up a little too late. Your motivation’s going to be flagging, right?
So if you don’t have a goal or a reason or a "why" or a purpose, it’s going to be really hard to actually get up the energy to get up. And so figuring out what that purpose is. And then trying to find ways to enjoy the process. Because if you’re always working towards a future goal—some people are very goal-oriented and that works for them—but finding joy in the process will help you.
So take alcohol, for example—like not an addiction issue, just like making changes to your drinking in your life. So if you’re just like, "Ah, I should stop drinking because drinking is bad for me," that’s like a relatively vague goal, right? It’s not really about anything that matters specifically to you, and it’s going to be hard to stick to that.
If instead you think, "Okay, I’ve started to realize that when I drink every single night, I don’t get the work done that I want to get done because I’m too tired and I fall asleep. I don’t feel refreshed in the morning because I’m not sleeping very well. I’m not getting up early to exercise, and that’s something that really matters to me. I’m not like as present with my family as I wanted to be."
Then it’s these all these little micro-goals that make it much easier to make a change. So you may decide, "You know, I’m not going to drink, I’m only going to drink two days out of the week, and when I do drink I’m going to keep it to this amount." But the reason why is not some vague recommendation from some doctor; it’s because, like, you’re working really hard at work and it feels good to be productive after dinner, and you’re training for a race and you want to get up in the morning and run. And so you actually notice those little steps—like, "Wow, it feels great, I woke up this morning and I feel so refreshed." Like you’re reinforcing your goal right there. You’re not working towards some abstract thing that doesn’t really matter to you.
So you want to make these like really focused, personalized goals, and really anchoring it on what is your "why." And your "why" may be very different than my "why" or someone else’s "why." So it may be, you know, that sleep really matters to you, or you may have a different relationship with alcohol.
So the other kind of example I’d give is: people are different, right? We respond differently to things. So some people can open a bag of, like, potato chips and eat two and walk away. Some people—like, they open the bag, they’re going to eat all of the chips. And so it’s just easier not to open the bag. And alcohol’s like that too. Some people might find if they open a bottle of wine or they have alcohol in the house, they’re going to drink all of it. And the idea of like trying to keep to these small amounts of alcohol is actually really hard, and it’s simpler and easier to just avoid it completely or to only drink at a restaurant or something. So you do have to understand like how your goals, your "why," your purpose interacts with your response to whatever it is that you’re working on, and that’s going to be different for everyone.
Are there any other things, any other habits that we should be thinking about when we’re trying to overcome an addiction? So if we think about alcohol as being at like the bottom of the stream, is there anything else upstream that I should be thinking about? So we talked about social connections and relationships, so I need to be making sure that I’m surrounded by people, I’m socializing, because that’s going to be an insulator to like stress and loneliness which is going to cause me discomfort which is going to lead me to alcohol. But are there any other things that I should be thinking about when I’m setting off to make a change in my life?
Yeah. Yeah, there’s a bunch. I think first, any behavior change—whether it’s alcohol or other—if you’re feeling like depleted and tired and not your best self, it’s going to be harder to make a change. So if you think about like any big decision you made—to change your job, to start an exercise routine, to leave your partner—you probably didn’t choose like the day that you were exhausted and feeling anxious and stressed and not your best self to make that change. Like, change is hard. So you want to try to boost up other things in your life: eat well, you know, get enough rest, try to exercise, things that are going to help you feel healthy and your best best self when you’re trying to make a change.
Is that linked to dopamine?
Yeah, because I mean so our natural reward system, the thing that triggers it is exercise, food, sex, connection. So, you know, trying to have healthy other ways of—of positive dopamine release. And so I think for many people, alcohol or substances can feel like a way of doing something nice for ourselves, like "I’m going to—this is going to help me reduce my stress after a bad day at work."
So the goal then is not that you just like white-knuckle it all night and feel really stressed after work; it’s that you figure out like: what are some other things that help me reduce stress after work? Maybe it’s going to a yoga class with a friend, maybe it is, you know, spending time with my family, maybe it’s getting a massage or meditating or watching a show I like. So you want to—it’s not just you’re removing the thing that you’re trying to change; you want to fill up the empty space with other things.
So what if I fill it up with like Häagen-Dazs ice cream and burgers? Because that will cause a dopamine hit. So presumably if I just eat loads of sweets and candy, then that’s going to stop me from engaging in the addictive behavior?
We see that all the time. So that’s like replacing things. And, you know, I was reading an article—people have probably heard of "Dry January," this idea of like not drinking for the month of January to rethink your relationship with alcohol. I was reading an article that "Dry January" has become "High January" because people are just smoking a ton of weed instead of drinking.
And so it’s very—I think you want to be cautious that you’re not just replacing the thing that you’re trying to change with something that’s also going to cause health problems. Now, having dessert once in a while for this, you know, you’re not getting calories from alcohol and having a nice ice cream cone once a week is a way of sort of treating yourself as healthier and maybe more aligned with your goals. That’s fine. I think thinking about these things—actually thinking about alcohol the way we think about dessert, sunbathing, eating processed meats—all of these things have risk and benefit in our lives.
I think where we’ve gone so wrong with alcohol was this idea that it’s like a health-promoting behavior—that you shouldn’t be drinking for your health; it’s not going to make you healthier. And also, much like many things we do that are not health-promoting activities, there are ways of reducing the health harms of that activity so that it’s okay in small amounts in your life.
I think B2B marketers keep making this mistake: they’re chasing volume instead of quality. And when you try to be seen by more people instead of the right people, all you’re doing is making noise. But that noise rarely shifts the needle and it’s often quite expensive. And I know, as there was a time in my career where I kept making this mistake, that many of you will be making it too.
Eventually, I started posting ads on our show sponsor’s platform, LinkedIn, and that’s when things started to change. I put that change down to a few critical things. One of them being that LinkedIn was then and still is today the platform where decision-makers go not only to think and learn but also to buy. And when you market your business there, you’re putting it right in front of people who actually have the power to say yes. And you can target them by job title, industry, and company size. It’s simply a sharper way to spend your marketing budget.
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Just thinking about something we said earlier about how early childhood trauma causes the brain to change and then results in addictive behaviors. If I went through an early childhood trauma and my brain is changed because of that, and then I get into—I become addicted to alcohol as a young man, and then I manage to find my way off the alcohol, my brain is still addictive, right? My brain still has that addictive sort of predisposition. So isn’t it the case that I’ll just end up being addicted to something else that gives me a dopamine hit?
So it turns out the brain is amazingly plastic, meaning it can change. We see that over time. So the first thing is even adverse childhood experiences are not a done deal. So we talk a lot about ACEs; we don’t talk a lot about PCEs, positive childhood experiences. But actually, you can reduce the risk that someone develops addiction by increasing the number of positive childhood experiences.
So take someone who’s experienced some terrible adversity: their parent has died, or they have a parent who’s in prison, or they have addiction in their family. If that kid has one single adult figure that they believe cares about them, that reduces their risk of addiction. So there are a lot of positive ways that we can actually change the trajectory even in the midst of terrible trauma.
When you think about someone who’s had a substance use disorder, we actually have good data on this that after five years of recovery—and often that is fits and starts—so most people think of like this is one fell swoop that you like decide to stop drinking and then success is that you never drink again. For most people what we find is that it’s actually like a series of steps. So I always like to think of progress, not perfection, and not have this kind of all-or-nothing mindset. That for many people they may early on have a month where they go without alcohol, and then maybe next time it’s three months, and then maybe it’s a year. And these recurrences happen, but ultimately they get to this place where they go into long-term recovery.
After five years of recovery, a person’s risk of subsequently developing addiction is no higher than the general public. So your brain actually does change, and we see this on functional imaging, we see this in longitudinal studies that follow people over time. So you actually can overwhelm those things and get to a place where you don’t have a higher risk than other people.
Because some people say, "I’ve got an addictive personality." They sort of self-label and self-identify as having an addictive personality. Sometimes they even reference their brain as being easily addictive. Is there truth in that? Is it possible to have an addictive personality?
It’s not so much about personality, but we do respond differently to substances. So, you know, take alcohol or opioids, anything. People feel different the first time they ever use it. So often if you talk to someone who then develops addiction, they tell you that first time they used the substance, it was like this amazing feeling. It felt like—I’ve had people describe it as falling in love, or you know, a warm hug, or like a relaxing bath. These like incredible comforting experiences. Other people, they get prescribed like an opioid for a tooth extraction, they feel nauseous and kind of like not like themselves and they don’t like the feeling.
So how we respond to substances is definitely based on our neurobiology and is different for different people. So some people are, both from a genetic reason and their own brain, are just more wired to be at risk of addiction. And that’s important to know about yourself, because then you can make different choices. You may decide, you know, never to keep alcohol in the house or not to drink because the risk is too great.
How much do you think about other things that are taking hold of society? Some of the other things that are non-substance related: so social media addictions, and pornography addictions, and what else—what else are some of the big ones? Food addictions?
Food, sex, gambling. I think there are a lot of similarities. It’s not my particular area of focus, but I think there are a lot of overlaps. I mean, I think many of the things you just listed, you could talk about—one, dopamine obviously—but two, this idea of needing to fill yourself with something else, either, you know, thinking about trauma, thinking about untreated mental illness, thinking about just kind of the deficit of connection and of meaning and reward, and reaching to these external solutions.
Can you tell me about a time where you’ve worked with a patient who, through the process of working with them and understanding their trauma, you discovered something unexpected about the root cause of their addictive behavior?
Yeah, yeah, I think of many patients, but one in particular who, you know, I—I had this—I knew that he’d experienced hard things in his life. He’d been in prison, for example, which is a traumatizing experience. He’d lost his parents and other things. I never truly understood the depth of his trauma and had—he had struggled his whole life with substance use disorder and in using lots of things, mostly opioids but also alcohol and cocaine and just had had a really, really hard time.
After years of knowing him, one day he broke down in my office and shared that he’d actually been molested as a young kid. And so sometimes there is that like that thing that people have never felt like they could share with anyone that really is at the root of so much of what they’ve been dealing with. And like the person who whispered to you, I think the pain of keeping that inside—not only the trauma of experiencing that as a child, but then holding that secret and feeling like you somehow are damaged or, you know, that this—this thing inside you is there, not being able to heal it, talk about it, share it with people—I think is just this like this well of pain that lives inside people.
Did he recover?
He actually passed away.
From substance abuse?
From substance use, yeah.
You must carry a lot of this stuff with you. Because your line of work sounds like you’re dealing with bad news quite often, more so than the average person. And the news you’re dealing with is a different type—and news you’re dealing with is somebody sort of reaching the end of their life through something that you also have said many times you believe is preventable in many cases. How do you manage that?
Yeah, I mean a couple things. One, there are so many stories of hope that I think counter-balance that for me. So I think, you know, the other stories in my mind are—you know, I carry with me and still care for and are in touch with people who are living these amazing vibrant lives in recovery. And I mean in the US alone, there’s 24 million people living in recovery.
So there are these stories of people who have overcome just trauma, tragedy, hardship and are doing awesome: they’re parenting, they’re working, you probably don’t even know they’re around you—you know, they don’t tell people necessarily that they’re in recovery. And getting to be sort of a part of that process with someone and watching... you know, there’s nothing in medicine where I can actually see as dramatic of a change as with addiction, where someone can be, you know, in a moment where they’re dealing with all of these health consequences and relationship challenges and then they get better and it’s just like the most beautiful thing to be a part of.
And so I think the hope from that, the sort of positivity of it, is what keeps me going every day. Obviously, finding ways to care for myself through that: and family and connection, exercise—I run, I write, you know, you gotta—you have to keep yourself whole through it all too. But I think I get—I get tremendous purpose and mostly like a lot of hope from working with people and seeing them recover.
What is the most important thing we didn’t talk about that we should have talked about?
I think one thing is language. It’s like this subtle thing. I sort of mentioned in an example where you did it really well where instead of saying someone failed treatment, you said the treatment failed them. But a lot of the language that we use with addiction actually subtly and not so subtly worsens stigma. And sometimes this sounds like I’m being politically correct or it’s like an issue of semantics, but there’s actually really good data on this.
So if you think about words we use for addiction, one is "substance abuse," right? So the term "abuse," what does abuse refer to? So it actually comes from an Old English word that means like a willful act of misconduct. And it’s a word that we use for child abuse, for sexual abuse, for domestic abuse—like it’s only for these like terribly violent acts of commission that are very stigmatized because they’re like terrible things. And yet we use it for this thing that we’re saying is a health condition—that you’re like a "substance abuser" or you have "substance abuse."
And so there have actually been these elegant studies that took like PhD-level psychologists, really highly trained clinicians, and they described a person as either a "substance abuser" or as a "person with a substance use disorder." And the clinician was actually more likely to recommend a punitive intervention for the person described as a "substance abuser."
What does that mean?
So in this case they were given like an option: you read this paragraph about a patient—and they don’t really know what the researchers are testing—and they’re given a bunch of different options for intervention. And one is this like "send them to drug court or send them to jail," one is like "offer them, you know, outpatient effective treatment," there’s a bunch of different choices. When they hear someone described as a "substance abuser," they’re actually more likely to recommend the like jail-based intervention.
So words actually like very—they influence how we think, even how we make clinical decisions. They’ve also done this with the public: so if you describe someone as a "drug addict," the public has a more negative view of them than if you describe them as a "person with addiction."
So there are these subtle ways—there’s been this shift in addiction to really using what we call "person-first language," which has been true across medicine. So like we used to use terrible words like we’d refer to someone as like "the schizophrenic," you know, or really labeling them as their health condition. And thankfully there’s been a change from that to realize that people are people first who have an illness; they’re not defined by it. So I would never say like "I’m going to see the lung cancer in room 204," I’d say "I’m going to see, you know, Mr. Smith who has lung cancer."
And so with addiction too—like people are more than that, so to say "person with addiction," "person with alcohol use disorder" rather than saying they’re an "addict" or an "alcoholic." And then even terms like "clean" and "dirty," which are commonly used when we talk about addiction. So you know, take the word "clean." It sounds really positive, like you’re saying, "Oh, you’re clean." But like what are you really saying? Are you saying like if you’re clean now, when you were actively struggling, what were you? You were dirty.
And so I always remember an example: a friend of mine who’s in recovery was interviewing for jobs in the recovery space. And so people on the interview trail would say to him like, "How long have you been clean for?" And he would say, "Well, I’ve been bathing since I was a newborn, so I’ve been clean my whole life! And I’ve been in recovery for five years" or whatever. So I think these little things actually matter—that we should use terminology that we’d use for another health condition. If we’re labeling, you know, people with active addiction as "dirty," or you know, people with addiction is the same as "child abusers" with that sort of language, we’re really sort of subtly increasing stigma. So that’s a small thing that we can all do is just try to use language that’s a bit more humanizing.
It’s so interesting, because I was aware of this but I still found myself accidentally using the word "abuse." I try to avoid the use of the word "addict."
It’s hard to change, but you know, like everything, you just want to be humble, curious, and keep trying. I mean, there’s lots of language that we’ve changed—like think about so many terms we used for, you know, people who were born with different abilities or for people of different races or other identities that were really stigmatizing and we’ve learned to use different language even if it feels a little awkward when you’re first learning it.
I think understanding the science and the data behind the impact it has to use certain language I think is really useful, because that’s helped me to understand—just because now I understand the first principles of it, I need to make sure I describe people as a person first. So "a person with addiction" is much better than calling someone an "addict."
Exactly. And one thing people ask me, they’ll say, "Well, what if someone refers to themselves that way?" because people may do that. And that’s—I mean that’s fine, people can use whatever language they want for themselves. But I think as a healthcare professional for sure, or someone who’s trying to help combat stigma, like we can choose to use different language. And I’ve actually had patients sort of ask me, "Well why do you use that terminology?" when they use a different language. And it actually can be sort of empowering to be like, "Oh yeah, I’m actually a person in recovery or I’m a person with addiction. I’m not going to label myself that way anymore."
Something I’ve been really curious about just in my life generally, because in conversation, I said something yesterday when we were at dinner with the team here. I said—I can’t remember the exact phrase, but it was words to the effect of "I’m not good at that" or "I’m not that type of person" or "I’m not organized." And I stopped myself, and the team will remember, and I go, "Actually, I shouldn’t say that. I should say right now I’m working on organization."
You’re like defining yourself as incapable of doing something instead of being like "I’m working on organization right now." Yeah, and I think it’s so important and we don’t think about it. How casually we create an identity for ourselves that is like fundamentally limiting or puts us in a box or frames us as having a deficit or captures our whole identity in some kind of deficiency we have, often in the case of the habits I’m referring to. Does the similar thing take effect when we’re talking about calling someone an "addict"?
Yeah, you’re sort of labeling them as that is the only thing that they are and that they will be that forever. And, you know, a friend of mine who’s a journalist who is in recovery and writes a lot about addiction, Maia Szalavitz, wrote this great New York Times piece that "addiction doesn’t always last a lifetime."
Because I think there’s this idea in our head that like people with addiction will always have addiction and it’s this like incurable thing. And that actually people have lots of different journeys, and for some people that becomes something they deal with and then they move on in their lives, for other people it’s something they actively manage. But this idea that you sort of boil things down to like the only thing I am in this world is a person with addiction—you really limit everything else about yourself.
We have a closing tradition on this podcast where the last guest leaves a question for the next, not knowing who they’re going to be leaving it for. And the question that’s been left for you is: "If you could redo or revise one thing that you have successfully accomplished, what would that be and why?"
I guess I would say—and I could think of lots of successful accomplishments I’d apply this to—but I’ll take the example of medical training, which is a successful accomplishment. I think I would be more present. That we are always like rushing to the accomplishment, to the finish line, to sort of getting to the next goal.
And I think back and wish I had realized what an amazing journey it was in that moment. And I mean even things with medical training that I was—I was never going to be a heart surgeon—but to stand in an operating room and look inside someone’s chest and watch a beating heart is an experience that I’ll never get again. And I think in this journey to always achieve and move forward and get to the next exam and the next thing, we sometimes miss like the miracle that’s right in front of us. And so I think I would have been even more present.
That applies to all of us. I felt like I was being called out. True for parenting, true for everything.
Thank you so much. I’m so grateful for the work that you’re doing because there’s so much—there’s so much conflicting information, especially as it relates to alcohol. There’s been so much information over the last 5, 10 years about the impact alcohol has on us. And I’ve sat here and had conversations with people who are pretty convinced that even moderate levels of alcohol are good for us. And having read your work, I’m now clear on what the truth there is.
Thank you for doing what you do. It’s incredibly important and I actually think it’s going to become increasingly important, unfortunately, because the way that the world is headed: the loneliness epidemic that we’re experiencing and the access we now have to digital devices and to low-cost consumption of addictive substances is terrifying for me.
I know you’ve got a book on the way, which I’m extremely excited about, which is due in autumn—next autumn?
Spring of 2027, so we have some time.
Spring of 2027. Okay. And what’s that book about? Can you give me—give me a clue? I mean I could guess, but...
It is going to be about changing the narrative around addiction and about really reframing how people think about it to see it as a treatable good-prognosis illness, and using some of the stories of people I’ve had the privilege of knowing to hopefully help people see things in a different way.
Where do people find you if they want to reach out or learn more?
Yes, they can find me on LinkedIn, on Instagram, they can email me. Yeah, happy to connect and would love to come back after the book is out too.
I look forward to that. I’d love to. So your Instagram, your LinkedIn, I’ll put those details below. I’m sure you’ll probably get a lot of messages because these issues in particular are incredibly—incredibly potent issues in people’s lives and very emotional issues as well. So thank you, on behalf of all my audience, thank you for your generosity today but also thank you for your wisdom. Really, really appreciated and I would love to speak to you again soon when the book is out.
Thank you. Thank you for having me.
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