the amount of alcohol it takes to begin

to cause health rellated problems is

much lower than you think. Okay. So, 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 If you're drinking two of those

glasses, we're talking like a 40%

increase. But even drinking that amount,

your risk of breast cancer would

increase by about 5%. This amount. Mhm.

Which for many people is very normal.

So, there's a lot of misinformation out

there about how much should you drink,

which I think people don't know, but I

can take you through everything. So, Dr.

Sarah Wakeakeman 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

lives. 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 43year-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 use. But what drives people

to use substances? It's probably the

most important question and if we look

at studies, one is about 40 to 60%

genetics. And the other half of the

equation is trauma. And so 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 sort of natural

painkiller system is activated by

drinking. It's an anti-anxiety and a

pain medication sort of allin-one. So

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 and they

found that people drink much less after

it. Yeah. Wow.

This has always blown my mind a little

bit. 53% of you that listen to this show

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continue to do what we do. Thank you so

[Music]

much, Dr. Sarah Wakeakeman. 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

sort of 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 who are you and what what

is your sort of body of

experience education? So I'm a medicine

doctor by training. So I still do some

general medicine like in the hospital

take care of pneumonia and heart failure

and in the outpatient setting take care

of people's diabetes and um depression

but I train especially 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 kind

of 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 health care that people get. And

then I train people so I'm um 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? Oh,

how much time do we have?

Where do we begin? I mean, 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 kind of knock it off and pull

themselves up by their bootstraps, and

that this is like a criminal legal

issue, that um it's an issue of

willpower. And so, 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 what

falls into the the bucket of addiction?

You know, because I'm I use my iPad a

lot. I use my phone a lot. Um is that is

that an addiction? Yeah, it's a great

question because we use that term

colloially a lot. You know, I'm addicted

to Netflix or whatever. Um, 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.

So we talk of addiction, we talk of the

four C's is a way to remember it. So one

C is loss of control, meaning like

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. So 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 C's that we think about. And

then we make the definition based on how

many criteria people meet out of this 11

list of different criteria. And then

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? Yeah, lots of things. I mean,

um, I focus mostly on alcohol and drugs.

So, alcohol obviously probably most

common. I think we'll talk about that a

lot today, which I'm excited about. And

certainly when we look worldwide, 400

million people have an alcohol use

disorder, meaning addiction alcohol.

It's a lot of people. The other are

drugs. So, that can be, you know,

opioids like heroin or pain pills or

fentanyl. can be cocaine or stimulants

like methamphetamine or prescription

stimulants, sedatives that people may

take for anxiety like bzzoazipines,

cannabis. And so there's a whole sort of

range of substances that can be

addictive and how addictive a substance

is um is really related to sort of how

much dopamine is released in the brain.

I know you've had a wonderful episode

with Dr. Lumpkkey about dopamine, so

you've talked about that a bit. Um and

there are different sort of addictive

indices of different substances. So

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 mean I drink coffee

every day. Certainly get a craving to

drink it now. Yeah. Well, there's, you

know, a couple important pieces there.

Is your coffee drinking causing harm in

your life in any way? No. I think it's I

think it helps. It may be helping you,

right? Okay. So, it's not Yeah. So, it's

not addiction. So, there's a difference

between physiologic dependence, meaning

like 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. We don't

really see this, but um buying more and

more coffee despite, you know, your

girlfriend nagging you about it and you

you're late to work cuz you're

purchasing coffee. We don't really see

that so much with coffee, but that would

be sort of addiction. And how big is the

problem? So, if you were to frame like

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. Yeah. So c

can you frame the situation for me and

explain to me why we should all care

about this and the I guess the scale of

the impact it's having? Well, I

guarantee 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. So 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 drugrelated deaths

annually. So that's like 1,600 deaths

today from drugrelated causes. And then

when we look at the criteria of sort of

meeting 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 in 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. So 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

you know it's only those people who are

injecting heroin who have addiction or

that person who you know has the shakes

every morning and is drinking as soon as

they wake up who has a problem with

alcohol. In which direction are we going

in as a society? Are we getting better

or are we getting more addicted? Yeah,

great question. Um the pandemic was not

kind to addiction. So we saw rates of

alcohol and drug use and deaths related

to those increase significantly after

the onset of the COVID pandemic. Um that

has started to level out. So for drug

use related deaths, we're now back at

the prepandemic levels. But there was a

very significant increase during the

time of the pandemic. And 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 some of the

life expectancy graphs and um this one

in particular I found quite shocking.

I'll throw it up on the screen but it

shows that obviously you know we would

expect 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. So I'm

wondering why in your view there was

such a significant decline in life

expectancy during the pandemic. Yeah. So

um obviously COVID was one driver. One

of the main other drivers was substance

related deaths. So actually immediately

following the onset of the pandemic, so

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 drugrelated overdose

deaths. And 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 you know

addiction is downstream from something

else. Yeah. What is actually going on?

Yeah. So that's a really great question

like what drives people to use

substances. It's actually probably the

most important question even in my work.

You know 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? Um

so trauma is probably the single biggest

driver. So, you know, 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,

they're 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 risks 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. And one of the number one

drivers is what we call adverse

childhood experiences. So there are this

famous study called the ACES study which

is stands for adverse childhood

experience and it's been replicated.

There's 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. So if you think about what's

happening in the brain with substances,

you know, when we use alcohol or drugs,

all sorts of feel-good hormones are

released, right? dopamine, your

indogenous opioid system, which is

literally your natural pain reliever.

And if you take someone who's

experienced trauma, there's great relief

that people can find in substance use.

And so we saw that in the pandemic, like

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. And it

was actually most pronounced in people

who are frontline workers. So that could

be a healthcare provider. It could also

be someone working in a grocery store or

a convenience store who had to work

through the scariest times of the

pandemic. And also people who are

caregivers. So 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. Um so you know very naively I

would assume a case if you feel bad

dopamine makes you feel good. You want

more dopamine. But is it is it more

complic complicated and nuanced than

that? Yeah. Yeah. Well, alcohol is a

really complicated one because alcohol

has lots of different effects on the

brain. Um, so any drug that can 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 so it binds to the part of our

brain um a system called GABA which is

sort of our anti-anxiety system. So it's

the same system that anxiety medications

like people may have heard of Adavan or

larazzipam or Xanax. These medications

that are kind of sedatives and anxiety

meds, alcohol acts on that part of the

brain and it actually then causes a

release of your indogenous opioids in

your brain. So like your brain's natural

painkillers. So that's actually why one

of the medications that's effective in

helping people stop drink 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 that actually your

sort of natural painkiller system is

activated by drinking. So 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 um

that gets activated when you're

drinking. Ah okay. So, if I'm having a

stressful time at work and work is

making me anxious and um is crippling

me, then I'm more likely to want to have

a big blowout on the weekend because

that's

effectively a a pain medication.

Totally. It's an anti-anxiety and a pain

medication sort of allin-one, you know,

and I think often this is part of the

area where I think just getting more

awareness and and education about

alcohol is so important because we see

that as a way of like treating

ourselves, right? And and it's very easy

to have that get out of control. And I

think especially if in your head you

think as long as I'm not like drinking

in the morning or missing work because

of drinking or you know 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. You know I

was thinking about a friend of mine who

is fairly well known um passed away from

issues related to his addiction. Yeah.

He had a lot of pressure on him when he

was fairly young. He wasn't

necessarily a a young child when he had

a lot of pressure put on him, but he was

young. And I was wondering as you

said childhood

experiences, what age that is? Yeah. 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 um to recover

from that and you're more likely to be

addicted. Yeah. So, 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. Um, so when we think

about the brain, you know, your brain

doesn't really fully form until early to

mid20s. And so both in terms of trauma,

but also in terms of early substance

exposure, you're at much greater risk

when you're younger, but that doesn't

mean that trauma in later life doesn't

um put you at risk for developing

substance use as well. So I've seen

people who, you know, their 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. And the

interesting thing is, you know, trauma

is not so much about the experience.

It's about often being left alone to

grapple with that experience by

yourself. And so what's traumatizing to

one person may not be traumatizing to

someone else. And you know, take the

pandemic for example. I've talked to

people who like being stuck at home and

alone and bored was deeply traumatic.

Other people were fine. They like were

in their living room, you know, 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. And often it's about feeling

disconnected. Um, 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 um that I

was referencing is is Liam Payne who's

from One Direction, the the boy band who

passed away. and he was on my podcast

and uh a few years before he passed away

and 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 and

then the way it worked was you know got

all this public spotlight and then

they'd like put him up on a stage and

he'd be in front of 100,000 people in

Dubai and then they after that

experience he was then like driven back

to a hotel room and like locked in the

hotel room because obviously you can't

go out because you're you're that famous

that if you walk out on the street the

crowds are going emerge. So he was then

locked in that hotel room and on the

show he said I was locked in there with

the mini bar which is full of alcohol.

Yeah. So I would drink and that cycle

would repeat itself and he'd be like

stage you know car hotel locked drink

stage car and that cycle repeat itself.

So when you were talking about isolation

and loneliness as well I never really

considered the fact that connection and

social

um relationships could play a role in

help in creating an addiction in someone

but it it tracks totally. I mean, it

makes me think of 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 like

watching TV by himself. And it doesn't

take very long for him to think that

like, you know, the thing that's going

to give me relief is having a drink. And

so, then the question becomes less about

the molecule of alcohol and more about

like 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

you're clearly extremely smart and when

I meet people like you, I always think

to myself, you could have committed your

life to anything. You could have 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? Yeah. Um, I think like many

people, I had kind of a personal thread.

I um had a family member who was

impacted by addiction who actually died

when I was in medical school. And so

that was a sort of a pivotal moment I

think that coming at the same time that

I was learning all of this science, I

was realizing like, wow, I wish I'd

known this when I was younger and

dealing with family members and friends

who were affected by this and that we've

gotten it so wrong and most people don't

have the kind of tools and knowledge to

do things differently. And so, you know,

you sort of 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. Mhm.

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. Yeah.

Can you can you describe that what they

feel to in I guess in 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 and especially thinking

about how society's moved on. So how do

you put into words how it feels to be a

family member with someone dealing with

addiction? Yeah, 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. Um, 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. And so if you're a family

member, then that's easy to feel like,

oh, they don't love me enough, you know,

that they're not choosing me over this

substance. And so I think often people

feel deeply hurt and they've, you know,

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, you

know, that you have to like kick someone

out or this whole concept of kind of

tough love and that people need to hit

bottom. And so sometimes people, you

know, 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 like

could I have done something differently?

Could something else have changed? And 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 and um and 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.

You know, the shift from like you are

the problem to like you have a problem

and we can help you with this. And I

think too often we have approached it as

if like you the person are the problem.

Do you sometimes think back and think

you know if if

id done something differently whether it

was you or someone else around you or

the system around that individual they

would still be here today. Cuz I think

that was the first thing that sprung 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 you know maybe

I could have called more. Maybe I could

have intervened here. Maybe, you know,

maybe there's something else I could

have done. Absolutely. I mean, I think

about that all the time. And um, you

know, I think I think of a friend, I

lost overdose. I think of the family

member, I lost alcohol. And not only

things that I could have done

differently, but also, you know, those

people, they they saw their doctor, they

were in the hospital, they had all these

touch points, 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 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 like 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 like all of

these moments of time with people that

you love and you you can't get those

back. And so there is this problem I

think in that binary model of like

you're either like sober in recovery or

you're actively using and this is good

and that is bad is that we lose the fact

that like 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 you know, the

both cases that I'm thinking about it,

like I'll never get that back. You know,

there's a phrase I had many years ago

which I'm now reconsidering, which is um

change happens when the pain of staying

the same becomes greater than the pain

of making a change. And that kind of

dovetales into this idea that someone

needs to hit their own rock bottom for

them to change. I think the part 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 that [ __ ] I need to change my

life. And people always reference that

like rock bottom moment where they took

action because you know they were at the

very bottom of the well. And um how does

that phrase sit with you? Change happens

when the pain of making a change becomes

greater than the pain of making a

change. I think that there are those

times for sure. It's not to discount

that and I hear those stories too. But I

think there are um from evidence what we

know there are probably more times where

people just endure the pain again and

again again until they never change. And

I think the part that we don't see are

are the folks who change happens when

they begin to get enough hope that

things could be better for them. That

you know 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. And so, you

know, take the example I'll often hear

from family members when their loved one

is in jail that they're like, "Thank

heavens." You know, they're they're in a

safe place at least like there's

actually this sense of relief. There's

even a term for it called a rescued that

people feel. I think it just goes to the

desperation that families are dealing

with, but this idea that like that's a

safe intervention. And you hear these

stories, right, of someone who they get

locked up and like 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 drugrelated 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 like 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, you know, make it

through and that's incredible. But that

doesn't mean that we should like 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

absolutely 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 is some combination of

psychotherapy medication

so alcohol yes there's I I mean,

alcohol's been on a journey. Yes. It's

been on a journey in terms of society's

opinion about it. Mhm. Can you take me

on that journey and tell me where we are

now and and in ter when I'm saying that,

I'm talking about society's opinion on

its health benefits and what it is and

and then and then also what we're

getting wrong now about alcohol. Yeah.

Yeah. Um, so I mean the journey of

alcohol is fascinating. So, first I

think we think of this as a relatively

modern thing, but you know,

archaeologists have discovered like beer

making equipment in hunter gatherers

cave dwellings from 13,000 years ago.

That's wild. Like 13,000 years of people

figuring out how to make beer. You know,

you look at China 9,000 years ago, it

was really about like 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. So

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. So in most of

those studies, what people do is they

take like 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 sort of

non-drinkers versus light drinkers,

moderate drinkers, or heavy drinkers.

And what they were finding is that

people who were drinking in the even up

to the moderate level were actually

doing better than the people who weren't

drinking at all. And so that was where

that um concept that drinking is good

for your health came from. And so people

talk about this like 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

realize is 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 like 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're not

drinking because of that. And so when

you change the reference group, you

actually make the the sort of group that

you compare people to to people who very

rarely drink. So, it's not that they're

not drinkers at all, but they drink, you

know, very very light levels. Then you

start to see that those like 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 slight shift that like

don't fool yourself into thinking that

drinking that glass of wine is like

going to exercise for 30 minutes. Like,

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 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. Say look at

this glass of wine here and this pint of

beer. Yep. If I drank one of these a

day, not a huge amount, um I think what

people tend to think is they think,

well, it's only one, so my body will

just flush it out and there'll be no

adverse health consequences.

Yep. I Is that true? Well, so part of

the challenge is what we think of as one

drink. So I think um much like, you

know, if you learn to re read the

serving size on a food, you realize that

like, oh, a serving of ice cream is like

a half a scoop. It's not like a giant

ice cream sundae. The same is true with

alcohol. So um in the UK the kind of

low-risisk drinking limits talk about

units of alcohol which is the equivalent

of 8 grams of alcohol. So how much of a

drink has eight grams of alcohol and to

be in that lowrisk 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

even though we think of it as a single

drink it's probably I mean I have to

guess but 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 um you know, you have

two glasses one day and then one glass

one day and then three glasses one day

cuz 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 this is roughly three units roughly

and you get 14 a week. You get 14 a

week. Mhm. So, 3 * 7. Mhm. 21. Yep. So,

yes, you're over if you're drinking that

size. Yep. Okay. Okay. So, if I have

this glass of wine every day, then I'd

be over the UK limit of lower risk

drinking. Lower 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. Cuz I was wondering why cancer has

been increasing. Yes. A variety of

different forms of cancer increasing.

You know, 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? Yeah. So the data

is um growing and really worrisome. So

for breast cancer so there's really

there's 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 there's no even

like low risk amount. So breast and

esophageal cancer are two examples of

that. So breast cancer if you were to

drink um below those low risk limits. So

in the US that would be fewer than seven

drinks but a drink in the US is 5 ounces

of wine which is smaller than that or in

the UK is below that 14 units. So it

would be you know fewer than seven of

that 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%. Now that's

not huge. So I think you know 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

their lifespan. 13% likelihood. Really?

Yeah. Wow. Really high. So 5% increase

would increase that to like 13.6 or so.

So that means that if there's nine women

in this room Yeah. one of them has is

going to get breast cancer

probabilistically in their life. Yep.

Damn. Yeah. Why is it is it and it's

increasing. Yeah. And so the reasons for

that are likely environmental because

your genes don't change over that time

period. So the risk factors, you know,

if you think about breast cancer, it's

alcohol, it's obesity, um it's, you

know, age 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. So, you know,

these very sort of normal behaviors.

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, you

know, things like plastics or other

things that we don't yet know, there's

um it's clearly something in the

environment that is driving these

increased cancer risks. So, even at even

at this sort of level, if I'm drinking

that might be one unit, right? Yes. So,

that would be one unit. So, that would

be fewer than 14 of that. So you could

see like an, you know, 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. Mhm. There's really

sort of no safe amount of alcohol when

when it comes to breast cancer. Is it

just breast cancer? So that lowrisk

category. So when we these big cancer

studies categorize people as sort of low

risk or light drinkers, moderate or

heavy. And 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? Yeah. Um, so colon

cancer, we're seeing that in a lot of

young men. Um, liver cancer, yeah,

prostate cancer, which is obviously a

male cancer, we don't think of as much

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 um species that sort of

change our cells and increase the risk

over time of the mutations that lead to

cancer. So yeah, can you drill down on

that? So if I if I'm a heavy drinker, so

say that I'm drinking

uh let's say I'm drinking two glasses of

wine a day consistently, which I guess

would cons like if I was drinking if you

drink two of those glasses. Yeah, you'd

be in the heavy category. So two of

those a day puts me in the heavy drink

category, which would surprise most

people, right? Like that for many people

is very normal. It is very normal. Yeah,

I think it's some 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 with every meal

that you have. So that would make me a

heavy drinker. And then what are my what

are the stats saying in terms of my

cancer uh risk profile? Yeah. So it

varies by cancer, but roughly we're

talking 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 you know 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 sort of do they call them

comorbidities? Yeah, exactly. So other

illnesses, other diseases in my body, my

probability is going to go up further

from obese some 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 um more

susceptible of 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. So a lot

of um cancers your risk goes up if

you're if you're you know 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'm

trying to I want to make sure I'm super

clear of my brain as to like what the

the the knock-on effects are and how

that ends up as cancer. Yeah. I mean,

there's lots of different mechanisms.

So, I mean, maybe starting just with

like what does alcohol do in your body?

So, you ingest alcohol. The like fancy

name for that is ethanol. It's a

molecule and it basically gets absorbed

pretty quickly from your stomach. And

so, you know, it hits your bloodstream

usually within 10 minutes or so of

having a drink. Um, 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. So 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

bloodb 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, you know, less anxiety. If

you keep drinking and that level keeps

going up, then you start having impaired

judgment. You might have motor lack of

motor coordination. So we've all seen

this and many people have probably

experienced it. You know, 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 know you talked about this Dr.

Lumpy but your body always wants to

restore what's called homeostasis.

You're always 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 um 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 o um alcohol generates a lot of that

inflammation in the process of getting

eliminated and so it can actually change

your cells 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

uh death rates and general li liver

disease compared to other parts of the

body. Yeah. Other organs in the body. I

believe it shows y what impact does

alcohol have on the liver and we have

our little mannequin here of the human

body. Where is the liver? Yeah, great

question. So here's um 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

hearts 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 quite large

and it's big. 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's metabolized by the liver. So the

liver is sort of the clearing house,

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. Yeah, it is.

Yeah. 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

you know 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 um 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 cerosis. Um, 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 is 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, um the

the main drivers of liver disease are

obesity and two is alcohol. And so those

are the leading causes of of liver

transplant. And the thing that is, you

know, 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 like what

really are the health harms of alcohol

and that we have normalized binge

drinking in many occasions, 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

around the liver. Um, does that mean

that my liver can take a bit of a

beating before there's any real

problems? Should I, you know, some

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. Yeah. I mean, so first,

every person is different. One blowout

weekend, you probably would be fine.

Anyone would probably 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. The

up you said that my 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 that we don't totally understand

who and why that happened 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 things 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? Yeah. Um so obesity. Um so food

does. Yeah. Food. So your liver is very

involved in glucose metabolism. Um so so

our diet and our body weight impact our

liver health. Um the other medications.

So um acetaminophen or Tylenol, which is

a very common over-the-counter pain

reliever, um above a certain threshold

can cause serious liver damage. So

sometimes you'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 do you think this might be a bit of

a strange bit of an an unclear question

but 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. Um, one thing is that

you know that 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-risisk guidelines which we just

learned are kind of eye opening and 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. Oh,

I've got one actually. Yeah. I think

this is, by the way, shocking. Yes. To

me. So, when we do an MRI of someone's

brain, um, we basically, this is like a

cross slice. So, it's almost like you're

you're facing me and I'm cutting your

face off and looking at your brain

onwards. Um, 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 the black space is essentially

water. So we see the brain starts

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 um 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? like what's causing the

brain to deteriorate in such a way

because of alcohol. Yeah. Well, um

remember I said um ethanol which is the

molecule crosses the bloodb 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 in

the setting of not getting enough

nutrients in your diet.

Okay, so that's the brain. That's the

brain. So 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 I'm like always having

heartburn. I'm having to pop all these

like ant acids 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. Um the heart is affected by

alcohol. So 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 um something

called atrial fibrillation, which is

basically where your heart starts

beating really irregularly. Yeah. So um

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. Mhm. 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 a term in medicine

called holiday heart because we see

sometimes people drink a ton over the

holidays and we'll 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

cardiammyopathy, which means the heart

muscle gets kind of weak and thin and

floppy and can't pump the way that it

needs to. Oh, damn. Sometimes we think

that if we're good at handling our beer

or our alcohol, then it's having less

harm on us. So, I'm for whatever reason,

I've always been good at drinking quite

a lot when I used to drink. 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 into your body fat. So, you're

essentially it's like if you took, you

know, 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, you know,

two drinks for you is going to diffuse

into a larger amount of water. Ah, that

explains a lot cuz I always wondered, he

was he was so much bigger than me at the

time. He was um he had much more body

fat. And he would get drunk very very

quickly. And you always think, oh, a 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 having I'm not as

drunk as he is. But but that's not true.

No. I mean so first of all 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 it

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 overtime you

know heart problems or esophageal

problems. What is a hangover? Yeah

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 acetal

aldahhide molecule we talked about but

it doesn't seem to be related to that.

that 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

squelli of your brain essentially being

bathed in this ethanol and then as it

leaves you just feel totally crappy

because people think of it sometimes as

just being dehydrated.

Yeah, it it is not just being

dehydrated. There's actual sort of

effects of ethanol on your brain that

lead to the hangover. Okay. I think if

you are drinking at an amount that

you're getting a hangover, it is a good

sign that you're drinking above a limit

that would be considered okay for your

body. Cuz sometimes I remember back in

the day if I had a big glass of water

before I went to bed, if I had 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 is

going to be higher. So drinking is going

to help you sort of flush it out and

feel better. I'm drinking water, but

it's not only because of dehydration.

There'll be people listening to this

now. I doubt they would have got this

far, but um because if they 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 Mhm.

Alcohol helps me socialize and

socializing is 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

that 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. So

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

aesthetic lifestyle where they never eat

dessert. So I think it really is like an

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. So 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 and how you

set up your life and your week and your

day. Um, 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 uh abuse disorder,

rehab is often the most widely known

form of treatment. Um, 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." Yeah. 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. Um, so you know, 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.

Mhm. 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 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, 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 offer 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. So,

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 not drink

as much. So, there's this medication I

mentioned at the beginning that actually

blocks your opioid receptors. Yeah.

which seems kind of funny that it works

on alcohol, but the reason it does is

that 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? Yeah, 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 benadryil or

psilocybin and then they sat with a

therapist for like eight hours for this

guided um psilocybin journey and they

found that people drink 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 imp 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. Yes,

exactly. Have you heard of iberane? I

have. Yeah. Which is often associated

which is another psychedelic often

associated with addiction. Yes. People

have looked at ibagane for um opioid use

disorder. um 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 um medications that are being

used for weight loss that people have

probably heard of so like WGOI ompic

that whole class of GLP-1

um medication seems to also reduce

alcohol use which is kind of interesting

Really? Yeah. Have they studied that?

Yeah. So, they Well, first of all,

there's I mean, there's 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, you know,

years and years and for the first time,

they don't feel that sense of like

craving and urge. Um, and there recently

have been some actual clinical trials

where they've done, you know, placeboc

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

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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

headlines going to ring out and say that

this person has passed away and that

happens all too often. We think about

you know Whitney Houston or um 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 and a 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 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 you know we

think they have an addiction, we think

they need help. What is your natural

reaction to to that and what what is it

that those people need? Yeah. Well, when

I 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

does is actually helpful. Um 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. 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 am I

remember I had this one particular

friend who had an addiction and um I

remember always the life of the party.

And I remember this one day he came up

to me at at an event and he'd sat down

in front of me and said to me

um he said he like whispered to me, "I'm

in so much pain." Mhm. And he told me

about rehab and how it had failed him,

etc. But it 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. Mhm. And then

funnily, I I then see how the world

treats that individual, him having

whispered that to me one day and the

world how the world responds to his

behavior and attacks him and criticizes

him. But I was privy to the whisper.

Yeah. Yeah. And that that one whisper

helped me to kind of reframe how to how

to treat that person, but also really

what was at the heart of what was going

on and probably gave you so much