#149 — The Problem of Addiction
Episode Stats
Words per Minute
158.01576
Summary
Sally Sattell is a practicing psychiatrist and lecturer at the Yale School of Medicine. She focuses on mental health policy as well as political trends in medicine and psychiatry. Her most recent book is Brainwashed: The Seductive Appeal of Mindless Neuroscience, which she wrote with Scott Lillienfeld.
Transcript
00:00:10.880
Just a note to say that if you're hearing this, you are not currently on our subscriber
00:00:14.680
feed and will only be hearing the first part of this conversation.
00:00:18.420
In order to access full episodes of the Making Sense Podcast, you'll need to subscribe at
00:00:24.060
There you'll find our private RSS feed to add to your favorite podcatcher, along with
00:00:30.520
We don't run ads on the podcast, and therefore it's made possible entirely through the support
00:00:35.880
So if you enjoy what we're doing here, please consider becoming one.
00:00:54.240
Once again, my meditation app is available at wakingup.com.
00:00:58.360
And if you're using the app and finding it valuable, your reviews are incredibly helpful.
00:01:04.260
Please leave those in the App Store or in the Android Store.
00:01:08.260
And any reports about bugs, please send directly to wakingup.com.
00:01:14.060
We are continually fixing those and pushing new updates, so please make sure you're using
00:01:21.500
My major priority for this year is to make the Waking Up course as good as it can be, so
00:01:32.800
Sally is a practicing psychiatrist and lecturer at the Yale School of Medicine.
00:01:37.820
She's an expert on addiction, and she focuses on mental health policy as well as political
00:01:45.980
And her most recent book is Brainwashed, The Seductive Appeal of Mindless Neuroscience,
00:01:56.800
We discuss the opiate epidemic and the significance of fentanyl.
00:02:03.060
We cover the intrusion of politics into medicine.
00:02:05.600
We also talk about the ethics of organ markets, the buying and selling of organs.
00:02:13.780
This is one that I hope will be of practical use to anyone who either has suffered from addiction
00:02:23.400
There were a few connection and latency issues that you'll hear, but nothing too terrible.
00:02:29.460
This is what happens when you do these interviews remotely.
00:02:31.980
In any case, I hope you enjoy the conversation as much as I did, and now I bring you Sally
00:02:43.900
So Sally, you were recommended to me by our mutual friend Steve Pinker.
00:02:50.040
It was a fulsome recommendation of your expertise on many topics that we're going to touch, and
00:02:58.160
Oh, well, thank you, and thanks to Steve Pinker.
00:03:06.120
So you were reminding me, we met at one of those Beyond Belief conferences at the Salk Institute
00:03:17.300
It was quite a while ago, and it was very interesting.
00:03:22.740
I think I was writing a book at that time with Scott Lillienfeld on the promise and peril
00:03:33.240
So that was a very important meeting for me, actually.
00:03:37.380
I learned about a lot of people's work there, and I was familiar with yours, but I heard
00:03:41.780
And I remember I spoke on, since I'm a clinician, I'm a psychiatrist, so I try to stick with clinical
00:03:47.260
matters and see most things through that lens, you know, how brain science, how junk science
00:03:59.440
So I spoke about post-traumatic stress disorder and how it is both a product of brain and mind,
00:04:09.800
in other words, you know, mechanism, which is brain function and meaning, and that in
00:04:16.400
my field, I think we've tended to be a little reductionist about it and see it largely through
00:04:23.960
the lens of anxiety, of a fear response that hasn't extinguished after the stressor has gone
00:04:31.040
away, which is, to me, the essence of, you know, of continuing fear.
00:04:34.880
And that's very highly legitimate, and of course, one of the best therapies is exposure
00:04:43.820
But there is so much more to post-traumatic stress disorder in terms of what keeps it alive
00:04:50.880
for people, and that often has to do with meaning.
00:04:58.340
I mean, there are many intersecting issues here with addiction and the opioid epidemic
00:05:07.180
But first, more generally, how do you view your work as a psychiatrist?
00:05:11.800
Because you're sort of at the nexus of clinical work on these various fronts, but also you comment
00:05:19.940
on the politicization of science and medicine, and you have been, there's kind of a, to some
00:05:28.580
degree, a culture war component to what you've been doing.
00:05:31.660
How do you summarize your approach to psychiatry at the moment?
00:05:35.660
Yeah, well, very much there is a culture war component.
00:05:39.240
In fact, I wrote a book back in 2001 called PCMD, How Political Correctness is Corrupting
00:05:46.880
And then I collaborated with Kristina Off-Sommers in 2005 on a book called One Nation Under Therapy.
00:05:52.660
And both of those books had a very, a very thick thread of politicized science or even
00:06:02.820
And in fact, in a way, so much of it comes down to, the critiques often came down to explanatory
00:06:12.240
And as an addiction psychiatrist, that's my main field.
00:06:15.900
And I do work, I do work part-time in a methadone clinic.
00:06:21.300
And this year, I'm actually spending the year in a small town in Ohio trying to understand
00:06:26.380
the, I even call it an addiction epidemic at this point, not just an opioid epidemic,
00:06:35.420
And there are lots of interesting differences we can talk about.
00:06:37.520
But the overarching, I guess, almost everything I've written has to do with some sort of perversion
00:06:45.340
of the data or some sort of questionable interpretation.
00:06:53.700
Take, for example, post-traumatic stress disorder, since I brought that up.
00:06:58.480
A reductionist approach, not an incorrect one, but just one explanatory level would be at the
00:07:05.500
level of the amygdala, at the level of neuroscience.
00:07:17.800
And when you reduce things to one level, we do that in addiction as well.
00:07:22.560
Now, the dominant view of addiction is that it's a brain disease.
00:07:27.260
And anytime you reduce things to one level, it's obviously a precursor to oversimplification.
00:07:32.500
And when you're in the clinical world and policy world, that's usually a recipe for a bad policy.
00:07:40.140
And it's also a recipe for politicization because it can foster a victim narrative because
00:07:48.400
someone, if there is a certain level of explanation that can be traced back to a perpetrator, then
00:07:56.980
And anytime, again, there's someone to blame, and in the case of the opioid crisis, there's
00:08:03.980
been much focus on, of course, the pharmaceutical companies.
00:08:07.260
And I do think they bear some responsibility, don't get me wrong, but it also very much fits
00:08:16.840
But of course, as a clinician, I'm most concerned with how it may undermine the best kind of care.
00:08:23.080
So pretty much everything I've written about, yeah, it goes to these kinds of oversimplifications
00:08:32.720
So let's start with addiction because it is obviously an enormous problem.
00:08:37.020
And many people listening to this podcast will either have some firsthand experience with
00:08:43.980
it themselves or know somebody suffering with some version of it.
00:08:48.940
So what should we understand about addiction at this point?
00:08:54.480
So I should reference another podcast I did, which I don't know, you may have heard.
00:09:01.360
So he's written a couple of books, one on the war on drugs and addiction, chasing the scream,
00:09:11.320
You know, he came on the podcast and, you know, he's a great speaker and a very interesting
00:09:17.200
guy, but, you know, he's taken a line through both of those topics that seems to de-emphasize
00:09:23.340
the role of biochemistry and, you know, the disease model, certainly, of addiction, and
00:09:29.240
puts the blame far more on the lack of meaning and lack of connectedness that someone may experience
00:09:37.660
And he draws a lot of motivation from a few experiments.
00:09:43.180
One is famously described as the rat park experiment, which you probably know about.
00:09:50.500
So in the aftermath of that podcast, I received some angry pushback from people who, you know,
00:09:58.840
And I mean, in Johan's defense, he doesn't actually discount the role of biochemistry, but
00:10:03.680
if you get him talking, he can certainly seem to.
00:10:07.440
One question off the top is, is there much daylight between your view of addiction and
00:10:14.820
And whatever your view is, what do you think people should understand at this moment about
00:10:21.000
I think one could walk away from his excellent work.
00:10:27.820
But you could walk away from that with a, perhaps an undue emphasis on the cultural, social,
00:10:36.920
However, I think that, and I would say my profession or the addiction field has over-medicalized
00:10:44.800
And I don't say that as someone who is not in thrall to the technology of brain imaging,
00:10:51.940
but I think we have, I think we have over-medicalized it to the point where we put too much emphasis
00:11:02.480
on the, I'll call them anti-addiction medications.
00:11:07.720
And I'm referring there to methadone, buprenorphine, and then there's another medication, naltrexone,
00:11:19.840
And occasionally there is a patient who gets on methadone, and I would say he would fit the
00:11:26.800
classic medical model, which is to say that addiction is something almost imposed on you.
00:11:32.420
Even we call it a person with substance use disorder.
00:11:35.920
And I realize in medicine, we have to give things shorthand names.
00:11:39.860
But I even cringe sometimes when I hear that because it makes it sound as if it's something
00:11:45.720
And addiction is a very intricate and deeply personal kind of affliction.
00:11:54.160
So for example, basically I see things on a large spectrum.
00:11:58.180
And as a clinician, you take people as individuals.
00:12:01.540
But occasionally I'll see a person who says, all I need is the methadone and I'll be fine.
00:12:13.460
Methadone, of course, is an opioid replacement.
00:12:19.500
Actually, can you remind people, why is the transition from heroin or another opiate to
00:12:28.580
Well, if one is abruptly withdrawn or one loses supply to opioids and they've been on it chronically
00:12:37.540
and on a substantial dose for a while, even though some people, low doses can even precipitate
00:12:46.960
And that's basically just your body, which is already adapted.
00:12:51.020
There's been neuroadaptation to the chronic exposure.
00:12:54.840
And so there's a withdrawal syndrome and it can be very intense, extremely intense to
00:13:01.280
the point where some people will continue using drugs just to just to avert the withdrawal.
00:13:10.740
It's been called the worst flu you've ever had.
00:13:13.080
Nausea, vomiting, shakes last about 72 hours at its worst.
00:13:19.740
Some people have documented what's called a protracted withdrawal syndrome, which is sort
00:13:24.360
of a low-grade withdrawal, which could go on even for months.
00:13:32.560
A lot of people can't break the cycle on their own.
00:13:34.940
I should add, many people do and clinicians don't see them.
00:13:38.700
But the folks we see, obviously, have a very hard time stopping drugs on their own.
00:13:43.280
So to suppress the withdrawal symptom, there's this replacement opioid.
00:13:49.100
And buprenorphine, which is a partial agonist, methadone is a full agonist of the mu receptor,
00:13:59.920
So as you can imagine, that's an excellent way to break the cycle and stabilize someone.
00:14:14.720
Not only do they have to repair all the damage to their life that was done while they were
00:14:19.240
addicted, you know, all the bridges they've burned, all the relationships they've destroyed,
00:14:23.720
all the jobs they may have lost, the reputation, the health.
00:14:27.520
There is also the problem of what predispose them to using in the first place.
00:14:33.280
And this is where I'm very much with Johan in saying that most, but not all, but most people
00:14:40.940
I've treated, most addiction memoirs I've, well, all addiction memoirs I've read, talk
00:14:45.880
to a kind of psychic, profound psychic distress.
00:14:50.260
It often takes the form of self-loathing as one of the most prominent themes, but other
00:14:57.240
Some people, I think, just should have been on a better dose of Prozac or something else
00:15:01.940
because they're using it to deal with anxiety and depression.
00:15:05.800
And sometimes a conventional medication can be what they need, but other times it's a more
00:15:17.840
And sometimes they're a very good, you know, they're just a good numbing agent.
00:15:23.820
I mean, you've heard of stimulants and depressants, and I have a new class called oblivions.
00:15:28.740
And that's what, in fact, that's what morphine is, right?
00:15:31.980
It's Morpheus, I mean, from the god of Morpheus, who lived by the river, I'm going to mispronounce
00:15:38.360
this because I'm not a Greek scholar, but Lethe, and that's the river of oblivion.
00:15:43.820
So, and these drugs, of course, have a profound history.
00:15:53.940
Now, occasionally there's a person for whom it is enough.
00:15:56.920
This is a person, let's say, for whom the withdrawal was so, or the avoidance of withdrawal
00:16:03.320
was such a powerful engine for continued use that once you took care of as a clinician,
00:16:10.520
you know, once we basically treated the withdrawal, the person had enough social capital, enough,
00:16:15.800
hadn't, you know, just had enough of a social network to be able to get back on his or her
00:16:24.920
That happens to be rare in my experience, but it would happen.
00:16:28.600
And in that case, I would say the person fit the medical model more snuggly.
00:16:35.080
But in most cases, in fact, we think of addiction, or we, I say we, because Scott Lillianfeld and
00:16:45.400
We think about it as operating on many different levels simultaneously, obviously on the neurobiological
00:16:53.960
plane, but on the psychological one, on the behavioral one.
00:16:59.760
It's incredible how important cues can be, how important conditioning is in perpetuating
00:17:07.700
drug use and, and also in treating drug use, because of course, one of the first things
00:17:12.260
you try to get patients to work on is identifying the kinds of, the kinds of situations, the kind
00:17:19.340
of internal mood states, the kind of people that are around that get them craving.
00:17:27.420
And that's part of cognitive behavioral therapy for addiction is to get people to recognize
00:17:37.040
I had a, I knew of a school teacher once who had to wear, had to get a, what do they call
00:17:44.160
Like a marker board as opposed to a chalkboard because, because a chalk dust reminded him of
00:17:53.760
So, so what is the role of AA in kind of framing our beliefs around addiction?
00:18:00.060
Because there's this, I mean, there's this model that specifically an alcoholic is somebody
00:18:06.300
who is irretrievably suffering from a kind of disease.
00:18:11.680
And once an alcoholic, always an alcoholic, you know, I actually don't have direct experience
00:18:18.060
with AA or addiction, but I may, I may be getting, it's slightly wrong in terms of just how they
00:18:26.920
But what's your view of the role AA has played in all of this?
00:18:31.500
And in what sense is addiction a disease and what sense does that analogy break down?
00:18:37.680
I actually don't consider AA the source of, of what I think is a problematic medicalization.
00:18:45.660
I, I attribute that to the National Institute on Drug Abuse and we, we can get back to that.
00:18:50.900
But as far as AA is concerned, interestingly, in the, in the early thirties, it did not use
00:18:59.520
But, but in any case, if you look at the 12 steps, there's so much about, they do have
00:19:07.260
There's, there's a big emphasis on the so-called moral inventory, not moral as in if, as in
00:19:14.060
you're a morally flawed person, that addicts are morally flawed people, just that, just
00:19:20.620
that in many cases, so many, I'll use their word, amends need to be made.
00:19:25.200
And, uh, going back to, I suppose what Johan would, where I agree with him is that so much
00:19:31.360
addiction flows from, from so much personal unhappiness that you want to also go back to the
00:19:37.140
origins of why you even became addicted in the first place.
00:19:41.080
So, um, so I find AA, uh, I, I, I personally have trouble with, you know, a higher power.
00:19:49.340
And I don't understand the surrender when in fact you're doing all the work so that, because
00:19:57.180
I believe in any case, there seem to be paradoxes, but the point is so many millions of people
00:20:04.080
But as far as it being a disease, I, I mean, I think if you took a poll, the majority of
00:20:13.340
And I do make a different, a distinction between disease, which is somewhat metaphorical and
00:20:19.280
a brain disease, which reifies it much more as a physiological problem and a physiological
00:20:26.820
But, um, when people say to me and very, I found this very interesting in this small
00:20:32.300
town I'm working in, Ohio, that a few of the, um, nurses and social workers have said
00:20:38.580
to me, yeah, they kind of lower their voice because they know they're being a little politically
00:20:43.480
But, you know, do I, do I really think that you're a psychiatrist?
00:20:49.400
And I like the fact that they asked me that question.
00:20:52.320
Now, if there were some crusty old sheriff, you know, who just wanted to lock people up
00:20:56.340
and didn't want his, his deputies to be administering naloxone, you know, that the, uh, the overdose
00:21:03.460
reversal drug and didn't want to be bothered with these folks, that would be a whole different
00:21:09.400
And there I'd say, yes, it's a disease because my, my usual response to that question is what
00:21:16.060
Because my choices is that it's a moral failure or it's a sin.
00:21:20.160
Well, then I'm going with disease, but I'd like to be able to be more nuanced about it.
00:21:24.860
So, uh, so when I, when I've had these conversations, I, I, I'll just stipulate if some people, some,
00:21:32.400
for some people, it's very important to embrace that disease model for others less.
00:21:37.520
So, but I just say, so if addiction is a disease, then, then it's more, most important for us
00:21:45.720
Because unlike one of the many slogans, uh, one hears lately, addiction is not a disease
00:21:57.100
And I'll get into that in a minute, but I would like to say that I acknowledge why the
00:22:02.780
National Institute of Drug Abuse, which is responsible for this brain disease formulation,
00:22:07.520
I want, and so many other advocacy groups endorse that, that I do see the virtues in it.
00:22:13.740
I understand that they were trying to, you know, wrest it out of the realm of criminal
00:22:22.000
They wanted more funding for treatment and research.
00:22:34.220
And there is a lot of interesting research, some of it by Nick Haslam as an Australian cognitive
00:22:40.900
behaviorist and others who have shown that the more you medicalize a behavior problem,
00:22:47.620
actually, the more you increase social, the desire for social distance on the part of others,
00:22:53.480
and the more it induces a sense of therapeutic nihilism.
00:22:58.300
And there's also research showing that patients who endorse a disease model for themselves
00:23:04.040
actually don't quite do as well because there's a sense of, there's a loss of self-efficacy
00:23:11.300
But again, these are studies and everyone, as a clinician, you deal with everyone on a
00:23:17.720
To be honest, Sam, it never comes up when you're treating someone.
00:23:23.140
You just deal with how do you put one foot in front of the other?
00:23:26.620
And, you know, what are the skills you have to use to stay, you know, to stay clean?
00:23:32.700
And then at some point, people get enough sober time, abstinence time, where they can start
00:23:39.200
exploring if they're interested, what are some of the kinds of problems that preceded their
00:23:44.380
drug use in the first place, because some of those vulnerabilities still exist and put them
00:23:49.960
But we don't do, you know, classic depth psychotherapy.
00:23:53.780
We're not getting into childhood traumas or primitive events because those are anxiety
00:24:01.020
And that's the last thing you want to do for a person whose habit has been to look for a
00:24:08.420
So for many years of therapy, I'm not saying people have to be in therapy for many years.
00:24:15.060
Hopefully, they internalize a lot of these skills for themselves.
00:24:18.840
But the effort is very much pragmatic and, I would say, cognitive behaviorally based in
00:24:24.540
terms of therapy therapy and then in terms of rebuilding their lives.
00:24:29.160
You know, again, vocationally getting their kids back if they've lost them, getting jobs
00:24:33.900
back, regaining trust, establishing a healthy social network, these kinds of things.
00:24:40.600
So the classical talk therapy, you're saying in this case, certainly in the acute stage
00:24:46.540
after cessation of drug use is counterproductive because just kind of endlessly taking an inventory
00:24:53.780
of all of your past suffering that may or may not explain how you got here, just produces
00:25:00.100
the negative mental states that people want to self-medicate away from in the first place.
00:25:05.560
And some patients have said to me, well, you know, shouldn't I be talking about, because
00:25:10.300
I see a psychiatrist and they have this, because most people in the addiction world are not
00:25:15.200
They're treated by counselors or social workers.
00:25:19.540
So they, you know, maybe they have Freudian images, I don't know, but, and they say, maybe
00:25:25.440
And then I explain just what I said to you, I explained to them and they say, you know,
00:25:31.000
And I say, that's a luxury you will have after you've been, you know, after you've, after
00:25:35.800
you've, you're stable for quite a while, if you still feel that's important to you,
00:25:40.700
And luckily they, they seem to, you know, accept that.
00:25:44.020
And of course, they're free to go to someone else who will do that with them.
00:25:47.180
Although I think most people who are sophisticated about working with people with drug problems
00:25:51.780
would not do that kind of exploratory work in an early stage.
00:25:57.360
Is it simply an empirical fact that people who can cross some line into a clear substance
00:26:05.800
abuse pattern can't then go back and, you know, let's take alcohol as the normal social
00:26:12.480
lubricant, is it possible for someone to become a, quote, healthy social drinker after having
00:26:22.280
Or is the AA model of once an alcoholic, always an alcoholic, a fair description of the pattern?
00:26:29.240
No, that, I would not say that's, that's fair, although it's very common.
00:26:32.940
Certainly it is probably not a good idea for someone who's had a severe alcohol problem
00:26:45.500
However, there is a group and it's, I, I think it's legitimate.
00:26:49.940
It's called moderation management and it does have membership.
00:26:53.460
And then it has a, it's, there certainly is a subpopulation of, of individuals who,
00:27:00.820
As a clinician, by the time they get, see, by the time someone gets to a clinician,
00:27:04.540
you have to remember there's so many layers at which people have peeled themselves off.
00:27:09.440
I mean, let, let's take this situation of, uh, two people who go, they seem to be matched
00:27:14.640
on almost every variable and they're both curious about like what, let's say cocaine,
00:27:18.900
because most people have, I suppose, experienced alcohol, but they, um, there's, they're going
00:27:23.920
to a party and they know there's going to be cocaine there and they both say, look, we'll
00:27:31.220
And one of them tries it and his reaction is, eh, which is actually most people's reaction
00:27:40.180
And most people's reaction, the first time they use a heroin is they throw up.
00:27:43.920
Then the, uh, but the other friend tries it and says, oh my God, this is fantastic.
00:27:51.660
And, and that's why I think more biologically oriented folks stop.
00:27:56.360
And, and frankly, you could build a whole career on figuring out why are, why are those
00:28:01.960
And I think they're mediated, you know, through neurochemistry differently.
00:28:06.020
But now here's another scenario where these two friends, two more friends go to a party.
00:28:12.200
One of them tries it and says, oh my God, this is fantastic.
00:28:18.760
And the other one says, oh my God, this is fantastic.
00:28:27.240
So that's someone who peeled off at the very first step.
00:28:30.660
Then you have people who peel off in terms of quitting use after they've used a few times
00:28:36.980
and, you know, they came home late and their wife gives them a dirty look and says, what
00:28:41.860
And they don't think, okay, I don't want to go down this road.
00:28:46.020
Then there are people who lose their job or about to lose their job and they think, wow,
00:28:51.900
And then there are the people I see who, despite so many of these consequences, didn't quite
00:28:59.940
Now, there's always one consequence that brings them in.
00:29:03.380
And why that one and not the one before is the alchemy of addiction.
00:29:08.720
There are too many variables because everyone who's walked into our clinic practically is there
00:29:13.660
because a spouse is going to leave them, a boss is going to fire them, or a probation
00:29:19.780
And that goes to one of the reasons why I find the brain disease formulation, which privileges
00:29:26.260
so much the neurobiological level, why I find it problematic.
00:29:30.660
Because it takes our eye off several other levels of explanation.
00:29:36.380
One of them being that addiction is a behavior that responds to consequences.
00:29:46.520
And so if you read the early papers, in fact, the brain disease was officially unveiled in
00:29:56.640
The definition why it was a brain disease is, I kid you not, because addiction changes the
00:30:02.000
Well, this conversation changes the brain, so that's absurd.
00:30:07.100
But you could then more generously say, well, okay, in what way does it change the brain?
00:30:12.680
Does it change the brain in which people have no choice but to use or but to continue to use?
00:30:18.940
And we know that's true just because of what I told you.
00:30:21.980
Because there's an enormous literature on contingency management, which is how you manipulate the
00:30:31.840
And one of the most fascinating, I'd say if I had to sum up all of addiction science in one,
00:30:37.220
in one vignette, it would be the Vietnam veterans experience, which I'll tell you.
00:30:46.340
And I remember the New York Times in the spring of 71 reported on the Department of Defense
00:30:54.860
research on all the veteran, all the GIs in Vietnam that were addicted, addicted, not just
00:31:03.340
using, but addicted to opium and heroin and really good high-grade Southeast Asian stuff.
00:31:10.820
And that's no surprise in a way, because what is war?
00:31:27.960
And there was so much demoralization and such a sense of betrayal by so many that there was
00:31:34.140
just a simmering rage that a lot of these men had.
00:31:39.360
Drugs were totally normalized in the military at that point, in Vietnam.
00:31:48.120
So every possible variable that lowers the threshold for using a drug was there.
00:32:04.600
And there was already a heroin problem in the urban centers.
00:32:08.480
And he was afraid that these men would come back and just seed that population even further
00:32:17.860
So he instituted a program, which just has the best name in the world, Operation Golden Flow.
00:32:24.400
And as you might guess, basically, it said, you know, for those of you whose year is up,
00:32:31.040
whose tour of duty is up, you will not be allowed back in the States until you pee in a cup and there's
00:32:38.440
And actually, once they were told this, the folks who are, you know, about to leave, the
00:32:45.560
vast majority of them were able to stop using on their own.
00:32:49.900
They did offer some treatment in Vietnam for those who had more trouble.
00:32:58.440
Now, these GI, well, now veterans, were followed by Lee Robbins of Washington University, who
00:33:04.760
wrote a paper that were in which she said this has blown the title of it or the subtitle
00:33:14.200
The date I'm about to present now blows out of the water.
00:33:20.500
And what she found following these guys for three years was that very few of them resumed
00:33:27.200
use of heroin, 12 percent over a three-year period.
00:33:31.220
The majority of those who resumed use had a prior use.
00:33:35.280
In other words, a use that predated their deployment and that the reason when she interviewed
00:33:41.300
many of them, a subset, and they said, well, you know, we we had lives to live now.
00:33:50.500
If we wanted to continue to use heroin, we'd have to go into in these terrible neighborhoods.
00:33:58.220
But, you know, and it was of course it was totally stigmatized.
00:34:02.700
And there and and that to me is the full spectrum of so many of the dynamics that are
00:34:16.240
What do we know, though, about the behavioral genetics here?
00:34:19.500
I mean, is it well understood that there is a there are a gene or or genes that govern a
00:34:27.060
person's susceptibility to falling into addiction regardless of context?
00:34:35.240
So, but I'm going to say that whenever you're in the realm of behavior in humans, it's rare
00:34:43.500
So everything and most things in psychiatry are highly polygenic.
00:34:47.120
But I have no doubt that there are some people whose circuitry is genetically built so that they find
00:35:00.340
their reward system is more sensitive, that they have their locus coeruleus is much more attuned
00:35:09.640
to the withdrawal phenomenon so that it's it's it's much less tolerable that we have impulse.
00:35:16.780
Of course, there's the issue of impulse control.
00:35:19.680
I mean, one becomes a highly steep discounter in the course of being an addict.
00:35:24.380
Some people are steep discounters before they become one, and that probably predisposes them.
00:35:29.360
But it's usually it's usually a combination of many, many, many things.
00:35:35.200
And we know that, you know, so-called adverse childhood experiences predispose, but they're
00:35:42.120
And one could argue, for example, that if everyone in your family were an alcoholic, to the extent
00:35:48.300
that anyone might use that as a justification for why they became an alcoholic, one could just
00:35:53.080
as easily say, well, you saw what it was like, you know, then it was your job to not drink
00:36:05.880
So on the spectrum of difficulty in kicking an addiction, where do these various drugs and
00:36:16.000
I mean, can you generalize about how hard it is to get off of heroin versus the pharmaceutical
00:36:21.260
opioids that people are having problems with now versus alcohol and anything else?
00:36:26.480
Well, as far as opioids, a lot of this is obviously dose dependent and often a root of
00:36:36.000
But if you're, conceivably, it could be as hard to get off opioids, prescription opioids,
00:36:42.360
especially if you've crushed them up and snored or injecting them as heroin.
00:36:48.040
Interestingly, nicotine is considered the most addictive drug, but that is highly conflated
00:36:55.580
with the fact that smoking itself as a behavior is addicted, highly addictive, arguably more
00:37:07.760
Yes, the social aspect of it, but also the fact that there's talk about context.
00:37:16.000
Of course, it's hard to, of course, the uptake, it's called capture.
00:37:19.800
The capture rate for nicotine is about one in four.
00:37:23.480
In other words, if you start smoking with some regularity, they will probably continue to
00:37:28.760
Whereas with heroin and other drugs, it's more like, you know, one in 10.
00:37:35.980
It looks like when you hear a capture rate is one in four, you think, wow, that must
00:37:44.840
I mean, in the form of cigarettes, nicotine is ubiquitous.
00:37:51.080
Admittedly, cigarettes are much more maligned, you know, nowadays and for good reason than
00:37:55.420
they were, but still, and nicotine, and this perhaps is one of the most important aspects,
00:38:07.200
So that the consequences for using, for smoking are so much less and so much less immediate.
00:38:14.060
And that's, that's very important too, because of course you can get lung cancer and devastating
00:38:21.360
Whereas the consequences for intoxicants come much sooner.
00:38:25.920
So all of these play in to the fact that someone would sustain their use, but that's
00:38:31.140
over and above the base addictiveness of nicotine itself.
00:38:35.340
And that's also why cigarettes are so hard to quit.
00:38:38.360
And that's been misconstrued as nicotine being one of the most addictive drugs in the world,
00:38:46.120
Is there an addictive component to it, or is there, is there some other category of
00:38:52.820
compulsive use that shouldn't be categorized as addiction?
00:38:58.300
Actually, the physical, yeah, the physical addiction, the physical withdrawal that I explained
00:39:02.900
before that you'll get from opioids, that you would get from alcohol, you would get from
00:39:06.900
barbiturates, you could, we'd get from benzodiazepines like Xanaxol withdrawal.
00:39:10.760
Those were considered the hallmark of withdrawal, but ever since cocaine, ever since the 80s,
00:39:18.220
that's been downplayed as an indicator of addiction because cocaine and the stimulants don't have
00:39:29.260
I mean, they have their own discontinuation syndrome, there's no question.
00:39:33.160
But, so some drugs have that and some drugs don't.
00:39:35.580
I have to say, I'm not that expert in marijuana.
00:39:38.640
I do know that because the potency is so much greater now than it was when, I'm sure we
00:39:45.980
were, might be a little older than you, but I think we were both, you know, when we were
00:39:52.100
So much of this, back to the concept that we have here.
00:39:54.900
If you'd like to continue listening to this conversation, you'll need to subscribe at
00:40:07.320
Once you do, you'll get access to all full-length episodes of the Making Sense podcast, along with
00:40:12.000
other subscriber-only content, including bonus episodes and AMAs and the conversations I've
00:40:18.800
The Making Sense podcast is ad-free and relies entirely on listener support, and you can