How Alcohol Rewires Your Brain and Increases Cancer Risk by 40%! The Alcohol Doctor, Dr. Sarah Wakeman

23:53And people always reference that rock bottom moment where they took action because they were at the very bottom of the well. And 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, from evidence, what we know, there are probably more times where people just endure the pain again and again until they never change. And I think the part that we don't see are the folks who change happens when they begin to get enough hope that things could be better for them, that someone loves them, someone cares not that they're reaching out a hand in the darkness, that there actually is a path forward.

24:37I 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 in a safe place at least. Like there's actually this sense of relief. There's even a term for it called a rescue 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.

25:05And you hear these stories, right, of someone who they get locked up and like, that's their Ureca moment. And yet, if imprisonment were an effective intervention for addiction, for example. We wouldn't see that actually the time after getting released from prison, there's 130 times increased risk of dying from a drug -related cause after people leave prison and that your risk of dying ever from addiction is much, much higher people have 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.

25:40And 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 way 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 there is.

26:15It depends on the type of addiction in their situation, but in most cases, there's some combination of psychotherapy, medication. So alcohol. Yes. There's, I mean, alcohol's been on a journey. Yes. It's been on a journey in terms of society's opinion about it. Can you take me on that journey and tell me where we are now? and what I'm saying that I'm talking about society's opinion on its health benefits and what it is. And then also what we're getting wrong now about alcohol. Yeah, yeah. So I mean the journey of alcohol is fascinating. So first, I think they think of this as a relatively modern thing, but you know, archaeologists have discovered like beer making equipment in hunter -gatherers caved wellings from 13 ,000 years ago.

26:57That's wild. That's 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 gonna improve your health. And that's where I think we got wrong. And the reason why I 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.

27:26But it was also how people were conducting the study. So in most of the studies, what people do is they take a massive population, tens of thousands of people, where we have some data where they're reporting how much alcohol they used. And then we look at health risk over time and scientists with one people into sort of non -drinkers versus light drinkers, moderate drinkers or heavy drinkers. And what they're finding is that people who are drinking in the even up to the moderate level, we're actually doing better than the people who weren't drinking at all. And so that was where that concept that drinking is good for your health came from.

27:55And so people 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 hard failure and they don't want to drink because they don't want it to mix with their medication or they might have had a history of alcohol use disorder and they're actually in recovery.

28:22So they've already had some damage from alcohol and they are not drinking because of that. And so when you change the reference group, you actually make 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 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.

28:58So it's a 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. So I look at this glass of wine here and this pint of beer. Yeah. If I drank one of these a day, not a huge amount, I think what people tend to think is they think, well, it's only one.

29:32Yeah. So my body will just flush it out and there'll be no adverse health consequences. Yeah. It is that true. Well, the part of the challenge is what we think of as one drink. So I think much like, you know, if you learn to read the serving size on a food, you realize that like serving an ice cream is like a half scoop. It's not like a giant ice cream Sunday. The same is true with alcohol. So in the UK, the kind of low risk drinking limits talk about units of alcohol, which is the equivalent of eight grams of alcohol. So how much of a drink has eight grams of alcohol? And to be in that low risk category, you have to be below 14 units.

30:08The problem is that glass of wine, just eyeballing it, has several units of alcohol. So it is not even though we think of it as a single drink, I think 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'll 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, you know, you have two glasses one day and then one glass one day and then three glasses one day cause you're at a social function. All of a sudden you're actually quite a lot over that limit. So if you said that this is roughly three, you ask roughly.

30:41And you get 14 a week. You get 14 a week. So three times seven, 21. Yeah. So yes, you're over if you're drinking that size. Yeah. 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 -restrainting. You'd be in what we call moderate risk, which is associated with pretty much every form of cancer, which I think people don't know. Okay. Because I was wondering why cancer has been increasing. Yes. A variety of different forms of cancer are increasing. Breast cancer is one of the ones we always hear about. That's increasing.

31:18So you're saying, what is the data in terms of low or moderate risk of drinking and cancer? Yeah. So the data is growing and really worries them. So for breast cancer, 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 no healthy, or there's no even low risk amount. So breast and esophageal cancer, two examples of that. So breast cancer, if you were to drink below those low risk limits, so in the US that would be fewer than seven drinks, but a drink in the US is five ounces of wine, which is smaller than that, or in the UK is below that 14 units, so it would be fewer than seven of that size glass of wine.

31:59We 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%. And that's not huge. So I think, you know, percent increase is kind of hard to do the mouth 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. Really high. So five percent increase would increase that to like 13 .6 or so. So that means that if there's nine women in this room, one of them is going to get breast cancer probabilistically.

32:33in their life, yeah. Damn. Yeah. Why 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 factor is, you know, if you think about breast cancer, it's alcohol, it's obesity. It's, you know, age at what, when you have children or don't have children, because it's really a 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 process meets increase your risk of colon cancer.

33:05So 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 talked to my colleagues were oncologists You know things like plastics or other things that we don't yet know there's 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, you know, if you had double that, it would be a decent poor wine.

33:39You could not have more than seven of those in a week to be in low risk. But even drinking that amount, your risk of breast cancer would go up a little bit. Even this amount. Mm -hmm. There's really sort of no safe amount of alcohol when it comes to breast cancer. Is it just breast cancer? So that low risk 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 Relationships 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 Asophageal 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?

34:29Yeah. So colon cancer, we're seeing that in a lot of young men. 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 species that sort of change ourselves and increase the risk over time of the mutations that lead to cancer. So yeah, can you drill down on that? So if I'm a heavy drinker, so say that I'm drinking, let's say I'm drinking two glasses of wine a day consistently, which I guess would cause like you're supposed to drink two of those glasses.

35:11Yeah, you'd be in the heavy category. So two of those a day puts me in a heavy drink category. Yeah, which, what's the prize most people, right? Like that for many people is very normal. It is very new. Yeah, I think it's somewhat more difficult for younger people to understand because younger people will drink less. But if I think about the generation above me, having two glasses of wine a day is quite normal. After work on the weekends with every meal that you have, so that would make me a heavy drinker. And then one of my, what are the stats saying in terms of my cancer 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.

35:52So, 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 coma more bidisees? Yeah, exactly. So, other illnesses, other diseases in my body, my probability is going to go further from obese and 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.

36:24How does that work? The thought is like if you take a soft agile cancer at like the cellular level, it makes you 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're actually almost going to multiply risk in terms of the risk of cancer. So smoking and then obesity is the other big one. So a lot of 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 is to like what the, the, the knock on effects are and that ends up as cancer.

37:01Yeah, 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. 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.

37:34But that's going to depend on you as an individual. If you have more body fat, you're going to have a different impact. So alcohol gets in your bloodstream. Alcohol can instantly cross across what we call your blood brain barrier. So it impacts your brain instantly. And that's where you feel the initially pleasurable effects from many people. A feeling a little relaxed, feeling more social, feeling a little bit less anxiety. If you keep drinking and that level keeps going up, then you start having impaired judgment. You might have motor, lack of motor coordination. So we've all seen this and many people have probably experienced it.

38:05You 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 of 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.

38:35Lemke, but your body always wants to restore what's called homeostasis. Your body is always going to fight to get back to what it feels it's normal is. And so ethanol is not something that belongs in your bloodstream. Your body is 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 that, I'll call on your body. You have to go through this process. and part of that process includes this toxic molecule that's gonna be floating around and causing damage to your cells.

39:02So that's one way that alcohol can cause cancer. The other is just general sort of inflammation. People have probably heard that inflammation is just not good for the body and increases the risk of cancer. And alcohol generates a lot of that inflammation in the process of getting eliminated. And so it can actually change your cells that over time that can lead to cancer. So I also found this graph, which shows, for anyone that can't see what we're describing at the moment, it shows the acceleration in liver disease, death rates, and general liver disease compared to other parts of the body. Other organs in the body, I believe it shows.

39:37What impact does alcohol have on the liver? And we have our little mannequin here of the human body. Where is the liver? Yeah, great questions. So here's our little mannequin. So just to orient people to the bodies who are 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. It's big. And it's an amazing organ. It is quite big.

40:07It 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 can 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.

40:44It's why we can do living liver transplant. So I could take half of your liver and give it to someone who needed a liver. you would still be able to live and they would get a second chance at life from that part of your liver. So it's this really cool organ that can regenerate. But it can only regenerate up to a point. So once you get to a level where you have a lot of scar tissue in your liver, we call that cirrhosis. You sort of reach a point of no return where at that point the liver can't heal itself. So I sort of think of it like to use a baking analogy if you're making muffins or a cake.

41:15You'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, what's going to 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 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.

41:43And so when you think about that graph or just the rising rates of liver disease, the main drivers of liver disease are obesity and to his alcohol. And so those are the leading causes 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 and liver failure. So people in their 20s coming in and fall in at 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.

42:15and by the time they get to the hospital, they're so sick, it's too late. And yet all of that could have been prevented or even repaired if it was caught sooner. And so that's where I think this education of understanding what really are the health harms valve call and that we have normalized binge drinking in many occasions, especially in young people as being totally normal. And yet they're very serious health consequences. So I've got a bunch of questions around the liver. Does that mean that my liver can take a bit of a beating before there's any real problems? Should I, you know, someone like me, I don't drink alcohol.

42:48I'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. You said that my liver regenerates first, or something, then this thing will just put back to normal again. As long as you haven't gotten to that scarring phase.

43:17So once you get too far down that path, even if you were to stop drinking, your liver won't recover. The hard thing is that we don't totally understand who and why that happened so young too. So this is an act of air 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.

43:52The 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 to liver transplant. What activities outside of alcohol cause great stress on our liver that we might not see as obvious?

44:27Yeah, so obesity so food does. Yeah food so your liver is very involved in glucose metabolism So our diet and our body weight, impact our liver health and the other medication. So acetaminophen or Tylenol, which is a very common over the counter pain reliever, and above a certain thresholds can cause serious liver damage. So sometimes we'll see cases where someone didn't realize that like their cold medicine, plus the Tylenol they were taking both had that ingredient and then they go out and drink heavily and that kind of combination effect can cause liver damage. How much do you think this might be a bit of a bit of an unclear question, but how much alcohol is going to cause liver damage?

45:11So again, it varies person to person. For liver damage, it does tend to be the moderate to higher amounts that cause damage. One thing is that 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 Surge is 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.

45:49And then keeping it to those low risk guidelines, which we just learned, or kind of eye opening and how low risk they are is going to reduce the risk of lower 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 got one last year. Yeah, I think. This is by the way, shocking. Yeah. So when we do an MRI of someone's brain, we basically, this is like a cross -lay. So it's almost like you're facing me and I'm cutting your face off and looking at your brain onwards.

46:25Healthy 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 start shrinking and shrinking and there's more water and less active healthy brain tissue. That process is accelerated with heavy alcohol use. And so you can see here this is a 43 year old person with severe alcohol use disorder where their brain looks the way, you know, a nine -year -old with dementia would look because of that brain damage over time from alcohol use.

46:59And 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, I remember I said ethanol, which is the molecule, crosses the blood brain barrier. And so, especially when you're having these high levels of blood alcohol, that ethanol is sort of bathing your brain. And if you think about what we talked about, inflammation and changes to cells and to DNA and proteins that is happening at the brain level, the other thing that can cause accelerate the brain damage we see with alcohol is actually nutritional deficiencies.

47:35So 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 sudden onset amnesia from heavy alcohol use in the setting of not getting enough nutrients in your diet. Okay, so that's the brain. That's the brain. 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 benign, but annoying and problematic health conditions, most notably acid reflux, so heartburn.

48:13So if you notice like, I'm like always having heartburn. I don't know how to pop all these like anacids and take this medicine. You might want to think like how much of my drinking is that contributing to my heartburn? So that's a very common thing. 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 of fold. One is something called atrial fibrillation, which is basically where your heart starts beating really or regularly.

48:43So in your heart, there's four chambers. The two chambers at the top. So this is really showing the ventricles in the atrium. So there's two chambers that blood flows through. And in a normal heart, your electrical activity comes from the top of your heart, goes down to the bottom of your heart and tells the heart to pump. And so you get a single impulse that goes to the bottom of the heart, says, pump, and that pumps blood out to your brain, and your body, and your organs, and your liver, and atrial fibrillation. The top of the heart is just kind of quivering with this abnormal electrical activity.

49:10And so the heart can't pump in a normal way. We actually, there's a term in medicine called holiday heart because we see sometimes people drink a ton over the holidays and 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 cardiomyopathy, 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 harmonies.

49:42So for whatever reason, I've always been good at drinking quite a lot when I used to drink, drinking more, 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 on your body fat. So you're essentially, it's like if you took you know glass of water and you dropped red dye in it, you're going to diffuse into that water.

50:13So the more water you have, the more diffuse it'll be in 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, it explains a lot. Because I always wondered, he was so much bigger than me at the time. He was, he had much more body fat. And he get drunk very, very quickly. And you always think of a big guy they can handle that beer or whatever, but you 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 that's not true.

50:44No, I mean, so first of all, I think the interesting story there one is not just a body fat, but also that people metabolize alcohol at different rates. You probably, I don't know, a few found a speech, 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 get. So people who don't metabolize alcohol as quickly tend to have worse hangover. So that may have been something you experienced, but it doesn't protect you from the other health harms about call like liver damage, like cancer, like overtime, you know, heart problems, or a softadial problems.

51:15What is a hangover? Yeah, hangovers are fascinating thing that people are, you know, there's a lot of emerging evidence found in 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, a seat all the high molecule we talked about, but it doesn't seem to be related to that. It seems to be related to ethanol. But essentially it's this syndrome where after you drink one through blood, alcohol content comes down to zero.

51:45You feel sort of apathetic, you're tired, you have a headache, you often feel nauseous. And so it's sort of that sequelae of your brain essentially being bathed in this ethanol. and then as it leaves, you just feel totally crappy. Could people think of it sometimes as just being dehydrated? Yeah, it is not just being dehydrated. There's actual sort of a fax of ethanol on your brain that leads to the hangover. I think if you are drinking at an amount that you're getting hangover, it is a good sign that you're drinking above a limit that would be considered okay for your body. Because 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.

52:24There is some element of dehydration, dogummy 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 because if they did, they probably wouldn't think this, but there'll be some people who would have gotten this far in the conversation and be thinking, yes, but alcohol helps me socialise and socialising is really important and I can't socialise very easily because 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.

53:16What 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 at 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 gonna live this like a sedic lifestyle where they never eat dessert. So I think it really is like, you need to go in with eyes wide open and understand what are the risks, what matters to you and how do you make that calculus? So if you decide it's a choice you wanna make, you wanna set yourself up for success.

53:46So if you decide like, I wanna cut back on how much I'm drinking, but I'm gonna go to happy hour every night with my friends and just try to like not drink while I'm there, you're probably not going to be very successful because you're going to be in a situation that's constantly like reminding you of alcohol use and everyone around you is using alcohol. So try to make some different sort of structural changes in how you set up your life in your week and your day. And you may find that actually 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.

54:16In terms of treating someone with alcohol abuse disorder, rehab is often the most widely known form of treatment. One of my friends who struggled with addiction really, really badly with alcohol addiction, but also drug addiction, said to me multiple times he said, I've been to rehab three or four times now and it's just not working. And I think when the most popular or the most well -known treatment doesn't work for you, you kind of develop in even great to sense of hopelessness. Are you a fan of rehab? Generally no. So rehab is this idea that you go away somewhere for a week, a couple weeks, and then you're kind of cured, right?

54:52It's almost like people have thought of addiction as an infection where you need two weeks of antibiotics and then you're done. What we really understand is that for many people addiction is more like iconic illness or even cancer, where you need a lot of treatment upfront for the first few years, and then over time you get into stability and and remission and you're almost like a cancer survivor, you're in long -term recovery. And so this idea that you go somewhere for a couple weeks and then you come out and you're all better, really doesn't match what we know of addiction. The other problem is that much of what happens in rehab is not all that therapeutic most of the time.

55:22So the things that we know are most effective for addiction, one are medications, which there's a lot of stigma that misunderstanding about. And then two are like evidence -based psychotherapies. So things like cognitive behavioral therapy, motivational enhancement therapy, be 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 pure support model. Sometimes the therapies that are offered are, frankly, not very evidence -based.

55:53Like we actually did this study. It was a secret shopper study where we called rehab programs across the country to ask about what they offered and many of them offer things like horse therapy or 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 during 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.

56:26So 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. Which seems kind of funny that it works on alcohol, but the reason it does is that for people who part of the thing that drives them to drink is that they drink, they feel this like pain relief pleasure sensation from the release of opioids in their brain and that makes them want to drink more. That if you block that, people don't get sick if they drink, but they just don't find it as rewarding.

56:57And 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, 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?

57:26Yeah, one of the most like groundbreaking trials in the last couple of years, falcal used to sort of was psilocybin. So there's a big study of psilocybin assisted psychotherapy for alcal use disorder, which showed really remarkable effects. So people took psilocybin. And actually, compared it, folks came in and they got a big dose of Benadryl or psilocybin. And then they sat with a therapist for like eight hours for this guided psilocybin journey. And they found that people 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 increase neuroplasticity, meaning the ability for the brain to form new pathways and kind of retrain itself.

58:02And so it does seem to be a potential therapeutic for alcohol use disorder. Sylasybin is the active compound in magic mushrooms. Yes, exactly. Have you had of eye -begin? I have, yeah. Which is often associated, which is another psychotelic often associated with addiction. Yes. People have looked at eye -begin for opioid use disorder. Those studies have been less promising than psilocybin, although it hasn't been tested in 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.

58:36One really interesting like new whole class of medications for alcohol is medications that are being used for weight loss that people have probably heard of. So like wugovie, ozempic, that whole class of GLP1 medications seems to also reduce alcohol use which is kind of interesting. Really? Yeah. F A study thought? 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.

59:09They've been trying to stop drinking for years and years and for the first time they don't feel that sense of like craving and urge. And they recently have been some actual clinical trials where they've done placebo controlled blinded studies and have shown that it does reduce drinking. And so it's a really interesting area where it seems like those medications kind of reset craving and appetite more globally and not just for food.

59:35What the hell is this? I'm going to tell you. All of you will probably know that I spend a huge amount of the year, about 50 weeks a year traveling around the world. And one of the great tips that I've always offered for traveling is to pack as light as you possibly can. Because if you do, I found that I can save hours by not having to check in my bags and then having to wait for them on the other side. So I always travel with a small tiny bag that can be stowed above me in the plane. Everywhere I go, even for trips that take weeks and weeks. It is a massive travel hack. And that's why I have to tell you about today's show sponsor, Exter.

1:00:06This bag uses some clever technology to suck all the air out of your luggage so that you can fit up to three times more things in a tiny, tiny little space. You can learn more at extra .com. And if you want to buy one of these, you can use code DOAC for 10 % off plus free shipping. and I 100 day trial. That's extra .com with code DOAC. 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.

1:00:42And ultimately, it seems often like it's inevitable that someday the TMZ headlines gonna ring out and say that this person is pop -past away. And that happens all too often. and we think about Whitney Houston or, I guess Michael Jackson's even been associated with dying from an addiction to, I think it was painkillers or something. Prince, Elvis Presley, Mac Miller, who a lot of people all know as well, and Nicole Smith. And even now in the public eye, there are certain individuals where we're starting to see this sort of erratic behaviour, they're posting on their Instagrams, they're showing up in society in a slightly different way.

1:01:16When 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 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 is it that those people need? Yeah. 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.

1:01:50But mostly that it was a totally preventable death. Like really no one to die from a substance -related death. We have tools to treat addiction. We know how to prevent the harms of drug overdose, for example. And so the fact that someone can die, especially someone that everyone has watched for so long is, I think, just like a tragic example of how what the mismatch is between what we do around addiction and what science says is actually helpful. I think when I see someone who actively is showing science, it's just sad to see that happen so publicly without people being able to support that person.

1:02:24And it's not a magic fix. It's not going to be like, 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 my their life would be better for them, based on whatever they believe better is if they were to make changes to their substance use. I remember I had this one particular friend who had their addiction and I remember always the life of the party and I remember this one day he came up to me at an event and he'd sat down in front of me and said to me, he said, he whispered to me, I'm in so much pain.

1:03:11And he told me about rehab and how it failed to me, et cetera. But it just almost sounded unbelievable that someone with such a big smile on their face would whisper to me, especially a man, because men don't really talk much about their emotions. I'm in so much pain. And then, finally, I then see how the world treats that individual, I am 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. And that one whisper helped me to kind of reframe how to treat that person, but also really what was at the heart of what was going on?

1:03:48I'm probably gonna give you so much empathy. A huge amount of empathy. Because I would have been like the rest of the world. I would have just thought, what an idiot, what a dickhead. Was he doing that, that strange behavior? Yeah. And you said something really important that was a slight shift in words. You didn't say he failed treatment. You said the treatment failed him. And that matters so much because I think too often we've made it seem as if people are failing. Like if they go to rehab and they don't get well, yeah, they're problem, you know. And actually the treatment wasn't right for them.

1:04:14As someone had cancer and their cancer came back or didn't get treated by chemotherapy, we wouldn't say like, oh, they failed. You know, we would say, oh, what's the next treatment? How do we get them to the right doctor? And so there is this like personal blaming. And that gets at stigma, which is one of the main reasons that people don't share that they're struggling with substances that they don't seek treatment. And so we have tremendous stigma towards struggling alcohol addiction. It's one of the most stigmatized kind of social conditions globally. And so of course, if you're a person who starts to think like, oh, maybe I do have a problem, like maybe my alcohol use is getting in the way of things.

1:04:43It's really harder than saying anything because you worry that you're going to be judged, you're going to be labeled, you're going to be misunderstood. In some cases, terrible things would happen. You might get your children taken away by, you know, child welfare, you could lose your housing or lose your job. And so that stigma has like played into this terrible cycle where people, you know, have to whisper it to someone shows how much you trust to do to even be able to say honestly what he was going through because there's so much stigma about the condition itself. You must have had many cases that broke your heart.

1:05:10Yeah. Can you tell me about one that changed you? Oh goodness, so many. You know, so one gentleman in particular, he was struggled with heroin addiction for a long time and had been, like I talked about, had been kind of a chronic illness for me. Had periods where he'd done really well. He'd had periods where he had struggled and had always stayed safe through all of that. And he actually, his like one really meaningful relationship in his life that kind of kept him together was a relationship with his mom and he lived with her. And they lived in public housing. They were dealing with economic insecurity like many people.

1:05:51And someone found out that he was staying with her and it would have put her at risk for her housing. and so he didn't want her to lose her housing, so he left, but he was newly homeless. And all of a sudden, because of just social barriers, was dealing with the stress of homelessness and being alone. And even with kind of all of the connection he had with his mom and with treatment, he was found dead between two parked cars at overdose to loan in the street. And I always think like if - And you knew him? Oh, yeah. The cascading effects that, you know, that it didn't have to be that way. And I think there so many deaths like that where I just think it doesn't have to be like this.

1:06:27You know, really no one should die like this. And there are so many things that, you know, in the moment, feel so out of our control. And I think that's part of what generates my passion for this work is I can't always save the person in front of me or change issues around homelessness or housing policy. But I can try to work on a broader scale to make things different for the next person. And And I think that kind of, that for me counteracts some of the distress of losing people that I care about. If you were President of the United States, for example, let's just use this country as an example, and you had to make upstream changes to the way society was designed in order to mitigate the downstream symptom of addiction, addictive behaviors, etc.

1:07:13What were, are those things that you would change about the way that our society is designed? You could change anything. Yeah. I mean, starting upstream, the biggest thing would be building resilience and building connection early on. So, you know, I think these things that feel so not related to addiction per se are actually deeply related and we think about adverse childhood experiences. So, we think about prevention for children, you know, often people have looked at like education, like, you know, telling people, telling kids that drugs are bad, that doesn't work. What does work is actually building resilience among young people.

1:07:42So building resilience, building connection. So what does that look like? That looks like affordable housing. That looks like parks where people can get outside and play sports and exercise and build relationships. That looks like, you know, supporting families so that families can stay together. And so those early relationships and attachment can be well formed. That's like the true prevention work is trying to break the cycles of intergenerational trauma, poverty, substance use, and actually supporting families' communities at the very start. It reminds me of Ratt Park. Yes. Yeah, Ratt Park is a great example of that.

1:08:14What is rat park for those that don't know? Yeah, so rat park was a series of experiments that were done, where essentially they took, they're trying to understand kind of drivers of addiction using rat models. And so they took rats and they had one model where rats were isolated in their own cage with nothing to do and no human connection. And they had access to a substance like morphine or cocaine, where they could push a lever and get more of it. And those animals when they were deprived of connection and isolation, anything to do used more of the drug. It gave them relief, it gave them pleasure.

1:08:47They took those same animals, and they put them in this amazing cage with areas to play and like wheels to climb on and lots of friends and other rats. And all of a sudden they saw the same animals were no longer kind of pushing the lever and trying to get more of the drug. And so it's a somewhat simplified model that there's lots of, it's probably oversimplified, but it demonstrates that so much of addiction really is around this idea of connection, and restoring sort of the world around us, the community, the interrelatedness that we all have, the opportunities and purpose and meaning and hope.

1:09:20So I think that's the real prevention. And then there's how do we actually address folks who are having a problem? And I think, you know, what I would do there is first make addiction treatment widely available immediately when people need it. So the minute you walk into your general practitioner's office or an emergency room, you get treated with compassion, with science, with people asking you, what can they do to help and offering you effective care the same way they would if you had a new cancer diagnosis or a new diagnosis of a heart problem. And that we really reframe treatment entirely to look like the way it looks for any other health condition.

1:09:51And that we stop punishing people who use substances where, you know, a lot of times people are still sent to jail for substance use, which, you know, is a confusing mixed message of we're saying this is a health problem on the one hand, but we're going to put you in prison or jail at the same time. Those two things don't necessarily align. Many of us are living in the first model of rap part. We're living alone, we're living in these big cities where more sedentary than ever before. Maybe we've moved to a big city because we don't have, which means we don't have our family around. We might be doing a job that's incredibly challenging.

1:10:27So it's no wonder when we think about addiction and alcohol and some of these other behaviors, but more broadly beyond alcohol as a substance, other addictive behaviors, whether it's social media or what we eat to a pornography or in the sort of inverse, the good habits, the healthy food, the working out, the exercise, the productive behaviors, why we're struggling so much. And I've often wondered if we should all just like go to like communes and live. Do you know who I mean, in groups. I don't think human beings are meant to live this way. And it's a relatively new thing, right? We often lived in a village or a community.

1:11:09We lived in these multi -generational households. I mean, I have little kids, and I think having kids with such an eye open are that of like, well, that makes sense. Why people live with their parents and their grandparents and have these big families to create community and a sort of extended family around you. And we have lost that in a lot of ways. And I think the ways that we used to get that, like, religion, maybe not, maybe that still resonates for some people, for others it may not. And so finding other ways of engagement, of meaning, a purpose, that can be through lots of different things.

1:11:38You know, I think people are finding creative ways of doing that. It can be through like, you know, finding a volunteer activity, finding some other type of social groups. Some people do it through sports, you know, they find connection and engagement with people. They don't really know over the shared love around, around an activity or a team, but really sort of seeing that as a priority, the same way you'd prioritize other things in your life and your health. And are you a fan of therapy as an approach to aim at the early childhood trauma? Absolutely. Yeah. I mean, I think one of the problems is that too often therapy has been like forced on people.

1:12:10I think that I'm much more of the approach of like we need to make treatment available and welcoming and high quality so that people get value out of it. And therapy is a huge part of that. You know, it's about a lot of things. It's about connection. It's about figuring out those reasons why people are using in the first place, addressing and healing those traumas. It also matters that we have good, well -trained empathetic therapist. So there's been a lot of interesting studies looking at actually how empathetic your therapist is is probably the strongest predictor of whether you stop, make changes to your alcohol or drug use.

1:12:40Really? Which is so interesting, because we often think like, you know, forget probably heard someone say like, I don't really like my therapist. And I think someone's reaction to that is like, oh, like you're not that into therapy, but they've actually done a lot of studies showing that a therapist who is less empathetic, their client is more likely to use more substances at the end of that course of treatment. So actually having a really well -trained, compassionate, evidence -based work force is hugely important to. And I guess the same applies for family and friends. Yeah, yeah. I think empathy is really powerful.

1:13:08Those kind of things that we think of as soft skills actually matter tremendously. Is it possible to prop somebody up? I mean, because I was talking to, I think it was talking to Dr Anna, look here about this, about the idea that you can play a role in someone's addiction. I want to help my friend who's addicted and so I'm there for them, I'm comforting them, but I'm actually in some way reinforcing that addictive behaviour because I'm positively reinforcing it because I'm supporting them so much and I'm loving them so much and I'm showing them so much empathetic attention that actually I'm playing a role in continuing that addiction.

1:13:46Is that - Yeah, and this is this concept of like enabling, which I think is nuanced. I would say at its court, it's really deeply problematic that for the most part love and support are never going to be harmful. And when I talk to patients, often the thing that caused them to ultimately engage in treatment was not some terrible consequence. It was the idea that someone cared enough about them in a moment where they didn't love themselves very much and felt hopeless, that someone was willing to sort of lift them up and believe in them. And it's these small moments of kindness. I'll tell you a story of a patient that we took care of in the hospital who was there for a really life -sreatening infection related to their drug use.

1:14:22And a year to the date after he was hospitalized, he wrote a letter to our team and he said, you know, I'll never forget the moments you guys came in and just sat with me and talked to me. And he now sends an email every single year on the anniversary of when he got out of the hospital. And it's those moments of humanity of connection. Again, that connection idea that often are the catalyst for change, the kind of hope and belief that your life could be better somehow, as opposed to this idea of like increasing someone's pain and suffering. And that plays out in different ways. So in families, one of the most effective tools we teach people is something called craft, which is um, stands for community reinforcement and family training.

1:14:58And it's very different than the like people may have seen like shows where you're supposed to like stage an intervention and you know tell someone all or nothing, but craft is very different. It teaches people first how do you understand the science of addiction family members. Second, how do you get support for yourself? Because it's really tough to deal the addiction in the family. And then how do you start to learn about consequences in a different way that your parent and your kid is missing school because they're using? You don't want to cover for them and reinforce their pattern. But you also don't need to kick them out of your house that there are sort of gradations of consequence that can actually help people change.

1:15:32And one of the biggest motivators for change is actually a positive reinforcement of the behaviors you want to see. So that's been called contingency management and the kind of treatment world. And you know health insurance companies, lots of companies that figure this out right. So if you get money back as you join a gym or you get those, you know, you get reimbursements for doing something that people want to see, people do more of it. It's true in human behavior. It's very true of addiction. But we have a new opposite. We try to punish people into getting well instead of reinforcing kind of the healthy behavior that what we want to see more of if that makes sense.

1:16:03Yeah, I, I, I guess I'm trying to represent the audience member that's listening to this right now that knows someone in their life that was addictive. And they tried to be empathetic. They, they tried to offer support. They tried to give the person a help and still nothing changed. Yeah. Well, in that situation, maybe the person that had, you should be struggling with the addiction, didn't accept the support, didn't go to the meetings, didn't speak to the therapist. in such a situation where you're offering help to someone and they're not taking it. They're not willing to investigate different medical treatments.

1:16:39They're living at your house, they're in your business, whatever. Is there a point where you say enough is enough? Yeah, well first, like it is just so hard to be there as a family member or a friend. So for anyone listening, I've been there. It's incredibly impossible. So have great. So with yourself, I think that's a different decision you're talking about is at some point, do you have to make a decision to protect yourself? So let's say you have someone in your home who's dealing with addiction who, you know, gets aggressive or is stealing money or is, you know, causing trauma to the people living in the house.

1:17:12At some point, you may need to decide that for my well -being, for the rest of the families well -being, I can't have this in my life right now. That's very different than saying kicking the mountain is going to make them better. So the distinction there is that it's okay to protect ourselves. Sometimes we have to do that. And sometimes there's only so much you can do, but to not sort of fool yourself into thinking that the action is to help the other person, and that's okay. I think the other piece is, you know, at the end of the day, first of all, it's easier to be a treater. So I've been a family member, I've been a clinician.

1:17:40As a clinician, I can truly be unconditional. So I can, I'm going to be someone's doctor whether they continue to use heroin or continue to drink or don't. And there's something really beautiful in that. Like my engagement with someone is not premised on whether they make changes or not. It's a family member that's harder, especially if you're a kid, dependent on someone or you're in a marriage or relationship. So you may have to make different choices. But I think at the end of the day, people don't change because of why we think they should change. They change because they think their life is going to get better in some way.

1:18:10So the key then becomes figuring out why might this person's life get better if they were to make changes to their alcohol or drug use. So it's a shift where you become sort of on their team instead of trying to drag them towards water, drag the horse towards water. And there's this fascinating human instinct that none of us like being told what to do. So there's something called the writing reflex, which is it's really hard for caregivers, it's hard for parents, because we love to tell people like our great advice and why what they're doing is wrong, and they should take our like brilliant doctor advice.

1:18:38And this can be like telling someone, like, do you see what you're doing is causing harm? You should make changes. It can also be a subtler. It can be like lecturing someone or trying to educate them. But when someone shoves something down your throat, your instinct is to resist. It's just like natural human behavior. Even if it's a great idea of someone's like shoving an ice cream cone in your face and like eat it. Even if you like ice cream, you might be like, wait, wait, I don't know if I want this ice cream. And so the key then is not to sort of tell someone what to do is to understand why might they want to make changes.

1:19:05And so once you do that, then you all of a sudden realize like it just feels better. You're not trying to drag someone towards something. It doesn't, you don't have like personal skin in the game about what choice they make, but you're really a partner with them and figuring out how is the same causing problems to you and why my, your life get better if you were to make changes to your alcohol use or your drinking or your substance use. What's the difference in delivery there in terms of delivering that message? Because they're both ultimately getting to the same outcome, but it sounds like the language might be slightly different.

1:19:35Yeah, very different. So in kind of like medical speak and therapy speak, we talked about some and called motivational interviewing, which is, it becomes almost like a mind trick, but it's, it is basically a way of trying to identify from the person their reasons for change and refreshing it back to them. And so it's not you telling them you think they should change, but you are trying to elicit their motivation and amplify it. And then the end of the day you're turning over the power back to them. So that might look like something someone says, you know, I'll be your your patient. So yeah, I do drink a lot.

1:20:08I drink a couple of times a day, especially in the mornings, but it's fine, you know, I'm still managing to get to work every day, obviously, I have a couple of misconduct issues at work, but other than that, you know, and my partner's left me, but other than that, everything else is fine. And I can manage this. It sounds like your alcohol use is causing some problems at work and in your relationships. It is, yeah. Yeah, my partner's left me and I keep getting these misconduct and notifications at work in disciplinaries because I sometimes get there late, and when I'm there, sometimes I fall asleep, etc.

1:20:39And I've worked with big machinery, so that's a little bit of a risk there, but otherwise it's okay. It sounds like you're worried about your safety at work and also how you're drinking and starting to affect your job and your relationships. That's true, yeah. I am, you know, I've been on the crane in particular being intoxicated on the crane in particular, has caused a few incidences and, you know, sometimes do worry that one day it'll go a little bit too far, yeah. Yeah, it sounds like that's really scary that you're really worried your alcohol use could cause even like a serious or life -frontening accident at work.

1:21:11Yeah, and then what am I going to do for work? You know, because if you get something like that on your file, then you I'm never going to be able to be a machine operator ever again. So yeah, and your job sounds really important to you. So important. I'll call starting to get in the way of that. You're 100%. Yeah. And so what are your goals looking forward around your job or your relationship? Well, I really should, I really should fix this alcohol issue that I have. And I would love to find a partner. I'd really, that's really important to me because I want to have a family. So, you know, obviously prerequisite of having a family is finding a partner really.

1:21:46So, yeah. Yeah, it sounds like you're really committed to thinking about making a change to your drinking and that you're looking for a defining a partner and family and you're worried that I'll call make it in the way of that. So what you're doing there is you're not leading me, you're kind of pushing me. That makes sense. Yeah, there's like a little bit of like a Jedi mind trick thing where you're, so essentially, It's actually really, it's a little tricky when you're first learning how to do it because what I'm trying to do is I'm listening for what's called change talk. So any little nugget you're giving me about making a change.

1:22:16So you're saying like, oh, I'm starting to get this in this conduct. I'm worried about this thing with safety at work. I want a partner. Those are like, it's a gold mine of little kernels of change. And I'm ignoring all of your sustained talk. So anything where you're arguing for the status quo, it's not a big deal, drinking something that I could deal. I can't make a change. I don't even acknowledge it or address it. And that's actually hard because I think most of us pay attention to the negative stuff. So if you think about like a performance review at work or someone telling you any kind of feedback, we tend to amplify and remember like the one bad thing that someone said to us and forget the millions of good things.

1:22:47So you have to change, you have to like train yourself to do the opposite to hear those little kernels of change talk. And then I'm basically being a mirror, but I'm amplifying it. So I'm taking these little kernels of change talk. I'm reflecting back to your own words. So I'm not telling you that you should stop drinking because it's unsafe at work. I'm reflecting to you like you're starting to get worried that you might have an accident at work and that's really serious and That's kind of guiding the conversation forward The other key is that if you meet a point of resistance you want to pivot because once you start arguing Whether it's about politics or anything people dig in so if you start arguing with someone You got to find another way you just got to pivot and roll to a different tactic Because the more you argue the more people dig in on their point of view and it's more about like winning the argument than it is about moving forward What if you want to change yourself?

1:23:33Is there a process of system, a methodology, to help you discover what your ideal behaviors are, what your why is, and to implement change? That's why I say all the time, what's your why? I think that's so exciting. Like, we all want to live our best lives, whatever that means to us. And so having a purpose, having a goal, is probably the most important thing. Motivation is important. We talk a lot about motivation, but motivation is fleeting. It can slip and slide over the course of one day. So you may, you know, take kind of a mundane example. You want to get in shape and you're feeling super motivated one day.

1:24:06And then the next morning your clock, your alarm clock goes off at like five in the morning and you're tired and it's cozy in your bed. And maybe you stayed up a little too late. Your motivation's going to be flagging, right? So if you don't have a goal or a reason or a wire or purpose, it's going to be really hard to actually get up the energy to get up. And so figuring out what that purpose is. And then trying to find ways to enjoy the process. Because if you're always working towards a future goal, Some people are very goal oriented and that works for them, but finding joy in the process will help you So I'll take alcohol for example like non addiction issue just like making changes to your drinking in your life So if you're just like, I should stop drinking because drinking is bad for me That's like a relatively big goal, right?

1:24:45It's not really about anything that matters specifically to you and it's gonna be hard to stick to that if Instead you think okay, I you know started to realize that when I drink every single night I don't get the work done that I want to get done because I'm too tired and I fall asleep. I don't feel refreshed in the morning because I'm not sleeping very well. I'm not getting a brilliant exercise and that's something that really matters to me. I'm not like as present with my family as I wanted to be. Then it's all these little micro goals that make it much easier and make a change. You made a side, you know, I'm not going to drink.

1:25:13I'm only going to drink two days out of the week and when I do drink, I'm going to keep it to this amount. But the reason why is not some vague recommendation from some doctor. It's because like you're working really hard at work and it feels good to be productive after dinner and you're training for a race and you want to get up in the morning and run. And so you actually notice those little steps like wow it feels great. I woke up this morning and I feel so refreshed. Like you're reinforcing your goal right there. You're not working towards some abstract thing that doesn't really matter to you.

1:25:38So you want to make these like really focused, personalized goals and really anchoring it on what is your why and your why may be very different than my why or someone else's why. So it may be, you know, sleep really matters to you or, you know, you may have a different relationship with alcohol. So the other kind of exemplied give is people are different, right? We respond differently to things. So some people can open a bag of like potato chips and eat two and walk away. Some people like they open the bag, they're going to eat all of the chips. And so it's just easier not to open the bag. And alcohol's like that too.

1:26:09Some people might find if they open a bottle of wine or they have alcohol in the house, they're going to drink all of it. and the idea of like trying to keep to these small amounts of alcohol is actually really hard and it's simpler and easier to just avoid it completely or to only drink at a restaurant or something. So you do have to understand like how your goals, your why, your purpose interacts with your response to whatever it is that you're working on and that's going to be different for everyone. Are there any other things, any other habits that we should be thinking about when we're trying to overcome an addiction?

1:26:38So if we think about alcohol as being at like the bottom of the stream, Yeah. Is there anything else upstream that I should be thinking about? So we talked about social connections and relationships. I need to be making sure that I'm surrounded by people. I'm socializing because that's gonna be an insulator to like stress and loneliness, which is gonna cause me discomfort, which is gonna lead me to alcohol. Yeah. But are there any other things that I should be thinking about when I'm setting off to make a change in my life? Yeah. Yeah, there's a bunch. I think first, any behavior change, whether it's alcohol or other, if you're feeling like depleted, and tired and not your best self, it's gonna be harder to make a change.

1:27:12So if you think about like any big decision you made to change your job, to start an exercise routine to leave your partner, you probably didn't choose like the day that you were exhausted and feeling anxious and stressed and not your best self to make that change. Like change is hard. So you wanna try to boost up other things in your life, eat well, you know, get enough rest, try to exercise, things are that are gonna help you feel healthy in your best best self when you're trying to make a change. Is that linked to dopamine? Yeah, because I mean, so our natural reward system, I'm the thing that triggers it is exercise, food, sex, connection.

1:27:43So trying to have healthy other ways of positive dopamine release. And so I think for many people, alcohol or substances can feel like a way of doing something nice for ourselves. I'm going to, this is going to help me reduce my stress after a bad day at work. So the goal then is not that you just like white knuckle at all night and feel really stressed after work. It's that you figure out what are some other things that help me reduce stress after work. maybe it's going to yoga class with a friend. Maybe it is, you know, spending time with my family. Maybe it's getting massage or meditating or watching a show I like.

1:28:15So you want to, it's not just you're removing the thing that you're trying to change. You want to fill up empty space with other things. So what if I fill it up with like a hog in does ice cream and burgers? Because that will cause a dopamine here. So presumably if I just eat loads of sweets and candy, then that's going to stop me from engaging in addictive behavior. But we see that all the time. So that's like replacing things. And you know, I was reading an article, people probably heard of dry January, this idea of like not drinking for the month of January to rethink your relationship with alcohol.

1:28:49It's reading an article that dry January has become high January, because people are just smoking a ton of weed instead of drinking. And so it's very, I think you want to be cautious that you're not just replacing the thing that you're trying to change with something that's also going to cause health problems. Now, having dessert once in a for this, you know, you're not getting calories from alcohol and having a nice ice cream cone once a week is a way of sort of treating yourself that's healthier and maybe more aligned with your goals. That's fine. I think thinking about these things, actually thinking about alcohol the way we think about dessert, sunbathing, eating process meats, all of these things have risk and benefit in our lives.

1:29:22I think for we've gone so wrong with alcohol is this idea that it's like a health promoting behavior that you shouldn't be drinking for your health. that's not going to make you healthier. And also, much like many things we do that are not health promoting activities or ways of reducing the health harms of that activity so that it's okay in small amounts in your life. I think B2B marketers keep making this mistake. They're chasing volume instead of quality. And when you try to be seen by more people instead of the right people, all you're doing is making noise, but that noise rarely shifts the needle and it's often quite expensive.

1:29:57And I know as I was the time in my career where I kept making this mistake that many of you will be making it to. Eventually, I started posting ads on our show sponsors platform LinkedIn. And that's when things started to change. I put that change down to a few critical things. One of them being that LinkedIn was then and still is today, the platform where decision makers go to, not only to think and learn, but also to buy. And when you market your business there, you're putting it right in front of people who actually have the power to say yes. And you can target them by job title industry and company size.

1:30:28It's simply a sharper way to spend your marketing budget. And if you haven't tried it, how about this? Give LinkedIn ads a try, and I'm going to give you a hundred dollar ad credit to get you started. If you visit LinkedIn .com slash diary, you can claim that right now. That's LinkedIn .com slash diary. Just thinking about something we said earlier about how early childhood trauma causes the brain to change and then results in addictive behaviors. If I went through an early childhood trauma and my brain has changed because of that, and then I get into, I become addicted to alcohol as a young man.

1:31:04And then I manage to find my way off the alcohol. My brain is still addicted, right? My brain still has that addictive sort of predisposition. So isn't it the case that I'll just end up being addicted to something else that gives me a dopamine hit? So turns out the brain is amazingly plastic, meaning it can change. We see that over time. So the first thing is even adverse childhood experiences are not a done deal. So we talk a lot about ACEs. We don't talk a lot about pieces or PCE positive childhood experiences, but actually you can reduce the risk that someone develops addiction by increasing the number of positive childhood experiences.

1:31:38So take someone who's experienced some terrible adversity. Their parent has died or they have a parent who's in prison or they have addiction in their family. If that kid has one single adult figure that they believe cares about them, that reduces their risk of addiction. So there are a lot of positive ways that we can actually change the trajectory even in the midst of terrible trauma. When you think about someone who's had a substance use disorder, we actually have good data on this that after five years of recovery, and often that is fits and starts. So most people think of like, this is one fell swoop that you like decide to stop drinking and then successes that you never drink again.

1:32:12For most people, what we find is that's actually like a series of steps. So I was like to think of progress, not perfection, and not have this kind of all or nothing mindset that for many people they may early on have a month where they go that out call and then maybe next time it's three months and then maybe it's a year and these recurrences happen but ultimately they get to this place where they go into long -term recovery. After five years of recovery a person's risk of subsequently developing addiction is no higher than the general public. So your brain actually does change and we see this on functional imaging, we see this in longitudinal studies that follow people over time.

1:32:45So you actually can overwhelm those things and get to a place where you don't have a higher risk than other people. Because some people say, I've got an addictive personality. That's the sort of self -label and self -identifies having an addictive personality. Sometimes they even reference their brain as being easily addictive. Is that truth in that? Is it possible to have an addictive personality? It's not so much about personality, but we do respond differently to substances. So, you know, take alcohol or opioid or anything. People feel differently the first time they ever use it. So often if you talk to someone who then develops addiction, they tell you that first time they use the substance, it was like this amazing feeling.

1:33:21It felt like I've had people describe it as falling in love or you know a warm hug or like a relaxing bath. These like incredible comforting experiences. Other people, they get prescribed like an opioid for a tooth extraction. They feel nauseous and kind of like not like themselves and they don't like the feeling. So how we respond to substances is definitely based on our neurobiology and is different for different people. So some people are both from a genetic reason and their own brain are just more wired to be a risk of addiction. And that's important to know about yourself because then you can make different choices.

1:33:53You may decide, you know, never to keep alcohol in the house or not to drink because the risk is too great. How much do you think about other things that are taking hold of society? Some of the other things that are non -substance related. So social media addictions and pornography of addictions and what else is some of the big ones? Food addictions? Food, sex, gambling. I think there are a lot of similarities. It's not my particular area of focus, but I think there are a lot of overlaps. I mean, I think many of the things you just listed, you could talk about one, dopamine, obviously, but two, this idea of needing to fill yourself with something else, either, you know, thinking about trauma, thinking about untreated mental illness, thinking about just kind of the deficit of connection and of meaning and reward and reaching to these external solutions.

1:34:38Can you tell me about a time where you've worked with a patient who, through the process of working with them and understanding their trauma, you discovered something unexpected about the root cause of their addictive behavior? Yeah, yeah. I think of many patients, but one in particular who, you know, I have this, I knew that he'd experienced hard things in his life. He'd been in prison, for example, which is a traumatizing experience. He lost his parents, another thing. I and he had struggled his whole life with substance use disorder and using lots of things, mostly opioids, but also alcohol and cocaine and just had had a really, really hard time.

1:35:19And after, I mean, years of knowing him, one day he broke down my office and shared that he'd actually been molested as a young kid. And so sometimes there is that like that thing that people have never felt like they could share with anyone that really is at the root of so much of what they've been dealing with. And like the person who whispered to you, I think the pain of keeping that inside, not only the trauma of experiencing not as a child, but then holding that secret and feeling like you somehow are damaged or you know that this thing inside you is there not being able to heal it, talk about it, share it with people I think is just this like this well of pain that lives inside people.

1:35:55Did he recover? He actually passed away. From substance abuse? From substance use, yeah. You must carry a lot of this stuff with you because your line of work sounds like you're dealing with bad news quite often, more so than the average person. And the news you're dealing with is a different type of news. You're dealing with somebody sort of reaching the end of their life through something that you all serve so many times. You believe is preventable in many cases. How do you manage that? Yeah, I mean, I think a couple things. One, there are so many stories of hope that I think counterbalance that for me.

1:36:37So I think, you know, the other stories in my mind are, you know, I carry with me and still care for and are in touch with people who are living these amazing vibrant lives and recovery. And I mean, in the US alone, there's 24 million people living in recovery. So there are these stories of people who have overcome just trauma, tragedy, hardship, and are doing awesome. They're parenting. They're working. You probably don't even know they're around you. you know, they don't tell people necessarily that they're in recovery and getting to be sort of a part of that process with someone and watching, you know, there's nothing in medicine where I can actually see as dramatic of a change as with addiction where someone can be, you know, at a moment where they're dealing with all of these health consequences and relationship challenges and then they get better.

1:37:18And it's just like the most beautiful thing to be a part of. And so I think the hope from that, the sort of positivity of it is what keeps me going every day. I obviously find ways to care for myself through that and family and connection, exercise, I run, I write, you know, you have to keep yourself whole through it all too. But I think I get tremendous purpose and mostly like a lot of hope for working with people and seeing them recover. What is the most important thing we didn't talk about that we should have talked about? I think one thing is language. It's like the subtle thing. I sort of mentioned an example where you did it really well, where instead of saying someone failed treatment, you said the treatment failed them.

1:37:51but a lot of the language that we use with addiction actually subtly and not so subtly, worse and stigma. And sometimes it sounds like I'm being politically correct or it's like an issue of semantics, but there's actually really good data on this. So if you think about words we use for addiction, one is substance abuse, right? So the term abuse, what does abuse refer to? So it actually comes from an old English word that means like a willful act of misconduct. And it's a word that we use for child abuse, for sexual abuse, for domestic abuse. like it's only for these like terribly violent acts of commission that are very stigmatized because they're like terrible things.

1:38:24And yet we use it for this thing that we're saying is health condition that you're like a substance abuser or you have substance abuse. And so there have actually been these elegant studies that took like PhD level psychologists really highly trained clinicians and they described a person as either a substance abuser or as a person with a substance use disorder. And the clinician was actually more likely to recommend a punitive intervention for the person described as a substance abuser. What does that mean? So in this case, they were given like an option. You read this paragraph about a fictional patient.

1:38:51And they don't really know what the researchers are testing. And they're given a bunch of different options for intervention. And one is this like send them to drug court or send them to jail. One is like offer them outpatient effective treatment. There's a bunch of different choices. When they hear someone described as a substance abuser, they're actually more likely to recommend the jail -based intervention. So where it's actually like very, they influence how we think even how we make clinical decisions. They've also done this to the public. So if you describe someone as a drug addict, the public has a more negative view of them than if you describe them as a person with addiction.

1:39:23So there are these subtle ways. There's been a shift in addiction to really using what we call person first language, which has been true across medicine. So we used to use terrible words like we'd refer to someone as like, thus gets a frontic, you know, or really labeling them as their health condition. And thankfully there's been a change from that to realize that people are people first who have an illness or not defined by it. So I would never say like, I'm going to go see the lung cancer in room 204. I'm going to see, you know, Mr Smith who has lung cancer. And so the diction too, like people are more than that.

1:39:51So to say, you know, person with addiction, person with alcohol, use disorder rather than saying they're an addict or an alcoholic. And then even terms like clean and dirty, which are commonly used when we talk about addiction. So, you know, take the word clean. It sounds really positive. Like you're saying, oh, you're clean. But what are you really saying? So you're saying like, if you're clean now, when you are actively struggling, what were you? You're dirty. And so I always remember an example, a friend of mine who's in recovery was interviewing for jobs in the recovery space. And so people on the interview trail would say to him, like, how long have you been clean for?

1:40:22And he would say, well, I've been bathing since I was a newborn. I've been cleaning my whole life. And I've been in recovery for five years or whatever. So I think these little things actually matter that we should use terminology that we'd use for another health condition. If we're labeling, you know, people with active addiction is dirty or, you know, people with addiction is the same as child abusers with that sort of language. We're really sort of subtly increasing stigma. So that's a small thing that we can all do is just try to use language that's a bit more humanizing. It's so interesting because I was aware of this, but I still found myself accidentally using the word abuse.

1:40:54Yeah. And I'd stumble into it. I try to avoid the use of the word addict. Yeah, it's hard to change, but you know, like everything, you just want to be humble, curious, and keep trying. I mean, there's lots of language that we've changed. I think about so many terms we use for, you know, for, you know, people who are born with different abilities or for people of different races or other identities that we're really stigmatizing and we'd like learn to use different language even if it feels a little awkward when you're first learning it. I think understanding the science and the data behind the impact it has to use certain language I think is really useful.

1:41:28Yeah. Because that's helped me to understand. Just to know I understand the first principles of it, I need to make sure I describe people as a person first. Yeah. So a person with addiction. Addiction is much better than calling someone an addict. Yeah, exactly. And one thing people ask me will say, well, what if someone refers to themselves that way? Because people may do that. And that's fine. People can use whatever language they want for themselves. But I think as a healthcare professional for sure, or someone who's trying to help combat stigma, like we can choose to use different language.

1:41:55And I've actually had patients sort of ask me like, well, why do you use that terminology when they use a different language? And it actually can be sort of empowering to be like, oh, yeah, I'm actually a person in recovery. I'm a person with addiction. I'm not going to label myself that way anymore. Something I've been really curious about just in my life, generally, because in conversation, I'll often, I said something yesterday when we were at dinner with the team here. I said, I can't remember the exact phrase, but it was words to the effective,

1:42:23I'm not good at that, or I'm not that type of person, or I'm not organized. And I stopped myself and the team were remembering, I go, actually, I shouldn't say that. I should say right now, it was a... You're defining yourself as incapable of doing something instead of being like, I'm working on organization right now. Yeah, I think it's so important and we don't think about it. How casually we create an identity for ourselves that is fundamentally limiting or puts us in a box or frames us as having a deficit or captures our whole identity and some kind of deficiency we have often in the case of the habits I'm referring to.

1:42:59Does this a similar thing take effect when we're talking about calling someone an addict? Yeah, you're sort of labeling them as that is the only thing that they are and that they will be that forever. And a friend of mine is a journalist who is in recovery and writes a lot about addiction by a solivates wrote this great New York Times piece that addiction doesn't always last a lifetime. Cause I think there is this idea in our head that people with addiction will always have addiction and it's this like incurable thing. And that actually people have lots of different journeys and for some people that become something they deal with and then they move on their lives for other people at something that they actively manage.

1:43:33but this idea that you sort of boil things down to like the only thing I am in this world as a person with Addiction, you really limit everything else about yourself. We have a closing tradition on this podcast where the last guest leaves a question for the next not knowing who they're going to be leaving it for and the question that's been left for you is If you could redo or revise one thing That you have successfully accomplished What would that be and why? I guess I would say, and I could think of lots of successful accomplishments I'd apply this to, but I'll take the example of medical training, which is a successful accomplishment.

1:44:15I think I would be more present that we are always like rushing to the accomplishment, to the finish line, to sort of getting to the next goal. And I think back in which I had realized what an amazing journey it was in that moment. And I mean, even things with medical training that I was never gonna be a heart surgeon, but to stand in an operating room and look inside someone's chest and watch a beating heart is an experience that I'll never get again. And I think in this journey to always achieve and move forward and get to the next exam and the next thing, we sometimes miss like the miracle that's right in front of us.

1:44:47And so I think I would have been even more present. That applies to all of us. I felt like I was being called out. So, for parenting, true for everything. Thank you so much. I'm so grateful for the work that you're doing because there's so much conflicting information, especially as a race to alcohol. There's been so much information over the last five, ten years about the impact alcohol has on us. And I've sat here and had conversations with people who are pretty convinced that even moderate levels of our call are good for us and having regular work. I'm now clear on what the truth there is. Thank you for doing what you do.

1:45:28It's incredibly important and I actually think it's going to become increasingly important, unfortunately, because the way that the world is heading, the loneliness epidemic that we're experiencing and the access we now have to digital devices and low -cost consumption of addictive substances is terrifying for me. I know you've got a book on the which I'm extremely excited about, which is June, Autumn, next autumn. Spring of 27, so we have some time. Spring of 27, okay. And what's that book about? Can you give me a clue? I'm a good gas book. It is going to be about changing the narrative around addiction and about really reframing how people think about it to see it as a treatable good prognosis illness and using some of the stories of people I've had the privilege of knowing to hopefully help people see things in a different way.

1:46:12Where do people find you if they want to reach out or learn more? Yes, they can find me on LinkedIn, on Instagram, they can email me. Yeah, happy to connect and would love to come back after the book is out too. I look forward to that. I'd love to. So your Instagram, you all LinkedIn, I'll put those details below. I'm sure you'll probably get a lot of messages. Great. Because these issues in particular are incredibly, incredibly potent issues in people's lives and very emotional issues as well. So thank you for, on behalf of all my audience, Thank you for your generosity today, but also thank you for your wisdom.

1:46:44Really, really appreciate it. And I would love to speak to you again soon when the book is out. Thank you. Thank you for having me. I find it incredibly fascinating that when we look at the back end of Spotify and Apple and our audio channels, the majority of people that watch this podcast haven't yet hit the follow button or the subscribe button wherever you're listening to this. I would like to make a deal with you. If you could do me a huge favor and hit that subscribe button, I will work tirelessly from now until forever to make the show better and better and better and better. I can't tell you how much it helps when you hit that subscribe button.

1:47:17The show gets bigger which means we can expand the production, bring in all the guests you want to see and continue to do in this thing we love. If you could do me that small favor and hit the follow button, whatever you're listening to this, that would mean the world to me. That is the only favour I will ever ask you. Thank you so much for your time.

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