TLDR;
This episode features Dr. Sarah Wakeman, a Harvard professor and addiction expert, discussing the science behind addiction, the impact of alcohol on health, and ways to approach addiction treatment with empathy and evidence-based strategies. She highlights the importance of connection over isolation, the role of trauma, and the need to reframe addiction as a health issue rather than a moral failing.
- Addiction is a health issue, not a moral one.
- Trauma is a significant driver of addiction.
- Connection and empathy are crucial in recovery.
- Alcohol has significant health risks, even at moderate levels.
- Effective addiction treatment involves science-based approaches and compassion.
Sarah's Mission [2:13]
Dr. Sarah Wakeakeman shares that her mission is to change the way people understand alcohol and drug problems. She aims to provide facts and evidence to help people make informed decisions about their consumption habits. There's a lot of misinformation out there, and she wants to equip people with the tools to make the right choices for themselves.
Sarah's Education and Experience [2:42]
Sarah is a trained medicine doctor who still practices general medicine, dealing with conditions like pneumonia, heart failure, diabetes, and depression. She is board certified in addiction medicine, which has been her life's work. She works at an academic medical center in Boston, focusing on integrating addiction care into the general medical system. She also trains doctors specializing in addiction medicine as the program director of a fellowship program.
Issues With Addiction Treatment in the Modern World [3:29]
The biggest problem with modern addiction treatment is the pervasive belief that addiction is a moral failing or a matter of willpower. This mindset prevents people from receiving compassionate medical care. Reframing addiction based on scientific evidence and effective treatment is essential, as current approaches often differ significantly from what people experience when seeking care.
What Is Addiction? [4:20]
Addiction is defined by continued use despite negative consequences. The four C's of addiction are loss of control (inability to stop), compulsive use (spiraling use), consequences (negative impacts on life), and craving (strong psychological urge). Addiction severity is categorized as mild, moderate, or severe based on meeting 11 criteria, with moderate to severe cases considered true addiction.
What Things Are Capable of Being Addictive? [5:37]
Many things can be addictive, but Dr. Sarah focuses on alcohol and drugs. Alcohol is the most common, with 400 million people worldwide having an alcohol use disorder. Other addictive substances include opioids, cocaine, stimulants, sedatives, and cannabis. The addictiveness of a substance relates to how much dopamine it releases in the brain, with some substances being more addictive than others.
Physiological Dependence vs. Addiction [6:36]
There's a difference between physiological dependence and addiction. Physiological dependence means experiencing withdrawal symptoms (like a headache from not drinking coffee), while addiction involves use despite harmful consequences. If coffee drinking caused negative impacts on your life, that would be addiction.
Scale of the Problem: Why Should People Care? [7:15]
Addiction touches many lives, even if people don't realize it due to stigma. Globally, 2.6 million people die annually from alcohol-related causes, and another 600,000 from drug-related deaths. Approximately 400 million people worldwide have an alcohol use disorder, and 80 million have a drug use disorder. Studies suggest that 15-30% of people may develop alcohol addiction at some point in their lives.
Is Society Getting Better or More Addicted? [8:49]
The pandemic worsened addiction rates, with increased alcohol and drug use and related deaths. While drug-related deaths have leveled out to pre-pandemic levels, the overall impact was significant. This rise is linked to factors driving substance use, such as fear, boredom, loneliness, and disrupted routines.
Substance-Related Deaths During the Pandemic [9:22]
The US saw a significant decline in life expectancy during the pandemic, partly due to substance-related deaths. Immediately after the pandemic's onset, alcohol-related mortality increased by 23%, and drug-related overdose deaths reached record highs. This impacted US life expectancy until this year.
What Drives People to Use Substances? [10:11]
Trauma is a major driver of substance use. Genetics account for 40-60% of addiction risk, while experiences, especially adverse childhood experiences (ACEs), make up the other half. The ACEs study shows a linear increase in substance use disorder risk with more adverse childhood experiences. Substances release feel-good hormones, providing relief for those who've experienced trauma.
Substances' Effects on the Brain [12:13]
Alcohol releases dopamine, driving reward, and binds to GABA, reducing anxiety. It also triggers the release of endogenous opioids, natural painkillers. This is why some medications block the opioid response to help people stop drinking. Alcohol provides both anti-anxiety and pain relief, making it easy for use to get out of control.
Does Trauma at a Young Age Increase Addiction Risk? [14:19]
Trauma at any age can increase addiction risk, but earlier trauma has a more lasting impact. The brain isn't fully formed until the mid-20s, making younger individuals more vulnerable. Trauma is less about the experience itself and more about feeling alone while grappling with it. What's traumatizing varies; feeling disconnected is a key factor.
The Opposite of Addiction Is Connection [16:26]
The opposite of addiction is connection, not sobriety. Building connections and social relationships can help in creating an addiction in someone. It's about filling people's lives, forming community, and building identity and purpose outside of substance use.
Why Addiction Matters to Sarah [18:01]
Sarah cares deeply about addiction because of a personal experience: a family member died from addiction when she was in medical school. This pivotal moment, combined with her scientific knowledge, made her realize how poorly addiction is understood and treated. She wants to provide the tools and knowledge she wished she had earlier.
Living With a Family Member Struggling With Addiction [18:51]
Living with a family member struggling with addiction often involves feeling powerless. The misconception that addiction is a matter of willpower can lead to feelings of hurt and the belief that the addicted person doesn't love you enough. Families often experience trauma and receive bad advice, such as "tough love," leading to guilt and anger.
Who Is Sarah Trying to Save? [20:33]
Sarah wishes her loved ones had received science-based treatment, compassion, and empathy. She wants to create a world where addiction isn't stigmatized but seen as a problem that can be helped. She reflects on missed opportunities for intervention and the lost time due to the "tough love" approach.
Change Happens When the Pain of Staying the Same Is Greater Than the Pain of Change [22:47]
While some change occurs when the pain of staying the same is greater than the pain of change, many people endure pain without changing. Change often happens when people gain hope that things can improve and receive support. Imprisonment isn't an effective intervention; the risk of drug-related death is higher after release. Hope, a strong "why," love, empathy, and effective treatment are essential for change.
Misconceptions About Alcohol [25:42]
Alcohol has been viewed differently throughout history. Initially a spiritual or social element, it later became associated with health benefits, which is a misconception. The idea that moderate drinking is good for health came from flawed data analysis, where non-drinkers were often unhealthy for other reasons.
Is There a Healthy Level of Alcohol Consumption? [28:05]
There's no healthy level of alcohol consumption. Drinking alcohol is not good for your health. Low-risk drinking can be part of a healthy lifestyle, but it's not health-promoting. It's more like having dessert or bacon, where you need to understand the risks and make informed choices.
Is One Drink a Day Safe for Health? [28:40]
What's considered "one drink" is often underestimated. A low-risk drinking limit is 14 units of alcohol per week (8 grams per unit). A typical glass of wine contains several units, so one glass a day can exceed the low-risk limit.
Link Between Moderate Drinking and Cancer [30:28]
Even low-risk drinking is associated with an increased risk of certain cancers, such as breast and esophageal cancer. For breast cancer, even drinking below low-risk limits can slightly increase the risk. The reasons for increasing cancer rates are likely environmental, including factors like alcohol, obesity, and processed foods.
Types of Cancer Linked to Alcohol Consumption [33:13]
Once you get to the moderate category, we start seeing increases in pretty much every cancer. There's a dose response relationship, so the more you drink, the higher your risk of cancer. Breast and esophageal cancer risks increase even at very low levels. Colon cancer is also seen in young men, and liver cancer is also a risk.
Cancer Risk Among Heavy Drinkers [34:41]
Drinking two glasses of wine a day puts you in the heavy drinking category, which can increase cancer risk by about 40%, depending on the cancer type. The more you drink, the greater the risk.
Heavy Drinking and Comorbidities as Cancer Risk Factors [35:21]
Having other illnesses (comorbidities) like obesity or smoking increases cancer risk further. Alcohol makes you more susceptible to the cancer-causing effects of tobacco, resulting in a multiplied risk.
How Alcohol Drives Cancer Mechanisms [36:10]
Alcohol, or ethanol, is absorbed quickly and enters the bloodstream within 10 minutes. It crosses the blood-brain barrier, causing initial pleasurable effects. As levels rise, it impairs judgment and motor coordination. The body tries to break down alcohol in the liver, converting it into acetate for excretion. This process involves a toxic molecule that damages cells, increasing cancer risk. Alcohol also generates inflammation, which can change cells and lead to cancer.
Alcohol and Weight Gain [37:49]
The body sees ethanol as poison and tries to restore homeostasis. Ethanol is converted into acetate to be eliminated. This process involves a toxic molecule that damages cells, contributing to cancer risk. Alcohol also causes inflammation, which can change cells over time and lead to cancer.
The Role of the Liver [38:43]
The liver processes toxins, including alcohol, with 90% of alcohol metabolized there. It's a clearing house for byproducts. The liver sits on the right side of the body, under the ribs.
Liver's Ability to Regenerate [41:57]
The liver can regenerate, even if 80% is removed. However, this regeneration is limited. Once scar tissue (cirrhosis) develops, the liver can't heal itself. The main drivers of liver disease are obesity and alcohol. Younger people are increasingly experiencing liver failure, often unaware of the problem until it's too late.
What Else Damages the Liver Besides Alcohol? [43:42]
Besides alcohol, obesity and diet (glucose metabolism) impact liver health. Medications like acetaminophen (Tylenol) can cause liver damage above a certain threshold.
How Much Alcohol Causes Liver Damage? [44:21]
The amount of alcohol that causes liver damage varies, but moderate to higher amounts are generally the cause. Binge drinking is more harmful than consistent moderate drinking. Minimizing heavy drinking episodes is crucial.
Alcohol's Impact on the Brain [45:17]
Alcohol affects many parts of the body, starting with the brain. Heavy alcohol use accelerates brain shrinkage, resembling the brain of a 90-year-old with dementia. This is because ethanol crosses the blood-brain barrier, causing inflammation and cell damage. Nutritional deficiencies can also accelerate brain damage.
How Alcohol Causes Brain Deterioration [46:27]
Ethanol crosses the blood-brain barrier, bathing the brain in high levels of alcohol. This causes inflammation and changes to cells and DNA. Nutritional deficiencies from heavy drinking can also accelerate brain damage.
Other Organs Affected by Alcohol [47:13]
Alcohol affects the mouth, esophagus, and stomach, increasing cancer risk and causing acid reflux. The heart is also affected; moderate to high levels can cause atrial fibrillation (irregular heartbeat) and congestive heart failure.
Alcohol's Impact on the Heart [47:50]
At low risk levels, there doesn't seem to be harm from alcohol on the heart. But once you get into the moderate and high, we see harms. The harms can be atrial fibrillation, which is basically where your heart starts beating really irregularly. Over time, if you're drinking at high levels, your heart actually dilates and you can end up with congestive heart failure from a cardiammyopathy, which means the heart muscle gets kind of weak and thin and floppy and can't pump the way that it needs to.
Body Fat Percentage and Alcohol Tolerance [48:57]
People with more body fat get drunk more easily because alcohol doesn't go into body fat. Alcohol diffuses into body water, so the more water you have, the lower your blood alcohol content.
Does High Alcohol Tolerance Prevent Organ Damage? [49:55]
High alcohol tolerance doesn't protect you from health harms like liver damage or cancer. It may mean fewer hangovers, but it doesn't reduce the risk of organ damage.
What Is a Hangover? [50:36]
A hangover is related to how high the ethanol concentration gets in your brain. It's a syndrome where, after drinking, you feel apathetic, tired, have a headache, and feel nauseous. It's not just dehydration but the effects of ethanol on the brain.
Balancing the Risks and Benefits of Alcohol [52:03]
There's no judgment in choosing to drink, but it's important to understand the risks. If you decide to cut back, make structural changes to your life and week. You may find you don't miss it much.
Is Rehab Effective for Addiction? [53:36]
Rehab, the idea of going away for a week or two and being cured, is generally not effective. Addiction is more like a chronic illness or cancer, requiring long-term treatment. Many rehabs don't offer evidence-based treatments like medications and psychotherapy. Effective treatments include cognitive behavioral therapy and addressing underlying trauma.
Psychedelic Therapy for Addiction [56:40]
Psilocybin-assisted psychotherapy has shown remarkable effects for alcohol use disorder. Psilocybin increases neuroplasticity, helping the brain retrain itself.
GLP-1 Medications for Addiction Treatment [57:26]
GLP-1 medications, used for weight loss, seem to reduce alcohol use. They may reset craving and appetite more globally.
Sarah's Reaction to Celebrity Addictions [59:49]
When celebrities die from addiction, it's gutting and heartbreaking because it's a preventable death. We have tools to treat addiction and prevent harms. Seeing someone struggle publicly is sad, and it highlights the mismatch between what we do and what science says is helpful.
Stigma Around Addiction [1:02:14]
There's tremendous stigma towards drug and alcohol addiction, making it hard for people to share their struggles and seek treatment. People fear judgment, labels, and potential loss of housing or jobs.
Addiction Cases That Broke Sarah's Heart [1:04:30]
One case involved a man with a long-time heroin addiction who lost his housing and support system, leading to his death from an overdose. These deaths highlight the need for broader changes to prevent such tragedies.
How Society Should Change to Reduce Addiction [1:06:16]
To mitigate addiction, society needs to build resilience and connection early on. This includes affordable housing, parks, and support for families. True prevention involves breaking cycles of intergenerational trauma and poverty. Addiction treatment should be widely available, compassionate, and science-based.
What Is Rat Park? [1:07:30]
Rat Park experiments showed that rats in isolation with access to drugs consumed more, while those in a connected, stimulating environment consumed less. This demonstrates the importance of connection, community, purpose, and hope in addressing addiction.
Is Empathy Positive Reinforcement for Addicted Individuals? [1:12:32]
Love and support are generally not harmful. Often, care and belief from someone else motivate people to seek treatment. Positive reinforcement of desired behaviors is more effective than punishment.
Setting Boundaries With an Addicted Person [1:15:24]
It's okay to protect yourself if someone's addiction causes aggression or trauma. This is different from thinking kicking them out will make them better. People change because they believe their life will improve.
Motivational Interviewing to Support Recovery [1:18:46]
Motivational interviewing involves identifying and amplifying a person's reasons for change. It's about eliciting their motivation and turning over the power back to them. It involves listening for "change talk" and ignoring "sustain talk."
Finding Motivation for Positive Change [1:22:08]
Having a purpose and goal is crucial. Motivation is fleeting, so a strong "why" is essential. Find ways to enjoy the process. Make focused, personalized goals anchored on what matters to you.
Habits to Support Addiction Recovery [1:25:52]
Any behavior change is easier when you feel your best. Eat well, rest, and exercise. Find healthy ways to release dopamine. Fill the empty space left by the addiction with other fulfilling activities.
Can the Brain Recover From Addiction? [1:30:07]
The brain is plastic and can change. Positive childhood experiences can reduce addiction risk. After 5 years of recovery, a person's risk of developing addiction is no higher than the general public.
Non-Substance Addictions [1:33:59]
There are similarities between substance and non-substance addictions (social media, pornography, food). They involve dopamine, filling a void, and addressing trauma or mental illness.
Unexpected Sources of Addictive Behavior [1:34:45]
Trauma, untreated mental illness, and a deficit of connection and reward can lead to addictive behaviors.
How Sarah Copes With Difficult Addiction Cases [1:35:24]
Sarah copes by focusing on stories of hope and the 24 million people in the US living in recovery. She finds purpose in helping people and cares for herself through family, connection, exercise, running, and writing.
Importance of Language Around Addiction [1:37:00]
Language subtly worsens stigma. Avoid terms like "substance abuse," "addict," and "clean/dirty." Use person-first language (person with addiction) to humanize individuals.
How Labels Limit People's Potential [1:41:30]
Labels limit people's potential. Avoid defining yourself as incapable. People with addiction shouldn't be defined solely by their condition.
Question From the Previous Guest [1:43:47]
If you could redo or revise one thing you have successfully accomplished, what would that be and why? Sarah would be more present during medical training, appreciating the journey and the miracles around her.