Making Sense - Sam Harris - #149 — The Problem of Addiction

00:00:00.000 Welcome to the Making Sense Podcast.

00:00:08.820 This is Sam Harris.

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00:00:46.900 Welcome to the Making Sense Podcast.

00:00:49.060 This is Sam Harris.

00:00:51.120 Okay, very brief housekeeping here.

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00:01:29.680 Today I'm speaking with Sally Sattell.

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

00:01:44.140 trends in medicine and psychiatry.

00:01:45.980 And her most recent book is Brainwashed, The Seductive Appeal of Mindless Neuroscience,

00:01:51.880 which she wrote with Scott Lillienfeld.

00:01:54.400 Anyway, we talk about addiction.

00:01:56.800 We discuss the opiate epidemic and the significance of fentanyl.

00:02:00.960 We talk about PTSD.

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.

00:02:11.900 Anyway, fascinating conversation.

00:02:13.780 This is one that I hope will be of practical use to anyone who either has suffered from addiction

00:02:19.900 or knows someone suffering.

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

00:02:37.600 Sattell.

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

00:02:55.660 here you are.

00:02:56.240 So thanks for coming on the podcast.

00:02:58.160 Oh, well, thank you, and thanks to Steve Pinker.

00:03:00.300 I'm obviously a great fan of his, and yours.

00:03:03.260 I'm a long-time podcast listener.

00:03:06.120 So you were reminding me, we met at one of those Beyond Belief conferences at the Salk Institute

00:03:12.500 back in 2006 or so.

00:03:15.220 Yeah, I think it was more like 2009.

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

00:03:30.200 of neuroscience in the public square.

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

00:03:40.760 your talk.

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

00:03:55.260 all refracts through a clinical lens.

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

00:04:39.460 therapy, which touches on that mechanism.

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.

00:04:55.720 So that was my talk.

00:04:56.680 Yeah, I want to talk about that.

00:04:58.340 I mean, there are many intersecting issues here with addiction and the opioid epidemic

00:05:02.920 and PTSD, and so I want to dive into all that.

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

00:05:45.560 Medicine.

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

00:06:00.840 junk medicine.

00:06:02.820 And in fact, in a way, so much of it comes down to, the critiques often came down to explanatory

00:06:10.100 reductionism.

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.

00:06:18.940 I've done that for about 20 years.

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,

00:06:31.180 in a small town compared to an urban area.

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.

00:06:49.720 And so I would just give you an example.

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.

00:07:09.660 And I'm not saying it's illegitimate at all.

00:07:13.280 It's very real.

00:07:15.020 It's very true.

00:07:15.880 But it's just one level.

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

00:07:55.540 it becomes a victim narrative.

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

00:08:13.980 into litigation.

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

00:08:28.580 and what's being left out.

00:08:29.980 Now we have to be more nuanced.

00:08:32.160 Right.

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.

00:08:58.660 Do you know Johan Hari, the journalist?

00:09:01.360 So he's written a couple of books, one on the war on drugs and addiction, chasing the scream,

00:09:07.380 and the other on depression.

00:09:10.040 Yeah.

00:09:10.360 Lost connections.

00:09:11.180 Yeah.

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

00:09:37.100 in their life.

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,

00:09:57.300 didn't like that line at all.

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

00:10:13.520 the one he's putting forward?

00:10:14.820 And whatever your view is, what do you think people should understand at this moment about

00:10:17.960 addiction?

00:10:18.020 I think there's a little daylight.

00:10:19.440 I agree with you.

00:10:21.000 I think one could walk away from his excellent work.

00:10:26.180 I admire him very much.

00:10:27.820 But you could walk away from that with a, perhaps an undue emphasis on the cultural, social,

00:10:35.120 psychological dimensions.

00:10:36.920 However, I think that, and I would say my profession or the addiction field has over-medicalized

00:10:43.680 addiction.

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.

00:11:06.100 People call it MAT.

00:11:07.720 And I'm referring there to methadone, buprenorphine, and then there's another medication, naltrexone,

00:11:13.500 which is an opioid blocker.

00:11:15.340 These are all excellent medications.

00:11:17.240 And I use them every day.

00:11:18.800 I mean, I prescribe them.

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

00:11:44.700 that happened to you.

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.

00:12:08.600 And usually that's not the case.

00:12:11.640 They're on the methadone.

00:12:12.540 So what does that mean?

00:12:13.460 Methadone, of course, is an opioid replacement.

00:12:16.340 It's a synthetic opioid.

00:12:19.500 Actually, can you remind people, why is the transition from heroin or another opiate to

00:12:25.320 methadone advantageous at all?

00:12:27.380 And why is it given as a treatment?

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

00:12:44.440 withdrawal when they stop it abruptly.

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.

00:13:07.900 It's people feel extremely ill.

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.

00:13:17.260 And then it's over in about a week.

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.

00:13:28.000 And so it's highly destabilizing.

00:13:31.240 And you can't break the cycle.

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.

00:13:47.800 It's called methadone.

00:13:49.100 And buprenorphine, which is a partial agonist, methadone is a full agonist of the mu receptor,

00:13:54.500 will suppress the withdrawal.

00:13:56.800 And it also suppresses craving.

00:13:59.920 So as you can imagine, that's an excellent way to break the cycle and stabilize someone.

00:14:06.040 For most people, it's not enough.

00:14:08.760 It's necessary, but it's far from sufficient.

00:14:11.580 They have so much repair work to do.

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

00:14:55.400 people want to repress painful memories.

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

00:15:10.280 existential kind of lostness.

00:15:13.740 And these drugs really help.

00:15:16.280 They really do.

00:15:17.840 And sometimes they're a very good, you know, they're just a good numbing agent.

00:15:21.820 In fact, I refer to them as oblivions.

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.

00:15:47.480 So that's what replacement opioids do.

00:15:50.720 And that's huge, but it's rarely enough.

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

00:16:21.620 feet just with a medication.

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

00:16:43.320 I have written about this quite a bit.

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.

00:17:24.400 And that's a pure Pavlovian phenomenon.

00:17:27.420 And that's part of cognitive behavioral therapy for addiction is to get people to recognize

00:17:32.320 these things.

00:17:33.080 And sometimes they're obvious.

00:17:34.300 You don't drive by your dealer's house.

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

00:17:43.680 those things?

00:17:44.160 Like a marker board as opposed to a chalkboard because, because a chalk dust reminded him of

00:17:50.640 cocaine.

00:17:52.460 Right, right.

00:17:53.460 Wow.

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

00:18:26.040 place emphasis on this.

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

00:18:57.160 the word disease.

00:18:59.520 But, but in any case, if you look at the 12 steps, there's so much about, they do have

00:19:05.360 a spiritual dimension to them.

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.

00:19:47.400 I don't quite understand that.

00:19:49.340 And I don't understand the surrender when in fact you're doing all the work so that, because

00:19:53.860 they have that.

00:19:54.560 And what are the steps I surrender my will?

00:19:57.180 I believe in any case, there seem to be paradoxes, but the point is so many millions of people

00:20:03.040 have found it useful.

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

00:20:09.900 Americans see it that way.

00:20:11.280 And I, I try not to debate it.

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

00:20:24.860 problem almost only.

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

00:20:42.640 incorrect here.

00:20:43.480 But, you know, do I, do I really think that you're a psychiatrist?

00:20:46.680 Is addiction really a disease?

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

00:21:08.860 discussion.

00:21:09.400 And there I'd say, yes, it's a disease because my, my usual response to that question is what

00:21:15.100 are my choices?

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

00:21:42.820 to say, well, what kind of disease is it?

00:21:45.720 Because unlike one of the many slogans, uh, one hears lately, addiction is not a disease

00:21:53.340 like any other.

00:21:54.880 And that's important to know.

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

00:22:18.540 justice.

00:22:19.080 And I'm all, of course, I endorse that.

00:22:22.000 They wanted more funding for treatment and research.

00:22:25.980 And those are completely laudable goals.

00:22:28.900 They think it can erase stigma.

00:22:31.600 I don't believe it can.

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

00:23:09.780 that goes along with that.

00:23:11.300 But again, these are studies and everyone, as a clinician, you deal with everyone on a

00:23:16.660 personal level.

00:23:17.720 To be honest, Sam, it never comes up when you're treating someone.

00:23:21.240 These concepts just never come up.

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

00:23:49.340 at risk.

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

00:23:59.980 provoking.

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

00:24:06.480 drug when they feel anxious.

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.

00:24:40.020 But that's interesting.

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.

00:25:04.700 Exactly.

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

00:25:13.820 treated by psychiatrists.

00:25:15.200 They're treated by counselors or social workers.

00:25:18.140 But I'm the psychiatrist.

00:25:19.540 So they, you know, maybe they have Freudian images, I don't know, but, and they say, maybe

00:25:23.680 I should be talking about my childhood.

00:25:25.440 And then I explain just what I said to you, I explained to them and they say, you know,

00:25:29.080 that makes a lot of sense.

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,

00:25:39.020 then you, you know, can pursue it.

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

00:26:20.760 had a problem with alcohol?

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

00:26:39.140 to attempt moderate drinking.

00:26:43.040 Presumably they tried that along the way.

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,

00:26:58.060 who can return to control drinking.

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

00:27:28.640 make a pact.

00:27:29.280 We'll both try it, see what it's like.

00:27:31.220 And one of them tries it and his reaction is, eh, which is actually most people's reaction

00:27:37.940 the first time they try cocaine.

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.

00:27:49.360 Now that's very interesting.

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

00:28:01.020 reactions different?

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.

00:28:10.680 They know there's going to be cocaine.

00:28:12.200 One of them tries it and says, oh my God, this is fantastic.

00:28:17.820 Give me more.

00:28:18.760 And the other one says, oh my God, this is fantastic.

00:28:22.760 Get it the hell away from me.

00:28:24.420 And that is, that's very interesting.

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

00:28:41.100 have you been doing?

00:28:41.860 And they don't think, okay, I don't want to go down this road.

00:28:44.780 Well, you can see where this is going.

00:28:46.020 Then there are people who lose their job or about to lose their job and they think, wow,

00:28:50.600 I better get it together.

00:28:51.900 And then there are the people I see who, despite so many of these consequences, didn't quite

00:28:58.740 get it together.

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.

00:29:07.500 I don't know why.

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

00:29:17.880 officer is going to violate them.

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.

00:29:43.240 It responds to sanctions and incentives.

00:29:46.520 And so if you read the early papers, in fact, the brain disease was officially unveiled in

00:29:53.140 1997 in an article in Science.

00:29:56.640 The definition why it was a brain disease is, I kid you not, because addiction changes the

00:30:01.640 brain.

00:30:02.000 Well, this conversation changes the brain, so that's absurd.

00:30:06.380 Yeah, well.

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

00:30:28.420 incentives and sanctions to help people stop.

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.

00:30:43.820 This was 1971.

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?

00:31:17.360 It's terror and boredom.

00:31:19.700 And what are drugs good for?

00:31:21.620 Terror and boredom.

00:31:22.940 Plus, this was towards the end of the 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.

00:31:37.240 So drugs worked for that.

00:31:39.360 Drugs were totally normalized in the military at that point, in Vietnam.

00:31:46.340 They were abundant.

00:31:48.120 So every possible variable that lowers the threshold for using a drug was there.

00:31:55.380 They had access.

00:31:56.360 It was normalized.

00:31:57.400 It was good quality.

00:31:59.020 And they had a reason for using it.

00:32:01.680 Well, Nixon was terrified.

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 0.75

00:32:16.620 of heroin users.

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 0.67

00:32:36.880 nothing in it but your pee. 0.79

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.

00:32:55.240 And then they and then they left.

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

00:33:12.660 was something like this.

00:33:14.200 The date I'm about to present now blows out of the water.

00:33:17.340 This once once addicted, always addicted meme.

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.

00:33:47.060 We're back in the States.

00:33:48.240 We have families.

00:33:49.080 We have responsibilities.

00:33:50.500 If we wanted to continue to use heroin, we'd have to go into in these terrible neighborhoods.

00:33:56.240 Now it's easier.

00:33:57.180 People will deliver.

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

00:34:09.320 involved with addiction.

00:34:12.160 Yeah.

00:34:12.460 Well, the context clearly matters.

00:34:14.500 Context is huge.

00:34:15.440 To a remarkable degree.

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?

00:34:32.800 I'm not a genetic, a behavioral geneticist.

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

00:34:41.940 that one gene is responsible.

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

00:35:40.460 all predisposing.

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

00:36:01.820 at all, something like that.

00:36:03.320 So it could that can also go both ways.

00:36:05.820 Right.

00:36:05.880 So on the spectrum of difficulty in kicking an addiction, where do these various drugs and

00:36:13.840 substances lie?

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

00:36:33.480 administration dependent.

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.

00:36:46.260 There should be no, probably no difference.

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

00:37:03.460 so than nicotine itself.

00:37:05.680 The ritual of it and the social aspect of it?

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

00:37:27.420 smoke with regularity.

00:37:28.760 Whereas with heroin and other drugs, it's more like, you know, one in 10.

00:37:32.440 And why would that be?

00:37:34.220 Why would it be?

00:37:35.980 It looks like when you hear a capture rate is one in four, you think, wow, that must

00:37:40.360 be highly addictive.

00:37:41.500 But think about the context.

00:37:43.600 Nicotine is legal. 0.68

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,

00:38:01.220 it's not an intoxicant.

00:38:02.880 It doesn't affect your performance.

00:38:04.480 If anything, it might enhance it in some ways.

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

00:38:19.060 diseases, but they're so delayed.

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,

00:38:42.540 but that's not true.

00:38:44.060 And where does marijuana fit in here?

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

00:39:26.720 that kind of physiological picture.

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

00:39:49.680 in college.

00:39:49.820 We probably had the same marijuana, though.

00:39:51.180 Yeah.

00:39:52.100 So much of this, back to the concept that we have here.

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Making Sense - Sam Harris - March 04, 2019

#149 — The Problem of Addiction

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