Harvard Medical Expert Links Moderate Drinking to Cancer Risks

哈佛医学专家指出适度饮酒与癌症风险存在关联 Sarah Wakeman 博士警告称，每日饮酒会使相对患癌风险上升 40%，同时还会破坏脑组织并加速肝脏疾病发展。 Sarah Wakeman 博士剖析了围绕酒精与成瘾的普遍文化误解，指出即使是低水平的酒精摄入也会带来可衡量的健康风险，例如增加癌症易感性和器官损伤。她解释了成瘾的神经生物学基础，强调创伤、孤立以及多巴胺劫持如何导致物质使用障碍。对话重点探讨了循证医学干预手段——包括纳曲酮（Naltrexone）和 GLP-1 受体激动剂等药物——同时批评了惩罚性模式、“严厉的爱”（tough love）策略以及污名化的医学用语。最终，Wakeman 强调，借助神经可塑性、循证医疗照护和深刻的人际连结，康复是可以实现的。 每日适度饮酒伴随着显著的健康风险，每天一杯葡萄酒会使乳腺癌风险增加 5%，两杯则会使整体相对患癌风险增加 40%。 (0:00) 临床成瘾由“4C”特征定义（失控 [loss of Control]、强迫性使用 [Compulsive use]、不良后果 [adverse Consequences] 和渴求 [Craving]），这与生理依赖有所不同。 (4:20) 创伤和童年不良经历（ACEs）是成瘾的主要驱动因素，而遗传因素占个体风险的 40% 至 60%。 (10:11) 酒精会影响多种神经递质系统，触发多巴胺释放，模拟 GABA 的抗焦虑作用，并在大脑中释放内源性阿片类物质。 (12:13) 将成瘾归结为道德沦丧或等待患者跌至“人生谷底”会造成系统性危害，而持续的康复则是由连结、希望和支持所驱动的。 (18:01)

Dr. Sarah Wakeman argues that alcohol inflicts substantial physiological damage even at socially normalized consumption levels, emphasizing that addiction is a treatable chronic medical disorder driven by neurobiology, trauma, and isolation rather than a failure of willpower. Dismantling the Healthy Drinking Myth (25:42) Longstanding cultural beliefs that moderate alcohol intake provides cardiovascular protection stem from flawed observational studies. Researchers grouped individuals who quit drinking due to pre-existing medical conditions into non-drinking baselines, creating an artificial "J-shaped curve" that made light drinkers appear healthier than abstainers. Correcting for this "sick abstainer effect" reveals that no amount of alcohol improves health. Drinking routinely places individuals at elevated risk for numerous malignancies; a single daily glass of wine correlates with an approximate 5% rise in baseline breast cancer risk, while two daily glasses drive an estimated 40% increase in overall cancer risk, compounded synergistically when combined with tobacco. Physiologically, ethanol diffuses into body water and readily crosses the blood-brain barrier. Elevated alcohol exposure bathes central nervous system tissue in toxic byproducts, accelerating structural decline; neuroimaging of a 43-year-old with chronic heavy alcohol use can exhibit brain atrophy mirroring that of a 90-year-old dementia patient. In the liver, while the organ possesses substantial regenerative capacity, chronic alcohol toxicity and repeated cellular inflammation ultimately produce permanent scar tissue. Once this progression crosses the threshold into cirrhosis, the damage becomes irreversible. Neurochemical Relief, Trauma, and Social Isolation (12:13) Clinically, addiction is distinguished from simple physiological dependence by the "Four Cs": loss of control, compulsive use, persistent use despite negative consequences, and intrusive cravings. Alcohol possesses high addictive potential because it acts across multiple neurotransmitter systems simultaneously. It stimulates dopamine release in the nucleus accumbens, binds to inhibitory GABA receptors to produce sedative and anti-anxiety effects similar to benzodiazepines, and triggers endogenous opioids that relieve both physical pain and emotional distress. This neurochemical pain relief makes alcohol a potent self-medication tool for individuals coping with adversity. While genetic factors account for 40% to 60% of an individual's susceptibility, Dr. Wakeman notes that trauma functions as the true gateway to substance use disorders. Epidemiological data demonstrates a step-wise correlation between Adverse Childhood Experiences (ACEs) and addiction risk, compounded by social isolation. When individuals lack community, meaningful purpose, or emotional safety—a vulnerability demonstrated by Bruce Alexander's historical "Rat Park" experiments—substances become the primary accessible mechanism for relief. Evidence-Based Treatments Versus Traditional Rehab (53:36) Dr. Wakeman critiques the standard commercial addiction paradigm, noting that traditional 28-day residential rehab programs often treat a chronic illness as an acute episode while offering non-evidence-based interventions instead of medical therapy. Similarly, punitive concepts such as enforcing "tough love" or waiting for individuals to hit "rock bottom" frequently lead to fatal delays in treatment. Effective medical management requires long-term chronic care combining psychotherapies, trauma-informed support, and FDA-approved medications. Pharmacological therapies remain severely underutilized despite clear clinical efficacy. Opioid receptor antagonists like naltrexone blunt the dopamine and endorphin reinforcement triggered by drinking, facilitating the extinction of heavy drinking urges through daily protocols or targeted regimens like the Sinclair Method. In therapeutic settings, clinical studies identify therapist empathy as one of the strongest predictors of whether a patient reduces substance use. Techniques like Motivational Interviewing capitalize on this dynamic by selectively exploring and amplifying an individual's internal "change talk" while avoiding confrontations that provoke defensive resistance. Stigma, Person-First Language, and Long-Term Recovery (97:00) Systemic stigma actively distorts healthcare delivery and public perception. Controlled studies reveal that when clinicians evaluate vignettes describing an individual as a "substance abuser" rather than a "person with a substance use disorder," they are significantly more likely to recommend punitive measures such as incarceration over medical treatment. Dr. Wakeman advocates for person-first language to decouple human identity from a medical diagnosis, emphasizing that substance use disorders are not universally permanent conditions. Despite the severity of alcohol-related harms, the brain exhibits substantial capacity for neuroplasticity. Positive Childhood Experiences (PCEs)—even the presence of a single caring, consistent adult—substantially mitigate early trauma risks. Furthermore, longitudinal research indicates that after five years of sustained recovery, an individual's risk of recurrence declines to a level comparable to the general public's baseline risk, with roughly 24 million Americans currently living in remission. Dr. Wakeman emphasizes that addressing alcohol use disorder requires treating it as a standard medical condition within primary healthcare rather than an isolated moral failure. While approximately 24 million Americans have achieved sustained recovery, reducing the global annual toll of 2.6 million alcohol-related deaths depends on abandoning punitive models, expanding access to evidence-based pharmacotherapies, and accurately communicating that alcohol consumption carries tangible physiological risks at any level.

哈佛医学院成瘾医学专家萨拉·韦克曼（Dr. Sarah Wakeman）指出，酒精并不存在所谓促进健康的“安全饮用量”，哪怕日常轻度饮酒也会显著增加多种癌症风险。她强调，成瘾并非个人意志或道德品质的缺陷，而是一种受基因、心理创伤与神经生物学机制驱动的慢性可治性疾病，现代社会亟需打破污名化叙事，将其纳入常规循证医学体系。 破解适度饮酒神话与癌症剂量反应 (25:42) 韦克曼博士剖析指出，长期流行关于“适度饮用红酒有益心血管”的观点源于流行病学观察研究的设计缺陷。早期研究在死亡率曲线上观察到的“J型曲线”，实质上是由“患病戒酒者效应”（sick abstainer effect）造成的统计假象：对照组中混入了大量因严重器质性疾病或过往重度成瘾而被迫戒酒的虚弱人群。一旦将对照组修正为极轻度饮酒者，所谓的心血管保护效应便不复存在。现代医学证实，酒精并不存在绝对健康的摄入阈值，它本质上与培根、甜食或日光浴一样属于带有生理代价的消费品。 流行病学数据显示，全球每年约有260万人死于酒精相关原因。即使是常规每天摄入1杯葡萄酒，在医学上也已被划入“中度风险”，会使女性终身乳腺癌发生风险相对上升约5%（在美国女性约13%的基线风险上增至约13.6%）。若日常饮酒量增加至每天2大杯（即重度饮酒，每日约4至6个酒精单位），综合患癌相对风险将飙升约40%。在细胞层面，乙醇代谢产生的乙醛具有强细胞毒性，并诱发活性氧自由基导致DNA损伤；当酒精与烟草协同作用时，乙醇更充当黏膜溶剂，成倍放大致癌物向消化道细胞的渗透。 酒精对大脑结构与肝脏的器质性损耗 (45:17) 作为高水溶性的小分子物质，乙醇在摄入后10分钟内即可进入血液并穿透血脑屏障。它在脑内激活多巴胺回路带来短暂愉悦，并结合中枢神经抑制系统GABA受体产生镇静与肌肉松弛，同时刺激内源性阿片受体缓解情绪与躯体疼痛。然而，长期高浓度酒精持续浸润脑组织会导致严重的不可逆萎缩。脑部MRI横截面扫描表明，一名患有重度酒精使用障碍的43岁患者，其大脑皮层萎缩程度与充满脑脊液的空隙已与90岁阿尔茨海默病患者无异。所谓的高“耐受度”仅反映体液对酒精的稀释能力或行为适应，绝不代表大脑与内脏对毒性免疫。 在消化系统，超过90%的酒精由肝脏分解。虽然肝脏具备切除80%仍可再生的惊人修复力，但反复发作的高峰式暴饮（binge drinking）极具破坏性。短时间内涌入的大量乙醇会造成乙醛瞬时蓄积，其对肝脏造成的纤维化速度往往超过持续适量饮酒。韦克曼博士打比方称，肝脏病变如同烘焙蛋糕：在脂肪肝与早期炎症阶段尚能通过戒酒逆转，但一旦组织重塑并跨过肝硬化（cirrhosis）的门槛，器官便进入不可逆衰竭阶段，再行干预也无法复原结构。 基因创伤交织与成瘾的4C诊断框架 (4:20) 医学上严格区分“生理依赖”与“成瘾”。每日饮用咖啡停用后产生戒断头痛仅属于生理依赖，而成瘾的核心特征在于“即便伴随持续负面后果仍无法自制”。临床通常采用“4C”框架作为评估核心：失去控制（Control）、强迫使用（Compulsive use）、忽视后果（Consequences）以及剧烈心理渴求（Craving）。在流行病学成因上，遗传易感性贡献了成瘾风险的40%至60%，影响程度堪比2型糖尿病；而创伤则是真正的“入门药物”，童年不良经历（ACEs）的累积评分与日后发生物质使用障碍呈现严格的线性正相关。 韦克曼指出，创伤的本质并非单纯经历不幸事件，而是个体在极度痛苦中陷入孤立无援的境地。以英国歌手利亚姆·佩恩（Liam Payne）的悲剧为例，舞台万人欢呼与酒店客房极端孤独之间的落差，促使酒精成为填补精神真空与平复应激反应的神经化学代偿工具。著名的“大鼠公园”（Rat Park）实验同样证实：处于隔绝、无刺激牢笼中的大鼠会过量饮用吗啡直至死亡，而处于社交丰富、活动充裕环境中的大鼠则极少滥用药物。2020年COVID-19大流行初期因社会阻断与高压，导致美国酒精相关死亡率暴增23%，进一步佐证了环境孤立对成瘾行为的放大效应。 摒弃严厉惩治与推进循证医疗干预 (55:24) 长期以来，传统戒断机构宣扬的“严厉爱意”（tough love）以及等待患者“跌落谷底”（rock bottom）才开始救治的理念，被现代医学证实存在致命缺陷。韦克曼博士直言，很多患者在等待触底的过程中失去了生命。相反，希望与社会联结才是驱动康复的核心动力。在临床药物方面，阿片受体拮抗剂纳曲酮（Naltrexone）展现出明确疗效，它通过阻断大脑内源性阿片受体来消除饮酒带来的欣快与解痛回路；欧洲推广的“辛克莱方法”（Sinclair Method）允许患者在预期饮酒前半小时服药，靶向阻断神经强化以逐步消退酗酒冲动。 在心理与家庭沟通层面，韦克曼推荐采用社区强化与家庭培训（CRAFT）以及动机访谈（Motivational Interviewing）技术。沟通者应抑制好为人师的“纠正反射”，专注捕捉患者微小的“改变谈话”（change talk）并予以同理镜像，避免针锋相对导致其固化防卫机制。研究证实，治疗师的共情水平是预测患者减少物质使用的最关键指标。此外，医疗界必须革新污名化词汇，实验表明即使是专业心理学家，在面对被贴上“物质滥用者”（substance abuser）标签的虚构个案时，也会显著倾向于司法惩处而非医疗援助；改用“物质使用障碍者”（person with substance use disorder）等以人为本的表述，是将成瘾真正作为普通慢性病治疗的制度性前提。 韦克曼博士总结强调，人类大脑具有强大的神经可塑性，长期纵向随访与脑功能成像显示，在实现持续康复5年后，个体的复发风险将回落至与普通公众无异水平。她透露正撰写将于2027年春季出版的新书，旨在系统性重构社会对成瘾的医学认知。然而，现代都市生活带来的广泛社交孤立、初级医疗系统中成瘾专科资源的长年匮乏，以及廉价数字和物质成瘾源的泛滥，依然是公共卫生领域有待通过“上游社会干预”予以弥合的结构性难题。

## Background 该内容由知名商业与成长播客《The Diary Of A CEO》（主持人 Steven Bartlett）于 2025 年 5 月 22 日发布在 YouTube 平台上。视频简介指出，哈佛医学院副教授、麻省总医院布莱根医疗系统成瘾医学资深专家萨拉·韦克曼医生（Dr. Sarah Wakeman）在此期节目中深入揭示了酒精对大脑多巴胺系统的劫持、所谓“适量饮酒有益健康”的科学谎言、单杯饮酒推高患癌风险的机制，以及社会与医疗体系在应对成瘾危机时的认知盲区与改革路径。 ## TL;DR 韦克曼医生结合流行病学与前沿神经科学指出，并不存在所谓“有益健康”的饮酒阈值，即便是极低摄入量也会线性推高乳腺癌和食管癌风险，重度饮酒更会引发类似严重认知障碍症的不可逆脑萎缩。她强调成瘾并非道德缺陷，而是由 40% 至 60% 的遗传易感性叠加心理创伤共同驱动的慢性脑部疾病，传统宣扬的“触底反弹”和“严厉的爱”往往导致灾难性后果。相比缺乏循证支持的封闭式戒断，结合心理动机式访谈（MI）、CRAFT 家庭支持以及靶向药物（如纳曲酮、前沿 GLP-1 受体激动剂）的长期慢性病管理方案更为有效。大脑具备卓越的神经可塑性，在重建人际联结并实现持续康复满 5 年后，个体的复发风险将恢复至普通人群基准水平。 ## Atmosphere & style 整场对谈兼具硬核扎实的临床科学底色与深沉温暖的人道主义情怀。主持人 Steven Bartlett 敏锐而充满共情的追问，与韦克曼医生条理清晰的神经生物学拆解形成了高密度的智力碰撞，现场模拟动机式访谈的角色扮演更具极强的沉浸感与实操启发性。随着话题深入至医者与家属亲历的丧亲之痛、名人悲剧及因制度断裂逝去的无辜生命，对话流淌着克制却触动人心的悲悯与反思，最终在全美 2400 万康复者重获新生的生机中升华为充满希望的治愈力量。 ## Bulletin - [25:42](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1542s) 适度饮酒有益健康的“J型曲线”被证实是流行病学对照组偏差所致，修正排除因病戒酒者后，酒精在全因疾病上不存在任何健康益处，每天一杯即已迈入中度风险区间。 - [30:28](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1828s) 中度饮酒几乎与所有癌症发病率上升相关，对于乳腺癌和食管癌甚至没有安全阈值，每天两杯酒即达重度饮酒标准，可使部分癌症相对风险提升约40%。 - [00:00](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=0s) 全球每年因酒精死亡人数达260万，临床扫描中43岁酗酒者的脑萎缩程度已恶化至相当于90岁阿尔茨海默病患者。 - [10:11](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=611s) 成瘾的本质是神经系统疾病而非道德过失，遗传易感性占40%-60%，而创伤才是真正的“入门毒品”；经过5年持续康复，患者大脑重塑后的复发风险可降至常人基准水平。 ## Key takeaways - [04:20](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=260s) 医学上对成瘾的诊断遵循“4C原则”（控制力丧失、强迫性使用、不顾后果、强烈渴求），与不损害生活功能的单纯生理依赖存在本质区别。 - [10:11](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=611s) 成瘾风险由遗传易感性（40%-60%）和后天创伤共同决定，童年逆境经历（ACEs）与成年后物质使用障碍呈显著线性正相关。 - [12:13](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=733s) 酒精能同时结合GABA受体并激活内源性阿片系统，生理上兼具抗焦虑药与强效止痛药的特性，许多人借此对心理创伤进行自我药疗。 - [25:42](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1542s) 流行病学研究中所谓的“适度饮酒有益健康J型曲线”存在对照组偏差，混入了因严重疾病而戒酒的人群，纠正后证实酒精无任何安全保护效应。 - [30:28](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1828s) 酒精与多种癌症紧密相关，乳腺癌在极低摄入水平下患病风险便已上升；若同时伴随吸烟或肥胖，致癌风险将呈现乘数级放大。 - [38:43](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2323s) 肝脏虽有强大的细胞再生特权，但一旦长期慢性损伤演变为不可逆的纤维化瘢痕，便无法自行修复，且终末期肝病呈现显著年轻化趋势。 - [45:17](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2717s) 酒精是可穿透血脑屏障的广谱中枢毒素，结合微量营养素（如维生素B1）缺乏，会导致严重的早发性不可逆脑萎缩与酒精相关性痴呆。 - [48:57](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2937s) 乙醇高度亲水而不溶于脂肪，因此体脂率高、肌肉量少的人在饮用同等酒精后血液酒精浓度上升更快，更容易醉酒并受到伤害。 - [50:01](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3001s) 宿醉的本质是大脑承受高浓度乙醇暴露后的神经功能紊乱与回退状态，并非单纯由脱水或乙醛引起，耐受度高也无法免除脏器慢性损害。 - [53:36](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3216s) 传统封闭式短期戒酒所往往脱离循证医学，成瘾应作为慢性病进行长期阶梯式干预，辛克莱方法（按需使用阿片受体拮抗剂纳曲酮）可切断饮酒欣快回路。 - [57:59](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3479s) GLP-1受体激动剂类减重药物在临床试验中证实可重置中枢神经欲望通路，显著降低患者对酒精、烟草的渴望。 - [01:07:30](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4050s) “老鼠乐园”实验证明成瘾不仅受生物化学驱动，更是环境与社群匮乏的产物；“成瘾的反义词不是清醒，而是联结”。 - [01:14:04](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4444s) 针对成瘾亲人的干预应采用CRAFT模式与相依性管理（正向强化），划定边界以保护自身安全，而非寄希望于“跌入谷底”或施加痛苦惩罚。 - [01:18:46](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4726s) 动机式访谈（MI）通过精准捕捉来访者的“改变谈话”并进行镜态反射，绕开说教阻抗，帮助其自主挖掘核心内在动机（Why）。 - [01:30:07](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5407s) 单一大脑并不存在所谓的“成瘾性人格”，但在持续康复满5年后，大脑神经可塑性修复能让复发风险回落至普通大众基准水平。 - [01:37:24](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5844s) 医疗与社会用语对去污名化至关重要，应摒弃“物质滥用者”等惩罚性标签，采用“以人为本的语言”（如“患有成瘾症的人”）。 ## Detailed walkthrough ### [00:00](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=0s) 饮酒的隐形危害与成瘾危机预警 饮酒对身体健康造成危害的阈值，远比绝大多数人想象的要低得多。当主持人史蒂文·巴特利特（Steven Bartlett）端起手中的一杯红酒询问：“如果我每天只喝这么一杯红酒呢？”萨拉·韦克曼医生（Dr. Sarah Wakeman）给出了令人震惊的答案：这种摄入量已经处于医学上定义的“中度风险”（moderate risk）区间，而该区间几乎与所有类型的癌症发生率上升都密切相关。如果每天喝两杯，患癌风险可能飙升约 40%；即便仅仅维持每天一杯看似非常正常的社交饮酒量，女性罹患乳腺癌的风险也会增加约 5%。公众社会中充斥着关于“适量饮酒有益健康”的虚假信息与误解，而真实的数据往往被掩盖在商业宣传与生活习惯之下。 作为哈佛医学院副教授、麻省总医院布莱根医疗系统（Mass General Brigham）的成瘾医学专家，韦克曼医生正在前线抗击当代最严重的公共卫生危机之一。成瘾绝非边缘人群的专利，全球三分之一的人在一生中的某个阶段都会遭遇酒精问题的困扰，每年有高达 260 万人因酒精相关疾病丧命。酒精具有强大的系统性毒性，身体内几乎每一个器官都会受到侵蚀。在临床扫描影像中，甚至可以看到年仅 43 岁酗酒者的脑萎缩程度，已经恶化到与 90 岁严重阿尔茨海默病患者的大脑无异。 是什么在驱动人们滥用物质？深入研究表明，40% 至 60% 的成瘾风险由遗传基因决定，而天平的另一端则几乎完全被创伤（trauma）占据。当人们试图通过饮酒来缓解肉体或精神上的痛苦时，酒精在生理上确实扮演着强效止痛剂和抗焦虑药的角色——它直接激活并劫持了人体天然的镇痛系统。然而现代医疗体系却未能跟上科学的步伐，许多戒瘾康复机构并未提供循证有效的治疗手段，反而让患者在错误的引导下反复挣扎。 ```mermaid flowchart TD accTitle: 成瘾的核心机制与健康影响 accDescr: 展示遗传与创伤如何驱动物质滥用，并最终导致器官损伤与成瘾循环。 subgraph Causes["核心驱动因素"] G["遗传易感性 (40%-60%)"] T["早期或严重创伤"] end subgraph Mechanism["大脑与身体代偿"] D["多巴胺与天然止痛系统被劫持"] A["暂时缓解躯体/情绪痛苦与焦虑"] end subgraph Outcome["长远健康代价"] C["癌症风险激增 (如乳腺癌)"] B["不可逆脑萎缩 (43岁脑如90岁)"] O["器官衰竭与年均260万人死亡"] end G --> D T --> A A --> D D --> Outcome ``` --- ### [02:13](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=133s) 萨拉·韦克曼医生的使命与职业背景 谈及毕生事业的核心使命，韦克曼医生表示，她致力于彻底改变全社会对酒精与药物成瘾问题的认知范式，用基于严谨科学研究的事实与证据，取代根深蒂固的误解与污名化。很多人甚至不清楚究竟喝多少酒才算安全，也不了解成瘾行为背后的神经生物学真相。她希望通过普及客观的医学证据，赋予大众掌控自身生活和健康决策的权利。 在专业资历方面，韦克曼医生是一名训练有素的内科医生，长期在波士顿大型顶级学术医疗中心（麻省总医院）工作，至今仍保持着基础综合内科的临床实践——在住院部救治肺炎与心力衰竭，在门诊管理糖尿病和抑郁症患者。更为核心的是，她是拥有执业认证的成瘾医学专科医生（Board-certified addiction medicine physician），并担任成瘾医学专科培训项目的主任（Program Director），负责培养下一代成瘾专科医师。她的核心职业抱负，是将成瘾医学治疗彻底融入常规主流医疗体系，彻底终结过去那种将成瘾者隔离在简陋、低效、与现代医学脱节的独立封闭机构中的不良现状。 --- ### [03:29](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=209s) 现代戒瘾医疗体系的制度性误区 当被问及对当下社会治疗成瘾模式的症结所在时，韦克曼医生反问道：“我们有多少时间？从哪里开始聊起？”她指出，整个社会乃至医疗界最根本的错误，在于普遍将成瘾视为“品行不良”（behaving badly）、道德缺陷或单纯的意志力问题。 千百年来渗透在大众潜意识中的观念，认为成瘾者只要“改过自新”、发愤图强（pull themselves up by their bootstraps）就能解决问题，甚至将物质使用当作刑法司法层面的违法犯罪对待。韦克曼医生尖锐地指出，如果人们打心底认为成瘾是道德败坏或纯粹的个人过失，就绝不会将其视为需要同情与专业照护的疾病：“如果你认为他们只是在做坏事，你又怎么会认为他们理应获得医疗照顾，或者用善意与同理心去对待他们？”当务之急是依托前沿神经科学，重塑对成瘾疾病本质的理解，彻底重构那些在现实中屡遭诟病且缺乏科学依据的传统戒瘾照护流程。 --- ### [04:20](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=260s) 什么是成瘾？诊断标准与“4C原则” 生活常识中人们常常滥用“上瘾”这个词，例如开玩笑说自己“手机上瘾”或者“看 Netflix 追剧上瘾”。韦克曼医生对成瘾给出了严格的医学定义：**成瘾是指即便遭受严重负面后果，依然强迫性地持续使用某种物质（use despite consequences）**。在临床评估中，可以通过易于记忆的“4C原则”来准确识别： - **控制力丧失（Loss of Control）**：多次尝试减少使用量或彻底戒除，却屡屡失败，无法按自己的理智意愿刹车。 - **强迫性使用（Compulsive Use）**：使用行为失控螺旋式升级，使用模式完全脱离理性思考，变得机械而不可抗拒。 - **不顾后果（Continued Use Despite Consequences）**：即使该行为已经对个人的躯体健康、心理状态、工作职场、家庭关系或社交生活造成了显而易见的严重损害，仍然无法停下来。 - **强烈渴求（Craving）**：存在极其强烈的心理驱力与生理冲动，脑海中全天被想要摄入该物质的念头占据，挥之不去。 在精神医学与临床诊断体系中，医生通常会根据《精神疾病诊断与统计手册》（DSM）中的 11 项核心标准进行对照评分。若符合 Standard Criteria 中的 2 到 3 项为轻度物质使用障碍，4 到 5 项为中度，6 项及以上则属于重度。通常在医学语境中所探讨的典型“成瘾”，对应的是中度到重度物质使用障碍的病理阶段。 --- ### [05:37](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=337s) 哪些物质具有成瘾性？多巴胺释放与生理依赖的区别 凡是能在大脑奖励中枢引发多巴胺（Dopamine）急剧释放的物质，都具备不同程度的成瘾潜力。不同物质的成瘾指数（addictive index）各不相同：例如大麻的致瘾性相对低于甲基苯丙胺（冰毒），但依然属于致瘾物质的范畴。 临床上最常见的致瘾物质分类包括： - **酒精**：全球最普遍的成瘾源，全球约有 4 亿人受到酒精使用障碍（Alcohol Use Disorder）的折磨。 - **阿片类药物**：包括海洛因、处方止痛药（如羟考酮）以及致死率极高的强效阿片类药物芬太尼（Fentanyl）。 - **中枢神经兴奋剂**：如可卡因、甲基苯丙胺以及某些治疗注意力缺陷的多动症处方兴奋剂。 - **镇静催眠药**：常用于抗焦虑和失眠的苯二氮䓬类药物（Benzodiazepines）等。 - **大麻**：精神活性物质，同样具备中枢成瘾潜质。 面对主持人提出“我每天喝咖啡，不喝就会犯瘾，这是不是成瘾”的疑问，韦克曼医生清晰地区分了**生理依赖（Physiological Dependence）**与**成瘾（Addiction）**： - 生理依赖属于机体适应某种外源物质的神经生理反应。例如长期喝咖啡的人如果早晨没喝，神经血管代偿机制会导致剧烈的戒断性头痛；但只要咖啡并未对生活功能造成损害，甚至还提升了工作专注度，这就绝非成瘾。 - 成瘾则伴随着破坏性后果。如果一个人为了购买咖啡倾家荡产、上班严重迟到、与伴侣频繁爆发争吵，甚至在严重威胁到工作和家庭关系时仍旧疯狂失控地购买囤积，这种“不顾负面后果的强迫行为”才能被定性为成瘾。 --- ### [07:15](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=435s) 成瘾危机的严峻现实与全球伤亡规模 针对公众普遍存在的“成瘾只会发生在某些边缘群体身上，与普通人无关”的侥幸心理，韦克曼医生强调，受制于强烈的病耻感（stigma），人们在生活中极力掩盖这一创伤，但成瘾波及的广度早已深入千家万户。每一个普通人的家庭、朋友圈或工作团队中，几乎都存在正在与酒精或药物苦苦挣扎的身影。 从全球硬性统计数据来看，成瘾带来的伤亡极其触目惊心： - **酒精相关死亡**：全球每年因酒精直接或间接诱发的疾病死亡人数高达 **260 万人**。换算下来，**平均每天有超过 7000 人**死于酒精毒害。 - **药物过量与致死**：全球每年死于各类药物相关原因的人数超过 **60 万人**，相当于**每天有约 1600 人**因药物滥用失去生命。 无论是从宏观公共卫生的沉重经济负担，还是微观家庭遭遇的无尽痛苦来看，成瘾都是人类社会无法逃避、必须正视的普遍健康危机。 ### [08:10](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=490s) 成瘾问题的真实规模与社会的“他者化”偏见 全球范围内物质使用障碍的普及程度远超公众的普遍认知。根据医学统计，全球约有 4 亿人符合酒精使用障碍（成瘾）的诊断标准，另有约 8000 万人面临药物滥用问题。若从终身患病率的角度来看，多项研究估算，一个人一生中在某个阶段患上酒精成瘾的概率高达 15% 至 30%——这意味着几乎每三个人中就有一人可能在一生的某个节点遭遇酒精危机。然而，面对如此庞大的患病群体，整个社会却长期对此保持沉默或刻意回避。 造成这种群体性沉默的核心原因在于病耻感（stigma）以及根深蒂固的“他者化”（othering）心理防御机制。普通大众在提及成瘾时，脑海中往往会自动浮现极端、边缘化的刻板形象：或是蜷缩在街角注射海洛因的流浪者，或是清晨醒来便浑身颤抖、必须立刻灌下一口烈酒才能勉强维系机能的重度酗酒者。人们习惯于将成瘾归咎为“那些人的问题”，以此拉开心理距离，却忽视了酒精依赖与药物滥用其实普遍潜伏在普通家庭、职场和社交日常之中。 - **全球酒精使用障碍人数**：约 4 亿人 - **全球药物滥用/成瘾人数**：约 8000 万人 - **终生酒精成瘾概率**：15% – 30%（约每 3 人中就有 1 人） --- ### [08:49](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=529s) 疫情的重创：美国预期寿命下降与物质致死率激增 在探讨社会整体成瘾趋势究竟是在改善还是恶化时，Sarah 博士明确指出，COVID-19 大流行对成瘾危机造成了毁灭性的打击。疫情暴发后，酒精与药物滥用现象急剧恶化，相关死亡人数出现爆发式攀升。尽管目前药物过量死亡率终于开始趋向平稳、逐步回落至疫情前水平，但疫情期间留下的创伤与死亡高峰是前所未有的。 这一冲击直接反映在人口宏观数据中。疫情期间美国的预期寿命出现了令人触目惊心的断崖式下跌，且降幅显著大于其他发达国家。除了新冠病毒本身的直接致命性之外，另一大核心元凶正是物质滥用致死。从 2020 年 3、4 月疫情爆发初期开始，全美与酒精相关的死亡率骤增了 23%，药物过量致死率更是刷新了历史极值。这种大规模的“绝望之死”持续拖累了美国整体人均寿命，直到今年数据才首次出现扭转迹象。 --- ### [10:11](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=611s) 创伤才是“入门毒品”：成瘾风险的双重驱动机制 针对物质滥用背后深层的心理与生理推手，Sarah 博士指出成瘾只是下游表象，若无法理解个体借助物质想要解决或逃避的根本问题，任何干预都无从谈起。在医学上，成瘾风险主要由两大要素共同决定：遗传基因与环境经历。遗传因素约占 40% 到 60% 的易感性，其机制与糖尿病等复杂慢性疾病高度相似——携带风险基因并不意味着一定会发病，而缺乏家族遗传史的人同样可能陷入成瘾泥潭。 另一半决定性因素则来源于后天的环境暴露与生活创伤。Sarah 博士纠正了大众常说的“大麻是入门毒品”这一观点，直言“创伤才是真正的入门毒品（trauma is the gateway drug）”。著名的“不良童年经历”（Adverse Childhood Experiences, ACEs）研究及其在欧洲的多项重复实验均证实，童年期经历的不良事件数量与成年后患物质使用障碍的风险呈显著的线性正相关关系。酒精和药物能够迅速刺激人脑释放多巴胺以及内源性阿片肽（人体天然的镇痛系统），对于深陷创伤痛苦的人而言，物质成了最直接的避难所与止痛剂。在疫情期间，恐惧、孤独、日常节奏崩塌以及失去至亲的痛苦交织在一起，导致物质滥用集中爆发，其中冲在最前线的基层工作者（如医护人员、超市及便利店员工）以及家庭照料者（caregivers）受到的冲击尤为剧烈。 ```mermaid flowchart TD accTitle: 成瘾风险的双重驱动模型 accDescr: 展示遗传因素与后天环境创伤如何共同诱发成瘾，并凸显酒精作为止痛与抗焦虑剂的作用路径。 subgraph RiskFactors["成瘾核心诱因"] Genetics["遗传易感性 (40% - 60%)<br/>类比糖尿病遗传风险"] Trauma["后天暴露与童年创伤 (ACEs)<br/>线性推高成瘾概率"] end subgraph BrainResponse["大脑生理机制"] Dopamine["多巴胺通路<br/>奖赏与强化机制"] GABA["GABA 受体<br/>类抗焦虑药镇静效应"] Opioid["内源性阿片系统<br/>天然镇痛机制被激活"] end subgraph Outcome["行为与心理结果"] Relief["情绪与躯体剧痛缓解<br/>形成病理性依赖"] end Genetics --> BrainResponse Trauma --> BrainResponse Dopamine --> Relief GABA --> Relief Opioid --> Relief ``` --- ### [12:13](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=733s) 酒精的大脑劫持机制：抗焦虑与天然止痛药的结合体 针对酒精对大脑神经递质系统的具体作用机制，Sarah 博士拆解了其复杂的神经生物学链路。不同于单一刺激多巴胺以产生愉悦感与奖赏反馈的行为，酒精对中枢神经系统的作用兼具镇静与麻痹效果。酒精能够直接结合脑内的 GABA（γ-氨基丁酸）受体系统，而该系统正是人体的核心抗焦虑网络——临床上常见的抗焦虑与镇静药物（如阿普唑仑 Xanax、劳拉西泮 Lorazepam / Ativan）正是作用于相同的神经靶点。 更关键的是，饮酒还会激活大脑的内源性阿片系统，促使脑内释放天然的阿片类止痛物质。这也解释了临床戒酒治疗中一个看似反常的现象：广泛用于对抗阿片类药物依赖的拮抗剂（如纳曲酮），能够通过阻断大脑阿片受体来有效削弱患者对酒精的渴望。酒精在生理层面上相当于“将抗焦虑药与止痛药融为一体”。许多职场人群在工作重压或严重焦虑下，习惯在周末通宵畅饮进行报复性宣泄，本质上是在用酒精对情绪创伤进行自我药疗（self-medication）。由于缺乏对这套神经机制的认知，大众往往误以为只要没有晨起饮酒、旷工或家庭破裂，自己的饮酒习惯就是健康的，从而在不知不觉中滑向不可逆的生理损害。 --- ### [14:19](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=859s) 创伤的本质并非事件本身，而是“孤立无援” 针对创伤发生的年龄对成瘾风险的影响，Sarah 博士指出，人类大脑直至 20 岁出头至 25 岁左右才完全发育成熟。大脑未发育完全时遭受创伤或过早接触致瘾物质，会在脑回路中刻下更为顽固、深远的病理印记；但这并不意味着成年后的创伤不会诱发成瘾，临床上因二三十岁乃至四五十岁遭遇变故而陷入物质依赖的病例屡见不鲜。 创伤的核心定义并不在于客观事件本身有多残酷，而在于个体在经历极度痛苦时是否陷入了“必须独自承受与消化”的绝境。同样的经历在不同人身上会激发出截然不同的心理现实：以疫情封闭为例，部分人能在家中找到寄托与联结安然度过，而对另一些人而言，被迫困在室内、无所事事且与外界割裂的状态则是灭顶之灾。因此，创伤的内核是剧烈的“失联感”与孤立感。正如成瘾治疗领域所揭示的真理：“成瘾的反义词不是清醒戒断，而是联结（The opposite of addiction is not sobriety, it's connection）”——重塑与人、与社会的深层情感纽带才是走出成瘾的核心解药。主持人随后以其年轻早逝的知名音乐人好友、One Direction 乐队前成员 Liam Payne 为例，探讨了年少成名所承受的巨大孤立与心理高压。 ### [16:40](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1000s) 孤独与成瘾：聚光灯下的极度隔离与生活虚空 主持人分享了一个极端的公众人物案例：当事人被推上聚光灯下的超级舞台，在迪拜面对多达十万名狂热的观众演出，然而一下台，他立刻被塞进车里送回酒店房间反锁起来——因为名气太大，一旦走上街头就会被狂热的人群包围吞没。房间里唯一陪伴他的，就是塞满了烈酒的迷你吧台（mini-bar）。于是，他只能靠喝酒来排解这种极端落差与空虚，陷入了“舞台演出、上车、锁进酒店、借酒消愁、再登台”的恶性循环。这种强烈的隔离感与孤独，生动印证了人际连结和社会关系的匮乏如何在成瘾形成中扮演核心角色。 萨拉·韦克曼（Dr. Sarah Wakeman）对此深有共鸣。她谈到自己当周刚接诊的一位患者：这名患者内心极度渴望戒酒，并且每次都能坚持自律几周，但他当下的现实生活却是一片彻底的“虚空”——没有工作，没有亲密的人际关系，不喝酒时就只能一个人坐在空荡荡的家里看电视。在这种极度枯燥与孤独中，过不了多久，大脑就会本能地跳出唯一的解脱路径：“喝一杯我就能好受点”。韦克曼医生指出，面对成瘾，我们往往过度纠结于酒精这种化学分子本身，但真正的核心议题其实是：**我们该如何填满一个人的生活？** 如果不能帮助他们建立真实的人际连结、社区归属、自我认同、人生目标感以及生活参与度，仅仅剥夺成瘾物质，留下的便只有无法忍受的痛苦虚无。 ```mermaid flowchart TD accTitle: 隔离孤独与成瘾代偿循环 accDescr: 展示从社会孤立、情感虚空到寻求酒精即时缓解，再到生活进一步荒芜的恶性闭环。 subgraph SG1 ["现实生活的荒芜"] A["极端隔离 / 缺乏社会关系"] --> B["生活失去目标与意义"] B --> C["沉重的情感虚空与痛苦"] end subgraph SG2 ["成瘾物质的即时代偿"] C --> D["寻求酒精/物质作为唯一解脱手段"] D --> E["获得短暂神经递质刺激与缓解"] end subgraph SG3 ["恶性循环加深"] E --> F["药效消退，现实问题未解且加剧"] F --> A end ``` --- ### [18:01](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1081s) 亲历丧亲之痛：哈佛学者的从医初心与家属的无力感 面对主持人的提问——“你如此聪明，明明可以在任何行业取得顶尖成就，为什么偏偏选择将一生奉献给成瘾医学？”韦克曼医生首次袒露了深藏于心底的个人遭遇。在她大约24岁、正在医学院求学期间，她的一位直系亲属（immediate family member）因成瘾问题不幸离世。这成为了她一生的转折点：一边在顶尖学府学习严谨的医学科学，一边目睹至亲被成瘾吞噬却无能为力。这种巨大的撕裂感让她深刻意识到，社会在成瘾问题上错得有多离谱，普通家庭在面对成瘾亲人时是多么缺乏科学的认知工具与应对策略。古语有云“知之愈明，行之愈笃”（when you know better, you do better），她决心将当年自己渴望获得、却未能得到的科学与支持，带给整个世界。 谈及成瘾者家属所承受的折磨，韦克曼医生描绘了那种近乎窒息的无力感。在长期以来充斥社会的偏见中，成瘾被错误地归咎于“意志力薄弱”或“个人道德选择”。这种荒谬的假设在无形中给家属刺上了最深的一刀——它让亲人误以为：“如果他们真的足够爱我，他们就一定会为了我而戒掉；他们继续吸毒酗酒，就是选择成瘾物质而不是选择我。”这种误解让家庭成员陷入被背叛的巨大创伤与心碎之中。更糟糕的是，社会上充斥着诸如“严厉的爱”（tough love）、“必须把他们赶出家门”、“让他们跌到谷底（hit rock bottom）才能醒悟”等糟糕至极的建议。无数家属在遵循这些残忍建议后，终日饱受内疚与自责的煎熬；而即便只是对患病的亲人表达温情与善意，也会背负上“纵容包庇”的道德罪恶感。一旦亲人意外离世，留给生者的只有无休止的创伤、愤怒与无法消解的自责。 --- ### [20:32](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1232s) 医疗系统的错失良机与“严厉爱”带来的时光剥夺 当主持人问及那些离去的亲友真正需要的是什么时，韦克曼医生给出了斩钉截铁的回答：他们需要的不是审判与羞耻，而是**基于循证医学的科学治疗、同情心与共情**。社会对待成瘾的范式必须发生根本性扭转——从居高临下的“**你这个人就是问题**”（you are the problem），彻底转变为充满人道关怀的“**你遭遇了一个难题，我们可以一起帮助你解决它**”（you have a problem and we can help you with this）。 韦克曼医生坦言，自己至今仍无数次在脑海中复盘那些失去的生命——因药物过量离世的挚友，以及因酒精丧命的至亲。令她痛心疾首的是，这些逝者生前并非孤立无援，他们频繁出入医院、看全科医生、与现有的医疗体系有过无数次交集。这些原本都是绝佳的干预时机（reachable moments），但整个系统却一次又一次错失良机，没有任何专业人员向他们提供充满善意且有坚实科学依据的成瘾治疗。 除了医疗失职，更让韦克曼医生感到终生遗憾的，是主流文化宣扬的“严厉的爱”对家庭时光的残忍剥夺。许多人被灌输了这样一种非黑即白的二元论观念：“在彻底戒断之前，我绝不和你见面。”人们天真地以为这种断绝关系的冷酷姿态能逼迫对方改过自新，但现实的代价却是永久失去了陪伴挚爱的宝贵岁月。 > “如果家人生了癌症，你绝不可能因为他们生病就拒绝花时间陪伴他们……在那种非黑即白的模式下，我们忘却了与成瘾搏斗的人本质上依然是风趣、善良、充满爱意的鲜活个体，他们只是生病了。而那些失去的时光，我再也无法找回了。” - **医疗体系的触点错失**：成瘾患者在急诊、门诊等常规医疗场景中频繁现身，但一线医护普遍缺乏基于医学证据的干预手段与共情沟通，错失拯救窗口。 - **“严厉的爱”的负面后果**：机械化地将成瘾者赶出家门或切断联络，不仅未提升戒除率，反而彻底斩断了患者的情感支撑，让家属在亲人离世后陷入不可逆的终生内疚。 --- ### [22:47](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1367s) 破除“触底反弹”的神话：希望的力量与监禁的虚假安全感 主持人抛出了一句流传极广的流行格言：“唯有当保持现状的痛苦超越了做出改变的痛苦时，改变才会真正发生”（change happens when the pain of staying the same is greater than the pain of change），并询问这是否坐实了成瘾者必须“触底”（rock bottom）才能重获新生的逻辑。 韦克曼医生对这一流行观点提出了极具颠覆性的医学反驳。她承认大众媒体充斥着各种极具戏剧性的叙事——某人被扫地出门、沦落街头，随后迎来顿悟瞬间（Eureka moment）逆袭重生；但临床科学证据表明，这类案例纯属幸存者偏差。绝大多数成瘾者在经受一轮又一轮常人无法想象的剧烈痛苦后，不仅没有改变，反而在痛苦中沉沦直至死亡。**真正驱动绝大多数人走出成瘾泥潭的核心动力从来不是痛苦，而是“希望”**——当黑暗中有人向他们伸出援手，让他们感受到自己依然被爱，让他们确信前方还有一条值得活下去的出路时，转变才会萌芽；而当一个人陷入彻底的绝望、认为自己一无是处且人生毫无指望时，大脑只会彻底锁死在成瘾惯性中。 这种对“触底与惩戒”的执念，在对待监禁的态度上体现得尤为荒谬。韦克曼医生指出，许多濒临崩溃的家庭在得知患病的至亲被抓进监狱时，第一反应竟然是松了一口气，甚至产生一种名为“被解救感”（feeling rescued）的心理慰藉，天真地以为监狱是一个能强迫其与物质物理隔离的“安全避风港”。然而冷冰冰的医学统计数据粉碎了这种幻想： - **刑满释放后的极度致死风险**：成瘾者在刚刚出狱的脆弱期内，死于药物相关原因的风险较常人**飙升了整整 130 倍**（130 times increased risk of dying）。 - **终生死亡率大幅增加**：数据明确显示，一旦成瘾患者有过被监禁的经历，其终生因成瘾相关并发症死亡的几率不仅没有下降，反而呈断崖式上升。 韦克曼医生总结道，社会习惯于神化那些戏剧化的“谷底反弹”叙事，却选择性忽视了在这套残酷逻辑下被无情吞噬的千千万万条无辜生命。成瘾是一门需要温情与科学救治的脑部疾病，而非一场靠施加苦难就能顿悟的道德苦修。 ### [24:56](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1496s) 成瘾戒断的核心支柱：希望、同理心与有效治疗 面对成瘾者难以自拔的困境，有人凭借惊人的韧性在逆境与创伤中杀出重围，但 Dr. Sarah Wakeman 强调，绝不能将少数人的幸存作为构建残酷体系的借口——如果失去希望，许多人最终只会在孤立与痛苦中走向死亡。当被问及帮助他人做出改变的关键要素是否在于“希望”、“强大的动机（the strength of their why）”以及“爱、同理心与人际联结”时，Dr. Wakeman 给予了高度肯定，并补充了至关重要的一环：“有效的医学治疗”。治疗方案因人而异、取决于成瘾的类型与个体处境，但在大多数临床实践中，通常是心理治疗与药物干预的有机结合。 ### [25:42](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1542s) 酒精历史与“适度饮酒有益健康”的科学假象 人类与酒精的纠葛已延续上万年。Dr. Sarah Wakeman 指出，考古学家早在 13,000 年前狩猎采集者的洞穴遗址中就发现了酿酒设备；在 9,000 年前的中国古代，饮酒也主要承载着精神追求或社交功能，与身体健康毫无关联。然而在近现代，社会舆论逐渐衍生出“适量饮红酒能促进健康”的说法。Dr. Wakeman 直言这种观念完全源于对流行病学数据的误读与研究设计上的缺陷。 在过往的大规模人口研究中，研究人员通常跟踪数万人自我报告的饮酒量，并将其划分为不饮酒者、轻度饮酒者、适度饮酒者以及重度饮酒者。数据一度呈现出一条所谓的“J 型曲线”（J-shaped curve）：适度饮酒者的健康状况似乎优于完全不饮酒者，只有饮酒量飙升到极高水平时，健康风险才会骤增。然而，这种对照组存在严重的系统性偏差——许多所谓的“不饮酒者”之所以滴酒不沾，恰恰是因为他们原本就身患严重疾病（例如严重心力衰竭以致无法饮酒或服药冲突），或是处于康复期、身体已被酒精摧残过的过往酗酒者（即“患病戒酒者偏差”）。当现代科学家将对照基准纠正为“极少饮酒的人”后，酒精在任何综合疾病指标上的“健康益处”便彻底烟消云散了。 ```mermaid flowchart TD accTitle: J型曲线与真实风险对比 accDescr: 展示流行病学研究中对照组偏差如何误导公众认为适度饮酒有益健康，以及修正后的真实风险走势。 subgraph Flawed["传统存在偏差的对照研究"] A1["基准组：完全不饮酒者<br>(包含重病患者/康复期酗酒者)"] -->|对比显示| B1["适度饮酒者风险更低<br>(虚假的 J 型曲线)"] end subgraph Corrected["修正基准后的真实流行病学"] A2["真实对照：极低频率饮酒者<br>(排除疾病戒酒干扰)"] -->|纠正显示| B2["健康益处完全消失<br>(全因疾病风险随饮酒上升)"] end ``` ### [28:05](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1685s) 是否存在“健康的饮酒量”？定义标准杯与摄入隐患 当主持人追问是否根本不存在所谓的“健康饮酒水平”时，Dr. Sarah Wakeman 明确表示：“我绝不会说饮酒对你的健康有益。”这并不意味着低风险饮酒不能成为健康生活方式的一部分，但人们不应自欺欺人地认为“喝一杯红酒就等于运动了 30 分钟”。她将饮酒类比为吃甜点、吃培根或晒太阳——这些行为伴随着固有风险，个人可以在了解风险的前提下自行取舍。 关于人们常说的“每天只喝一杯酒”，Dr. Wakeman 指出了认知与现实的巨大差距，这与人们常误判冰激凌的分量类似。在英国，低风险饮酒指南规定每周摄入量需严格控制在 14 个酒精单位（Units of Alcohol）以内，每个单位相当于 8 克纯酒精。然而，吧台上常倒的一满杯红酒（glass of wine），肉眼目测往往就含有约 3 个酒精单位： - **摄入量换算**：如果每天习惯性喝上这么一杯红酒，一周累计摄入量将达到 $3 \times 7 = 21$ 个酒精单位，已经远远超出了每周 14 个单位的低风险红线。 - **现实生活场景**：大多数人很难长期坚守“每天恰好一杯”，一旦在社交聚会上一天喝两三杯，总摄入量便会迅速突破安全限度，直接跨入“中度风险饮酒”（Moderate Risk Drinking）区间。 ### [30:28](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1828s) 酒精与癌症的直接纽带：乳腺癌风险的无安全阈值 绝大多数公众并不知道，中度风险饮酒几乎与所有类型的癌症发生率上升都密切相关。对于乳腺癌和食管癌而言，甚至在极低的摄入水平下（即便低于官方推荐的低风险上限），发病风险就已经开始攀升，根本不存在所谓的“绝对安全剂量”。 Dr. Sarah Wakeman 列举了一组令人警惕的乳腺癌统计数据： - **低风险饮酒下的增幅**：即使每周饮酒量控制在低风险限制之内（在美国为少于 7 杯标准 5 盎司葡萄酒；在英国为少于 14 个酒精单位），女性患乳腺癌的相对风险依然会增加约 5%。 - **终生发病基数**：在美国，普通女性一生中患乳腺癌的基线概率高达 13% 左右（相当于一个有 9 名女性的房间里，概率上会有 1 人罹患乳腺癌）。在增加 5% 的相对风险后，终生发病概率会上升到约 13.6%。 针对癌症在年轻群体中持续攀升的现状，Dr. Wakeman 分析指出这主要是环境因素所致，因为基因不可能在短短数十年间突变。除了酒精，肥胖、激素波动（与生育年龄相关）也是乳腺癌的重要推手；而结直肠癌等在年轻群体中激增的病症，则与加工肉类消费以及微塑料等尚未完全探明的新型环境污染物紧密相关。而在大型癌症流行病学研究中，只要个体的饮酒量进入中度范围，几乎所有癌症的发病率都会显著走高，并呈现出极其清晰的“剂量反应关系”（Dose-Response Relationship）。 ### [33:30](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2010s) 酒精与癌症风险：即使微量饮酒也会受影响的器官 饮酒量与患癌风险之间存在着明确的剂量反应关系——喝得越多，罹患癌症的概率就越高。然而，医学证据显示，某些癌症甚至在极低的摄入水平下风险就会攀升。Dr. Sarah Wakeman 指出，乳腺癌（breast cancer）和食管癌（esophageal cancer）便是典型代表，哪怕只是少量摄入酒精，患病概率也会随之增加。而在男性群体中，年轻男性结直肠癌（colon cancer）的发病率正在急剧上升，肝癌以及前列腺癌等也与长期饮酒有着复杂关联。 值得注意的是，除肝脏外，酒精导致癌症的主要机制并不是单独靶向某一个特定器官，而是作用于全身细胞底层的 DNA 结构。当人体摄入酒精后，体内会引发炎症反应并产生大量的活性氧自由基（Reactive Oxygen Species, ROS）。这些有害分子会持续攻击并破坏正常细胞，随着时间推移累积基因突变，最终诱发癌变。 - **低剂量即可激活风险的癌症**：乳腺癌、食管癌。 - **男性中显著关联的癌症**：结直肠癌（近年来年轻群体发病激增）、肝癌、前列腺癌。 - **细胞层面的致病根源**：酒精代谢生成的有害分子与活性氧引发慢性炎症，造成 DNA 突变并破坏细胞修复机制。 --- ### [34:21](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2061s) 何为“重度饮酒”？烟草与肥胖带来的乘数放大效应 当主持人提出假设——如果一个人每天雷打不动地喝两杯红酒，这算不算严重？Dr. Sarah Wakeman 给出了肯定的答复：每天两杯酒已经完全达到了医学定义上的“重度饮酒”（heavy drinking）范畴。这一结论往往让大众感到不可思议，因为在很多人的认知中，尤其是年长一代的社交日常里，下班后小酌一杯、晚餐配一杯酒是再寻常不过的生活习惯。然而在大规模流行病学数据面前，这种看似惬意的习惯会让个体罹患某些癌症的相对风险平均飙升约 40%，且具体数值会随饮酒总量进一步上扬。 更严峻的问题在于共病（comorbidities）的叠加效应。如果饮酒者同时伴有吸烟或体重超重，健康风险绝非简单的相加（$1+1=2$），而是呈指数级“乘数放大”（multiplied risk）。以食管癌为例，酒精会削弱细胞屏障，使组织对烟草中的致癌复合物更为敏感，细胞直接暴露在更猛烈的致癌物浸泡中；而肥胖所导致的慢性系统性炎症，则与酒精协同加速恶性肿瘤的滋生。 - **重度饮酒判定标准**：每日规律饮用 2 杯酒即迈入重度饮酒门槛，该习惯可使部分癌症发病率提高约 40%。 - **吸烟与酒精的协同毒性**：酒精改变细胞通透性，放大烟草致癌物（carcinogens）对细胞的破坏力。 - **代谢共病**：肥胖引起的机体代谢紊乱与酒精毒性叠加，显著加剧病变风险。 --- ### [36:10](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2170s) 酒精进入人体后的生化通路：从胃部吸收到底层 DNA 损伤 ```mermaid flowchart TD accTitle: 酒精在体内的代谢与致癌级联过程 accDescr: 展现乙醇从胃部吸收、入脑、肝脏分解直至引发细胞炎症与DNA损伤的生理通路 subgraph Absorption ["吸收与分布"] A["摄入乙醇 (Ethanol)"] --> B["胃与肠道快速吸收<br/>(约10分钟入血)"] B --> C["扩散至全身水分组织<br/>(体脂越高者血液浓度越高)"] end subgraph Neurological ["神经系统影响"] C --> D["瞬间穿透血脑屏障"] D --> E["轻度放松 / 抑制减弱"] E --> F["判断力与运动协调障碍"] F --> G["严重过量导致意识丧失 (断片)"] end subgraph LiverMetabolism ["肝脏代谢与毒性"] C --> H["肝脏代谢 (~90%)<br/>(视乙醇为毒素，打破稳态)"] H --> I["代谢中间产物 + 活性氧 (ROS)"] I --> J["最终转为乙酸盐 (Acetate)<br/>(随呼吸及尿液排出)"] I --> K["慢性炎症与细胞突变 (致癌诱因)"] end ``` 从生理机制来看，酒水中的核心分子是乙醇（ethanol）。饮入后，乙醇会在胃和上消化道被极快吸收，往往在 10 分钟内就进入血液循环。乙醇具有亲水性，它不会渗入脂肪组织，而是在体内的含水体液中扩散。正因如此，在摄入同等量酒精的情况下，由于女性平均体脂率高于男性、体内水分占比更低，其血液酒精浓度上升得更快、受到的神经与生理冲击也更强。 酒精最可怕的特性之一是能够瞬间跨越血脑屏障（blood-brain barrier）。刚开始它会带来短暂的松弛感、社交兴奋或焦虑缓解；但随着血液浓度攀升，大脑神经功能受到全面抑制，进而出现运动共济失调、步态蹒跚、危险驾驶倾向和决策能力丧失，过量时则会直接致使意识丧失（晕厥断片）。为了恢复机体的自稳态（homeostasis），人体会迅速启动防御机制将乙醇视作外来毒物进行清除。大约 90% 的解毒工作落在肝脏肩上：肝脏虽然最终能将酒精分解为可以通过尿液和呼气排出的乙酸盐（acetate），但整个清除链条中产生的毒性中间产物、活性氧自由基以及广泛的组织炎症，会像潜伏的定时炸弹一样不断蚕食细胞健康并诱发基因突变。 --- ### [38:43](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2323s) 肝脏的惊人韧性与不可逆的“烘焙拐点” 现场借助人体内脏模型直观展示了肝脏的物理位置与宏观构造。掀开胸腔模型，在双肺与心脏下方、人体右上腹肋骨内侧，坐落着暗红褐色的巨大脏器——肝脏。它的体积极为庞大，几乎与一侧肺叶相当。作为身体的“综合生化解毒厂”，人体摄入的毒素、营养物质、葡萄糖以及 90% 的酒精全部需要经过它的过滤与代谢转化。 肝脏拥有人体内极其罕见的奇迹般再生能力：正如某些蜥蜴断尾后能重新长出一条新尾巴一样，哪怕手术切除高达 80% 的肝脏组织，它依然能够完整再生。这种特性使得“活体肝移植”（living liver transplant）成为可能——健康人捐献半个肝脏给重症患者，两人的肝脏都能重新生长恢复。然而，这种近乎神话的修复能力并不是无止境的。如果慢性损伤持续存在，肝组织就会不可逆地形成纤维化瘢痕，演变为肝硬化（cirrhosis）。Dr. Wakeman 用了一个形象的烘焙比喻来阐述这个临界点： > “这就像烤松饼或做蛋糕。如果你在把面糊推进烤箱前发现自己忘了加鸡蛋，你随时可以补打鸡蛋搅拌均匀，烤出来的蛋糕依然完美；但如果松饼已经在烤箱里烤熟定型了，你才想起来没放鸡蛋，这时候把生鸡蛋浇在烤熟的松饼表面，就无论如何也回天乏术了。” 在肝脏彻底被瘢痕组织占据之前，戒酒和改善代谢几乎可以逆转所有的脂肪变性与早期炎症；但一旦跨过了那道不可逆的终点线，肝脏就丧失了自愈能力。令一线医护人员心碎的是，如今由肥胖和酒精引发的终末期肝病正在急剧年轻化，大量年仅二十多岁的年轻人因为长期过量饮酒突发暴发性肝衰竭（fulminant liver failure）被送进重症病房并迅速离世。他们在病发前甚至完全没有意识到自己的身体已经千疮百孔，而当他们因黄疸或剧烈衰竭赶到医院时，一切早已错过了最佳的逆转契机。 ### [41:43](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2503s) 暴饮与肝脏的耐受极限：肝脏真的能无限再生吗？ 社会文化往往将年轻群体中的“暴饮”（Binge drinking）彻底正常化，将其视作无伤大雅的社交仪式，却普遍忽视了其背后极具破坏性的健康隐患。主持人谈到自己平时滴酒不沾、生活节制，但心中难免好奇：普通人的肝脏是否足够强韧，能承受偶尔一次“彻底放纵的周末”（blowout weekend），随后依靠肝脏强大的再生能力完全复原？ 萨拉·韦克曼（Dr. Sarah Wakeman）医生对此打破了幻想。她指出，单一一次极端放纵在个体层面或许侥幸能挺过去，但最大的陷阱在于“放纵一次”往往会迅速滑向“多次放纵”，长此以往会急剧加速肝损伤。肝脏虽然具备非凡的细胞再生机制，但这个特权有一个不可逆的绝对红线——**纤维化瘢痕**（Scarring/Fibrosis）。一旦病变越过了这道红线，即便彻底戒酒，肝组织也无法再逆转重生。 令医学界深感棘手的是，不同个体对酒精毒性的耐受异质性极大。临床上既能见到连续酗酒 60 年却未出现明显肝硬化瘢痕的长寿老人，也能看到年仅 25 岁就因急性酒精性肝衰竭在医院病房死去的年轻人。遗传易感性与个体代谢因素无法提前预知，因此最稳妥的策略就是杜绝剧烈的暴饮行为。 ```mermaid flowchart TD accTitle: 酒精性肝损伤恶化路径 accDescr: 展示从脂肪堆积、炎症发展至不可逆纤维化与肝衰竭的过程 subgraph 可逆阶段["早期阶段（可逆转）"] A["正常肝脏组织"] --> B["肝脏脂肪堆积 (Fat Deposition)"] B --> C["脂肪肝与炎症反应 (Fatty Liver & Inflammation)"] end subgraph 不可逆阶段["终末阶段（不可逆）"] C -->|"持续酒精毒害 / 突破临界点"| D["肝纤维化 / 瘢痕组织 (Fibrosis / Scarring)"] D --> E["进行性晚期瘢痕形成"] E --> F["终末期肝功能衰竭 / 需肝移植或致死"] end ``` - **隐匿性进展**：肝损伤早期通常毫无自觉症状，往往需要通过常规血液生化筛查（肝酶指标）或腹部超声波才能捕捉到脂肪浸润与初期炎症。 - **不可逆临界点**：在出现纤维化瘢痕之前戒酒，肝脏尚能完全复原；一旦瘢痕广泛蔓延，肝小叶结构破坏，肝功能便不可逆转地衰竭。 --- ### [43:42](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2622s) 伤肝的隐形杀手与暴饮对代谢的猛烈冲击 除了酒精，现代人生活中的其他常见因素同样给肝脏代谢施加了沉重负担。韦克曼医生强调，肝脏是人体葡萄糖与能量代谢的核心枢纽，饮食失衡与肥胖（非酒精性脂肪肝病）正成为肝损害的主要诱因。此外，药物代谢毒性也是急诊中屡见不鲜的祸首，其中最典型的是非处方镇痛药对乙酰氨基酚（Acetaminophen，即泰诺 Tylenol）。当患者因感冒同时服用复方感冒药与对乙酰氨基酚，药物剂量叠加上限后又外出大量饮酒，两者的协同毒性可在极短时间内诱发爆发性肝坏死。 针对“摄入多少酒精才会致病”的疑问，韦克曼医生指出，损伤程度因人而异，但中度至高量摄入必然带来危险。尤其值得警惕的是，**短时间内摄入天量酒精的“暴饮模式”，其杀伤力远超多年低中度维持饮酒**。 - **毒性蓄积机制**：突发的大剂量暴饮会引发乙醛等有毒代谢副产物在体内爆发式蓄积，瞬间击穿肝脏酶系统的解毒上限。 - **危害对比**：数年内频繁发生重度暴饮，其诱发不可逆肝病的速度与严重程度，往往比长期处于低风险摄入上限之上的稳态饮酒更为剧烈。 - **防御原则**：极力避免单次急性过量饮酒，并将饮酒量严格控制在国际公认的低风险指南区间之内。 --- ### [45:17](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2717s) 酒精如何“吞噬”大脑：43岁患者萎缩如90岁痴呆老人 酒精绝非仅对肝脏作祟，它是贯穿全身器官的广谱毒素。韦克曼医生展示了一张震撼人心的脑部核磁共振（MRI）横切面影像。健康成年人的大脑截面中，皮层灰质与深部白质组织应当紧密饱满，最大程度填充颅内空间以维持数十亿神经元的高速运转；而在严重衰老或患有认知障碍症（阿尔茨海默病等）的患者脑中，脑回萎缩、脑沟增宽，原本致密的脑组织被大片呈黑色的脑脊液水样腔隙所取代。 令人不寒而栗的是，MRI 图像上一个仅 43 岁、患有重度酒精使用障碍（Alcohol Use Disorder）的患者大脑，其脑容积萎缩与结构坍塌程度，竟与 90 岁高龄的重度认知障碍症患者毫无二致。酒精相关性痴呆（Alcohol-related dementia）是切实存在的临床诊断。 ```mermaid flowchart LR accTitle: 酒精对脑结构与功能的破坏机制 accDescr: 乙醇穿透血脑屏障并结合营养不良导致脑萎缩的机制 subgraph 毒性侵袭["中枢毒性"] A["高浓度血液乙醇"] -->|"直接穿透血脑屏障"| B["脑组织细胞浸润与炎症"] B --> C["神经元DNA与蛋白质结构破坏"] end subgraph 代谢剥夺["代谢剥夺"] D["酗酒相关饮食恶化"] --> E["关键微量营养素严重匮乏（如维生素B1）"] end C & E --> F["脑灰白质严重流失 / 脑萎缩"] F --> G["突发性遗忘症 / 酒精性痴呆"] ``` - **屏障穿透**：乙醇是微小脂溶性分子，可自由穿透血脑屏障，高浓度饮酒意味着整个脑组织长期“浸泡”在乙醇及其炎性代谢环境之中。 - **营养剥夺协同损伤**：长期嗜酒者往往伴随严重的摄食障碍与吸收缺陷，关键营养素（特别是硫胺素/维生素 B1）的匮乏会成倍放大神经变性速度，甚至引发突发性记忆丧失、定向障碍与急性遗忘综合征。 --- ### [47:13](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2833s) 从消化道灼伤到“假日心脏综合征”：心脏与食管的代价 在顺流而下的过程中，酒精首先直接灼烧并浸润口腔、咽喉、食道黏膜和胃壁。这种长期的局部化学刺激不仅显著推高上消化道癌症风险（在与吸烟协同作用时风险呈几何级数暴增），更会诱发广泛的良性但极折磨人的慢性疾病——胃食管反流病（GERD/胃灼热）。韦克曼提醒，许多习惯性依赖抗酸药片缓解烧心反酸的人，首先应当审视自己的日常饮酒习惯。 转向心血管系统时，韦克曼明确表示，酒精在中高摄入量下对心肌具有极强的电生理与机械结构毒性： - **假日心脏综合征（Holiday Heart Syndrome）**：正常状态下，心肌电信号始于心房窦房结并规整传递至心室，触发强有力的同步泵血。而在节假日或周末大规模暴饮之后，急诊室常会收治大量突发心房颤动（Atrial Fibrillation）的患者。心房上部因异常电风暴而陷入快速无序的“颤动”失控状态，丧失泵血功能。 - **酒精性心肌病（Alcoholic Cardiomyopathy）**：长期慢性高剂量饮酒会促使心肌细胞变性坏死。心脏腔室逐渐病理性扩大，心室壁变得如纸般薄弱、松弛乏力，丧失回缩泵血能力，最终导致不可逆的充血性心力衰竭。 --- ### [48:57](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2937s) 体脂率与酒量的迷思：为什么体型庞大的人反而更容易醉？ 谈及酒量与身体耐受度，主持人分享了自己以往饮酒时的困惑：人们通常直觉认为体格强壮、体重大的人更能“喝”，然而他过去却经常看到体脂率较高、块头更大的朋友比精瘦的自己更快喝醉，而自己却能喝很多且看似毫无醉意，这曾让他误以为酒精对自己造成的身体伤害更小。 韦克曼医生揭示了隐藏在人体成分中的生理学机制：**酒精（乙醇）是高度水溶性的，完全不溶于身体脂肪组织**。 > “这就像拿一杯水往里面滴红墨水。体内的水分越多，酒精扩散稀释的范围就越广，血液酒精浓度（BAC）也就越低。” - **体内水分决定稀释度**：骨骼肌组织含水量高达 70% 以上，而脂肪组织中水分极少。低体脂、高肌肉比例的人群，体液总容积往往显著大于同等体重（甚至更重）但体脂率偏高的人。 - **浓度飙升陷阱**：对于体脂偏高的人，两杯酒进入体内后，实际上只能在一个相对少得多的体液空间内进行稀释，导致其血液酒精浓度以远超预期的速度飙升，迅速产生醉态。 - **耐受度与器质性损害的脱节**：许多人误将“脑部对酒精的主观耐受好、不易显醉”等同于“身体器官免疫损伤”，这种错觉往往导致所谓“酒量大”的人在不知不觉中摄入致死剂量的毒素，器官深层的退行性纤维化与细胞凋亡仍在无声加剧。 ### [50:01](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3001s) 宿醉的生理机制与耐受度误区 当主持人提到自己过去酒量比朋友好、不易喝醉，是否意味着身体受到的伤害更小时，萨拉·韦克曼医生给出了明确的否定。高耐受度绝不代表对酒精具有生物学上的免疫力。人体对酒精的代谢速率因人而异，体脂率与体内水分含量直接影响血液酒精浓度（BAC）。代谢较快或体型较大的人可能在饮酒过程中血液酒精浓度峰值相对较低，从而经历较轻的宿醉，但这丝毫不能阻止酒精对内脏的隐性侵蚀——肝脏纤维化、癌症发病率、心血管退行性病变以及食管损伤等慢性危害，依然在悄无声息地累积。 关于“什么是宿醉”，医学界近年来通过大量的人体和啮齿动物实验推翻了许多传统假设。过去人们普遍认为宿醉是由乙醛等中间代谢副产物中毒造成的，但最新研究表明，宿醉的严重程度主要取决于大脑暴露于高浓度乙醇的程度和持续时间。当体内的血液酒精浓度降至零时，大脑经历了一段“被高浓度乙醇浸泡”后的撤退期，引发一系列中枢神经紊乱，表现为重度疲乏、情绪淡漠、剧烈头痛和恶心反胃。虽然脱水会加剧体液浓缩，导致睡前喝一大杯水确实能稍微缓解症状，但宿醉的核心并不是简单的脱水，而是大脑承受乙醇毒性冲击后的典型后遗症。韦克曼医生强调，只要饮酒后出现了宿醉，就明确说明摄入量已经突破了身体可以承受的安全界限。 - **宿醉核心成因**：大脑在承受高浓度乙醇暴露后进入的神经功能紊乱与回退状态，并非单纯由脱水或乙醛引起。 - **耐受度假象**：主观感受上“不醉”并不保护肝脏、食道、心脏等器官免受细胞层面的长期损害。 - **饮水缓解机制**：补水仅能通过增加体内总水量来降低血液酒精浓度、补充体液，无法逆转神经毒性。 --- ### [52:03](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3123s) 社交需求与健康风险：理性抉择与生活架构调整 面对听众可能提出的现实抗辩——“酒精是我融入现代社交的催化剂”、“没有酒局就很难维系人际关系”、“喝酒让我感到快乐，我并不想戒酒”——韦克曼医生表示行医的核心在于支持患者，而非道德审判。在她看来，乙醇分子本身没有任何道德属性，它与葡萄糖分子并无二致。现代营养学已充分揭示了精制糖、白面粉和超加工食品的害处，但并不意味着所有人都必须过苦行僧式的禁欲生活、彻底放弃甜点。对待饮酒，每个人都应在“充分知情、认清风险”的前提下，权衡自身的生活目标并做出选择。 如果目标是降低健康风险，关键在于改变生活结构，而非依赖脆弱的意志力。如果一个人决定少喝，却依然每晚准时出现在挤满饮酒人群的欢乐时光（Happy Hour），靠纯粹的自律抵抗诱惑，几乎注定会以失败告终。更明智的害处缩减策略是通过重新规划生活节奏：比如将每周饮酒天数削减到一至两天，将其余几天替换为无酒精的社交或休闲活动。这样既能保留酒精带来的社交愉悦，又能使慢性健康风险出现断崖式下降。 --- ### [53:36](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3216s) 传统戒酒所的盲区与循证医学方案 谈及酒精使用障碍的治疗，大众熟知的传统全封闭式康复戒酒所（Rehab）往往并不奏效。许多患者经历过三到四次住院戒断后依然复发，陷入更深层的绝望。韦克曼医生坦言，传统康复模式存在严重的认知误区：它将成瘾错误地当成类似细菌感染的急性病，以为把患者与外部环境隔离两周、吃一段时间药就能“彻底治愈”。实际上，成瘾在生物学本质上更类似于癌症或糖尿病等慢性疾病，需要在发病前几年进行密集的医学干预，随后逐步过渡到长期的病情稳定与缓解期，如同“癌症康复者”一样需要持续维护。 韦克曼医生团队曾通过“神秘顾客”（Secret Shopper）调研全美各地的商业戒酒机构，结果发现行业内充斥着大量缺乏科学依据的疗法，例如骑马治疗（Horse Therapy）或海豚伴游疗法（Dolphin-assisted Therapy）。这些活动固然能提供心理放松，但没有临床试验证明其能治疗成瘾。相反，被临床指南验证有效的认知行为疗法（CBT）、动机强化治疗（MET）、深层创伤干预以及正规药物治疗，在许多传统机构中却严重缺位。 ```mermaid flowchart TD accTitle: 传统戒酒模式与慢性病医学干预模式对比 accDescr: 对比传统封闭式戒断模式的急性短期思维与循证医学的长期阶梯式干预 subgraph Traditional["传统全封闭戒酒模式 (Rehab)"] T1["环境物理隔离 (数周)"] --> T2["非循证项目 (马术/海豚疗法)"] T2 --> T3["期满出院 (缺乏长期维持)"] T3 --> T4["重返现实诱发环境 (高复发率与无助感)"] end subgraph EvidenceBased["循证医学慢性病管理模式"] E1["急性期医疗干预 (药物联合心理治疗)"] --> E2["靶向受体调节 (如阻断内源性阿片受体)"] E2 --> E3["长期认知重构 (CBT/动机强化/创伤治疗)"] E3 --> E4["持续性缓解与复原 (类似癌症康复长期维持)"] end ``` 在药物治疗领域，多数人并不知晓目前已有非常成熟且高效的处方药。例如通过阻断大脑中的阿片受体，能够直接切断饮酒带来的神经欣快感。欧洲研究学者大卫·辛克莱（David Sinclair）据此提出了著名的“辛克莱方法”（Sinclair Method）：患者无需每日服药，而是在明知可能过量饮酒的社交场合（如节庆聚会）前30分钟按需服用阿片受体拮抗剂（如纳曲酮）。药物切断了酒精刺激内源性阿片类物质释放所产生的舒适感与微醺奖赏，患者在喝完第一杯酒后便会自然觉得“索然无味”，丧失继续暴饮的冲动。 - **传统机构弊病**：将慢性脑部病变误作为期数周的急性病处理，过度依赖同伴支持和非循证娱乐项目。 - **辛克莱方法（The Sinclair Method）**：在饮酒前约30分钟按需服用阿片受体拮抗剂，靶向阻断饮酒引发的内源性欣快回路。 - **临床药理反馈**：阻断大脑犒赏反馈后，饮酒者不仅不会产生躯体不适，反而会主动终止进一步摄入。 --- ### [56:40](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3400s) 迷幻药与神经重塑在成瘾治疗中的前沿探索 在药物创新的讨论中，主持人询问了迷幻药（Psychedelics）在对抗成瘾行为方面的应用潜力。韦克曼医生指出，近年来关于裸盖菇素（Psilocybin，大朵迷幻蘑菇中的活性成分）辅助心理治疗酒精使用障碍的高质量临床试验取得了令人瞩目的突破。 在一项严谨的对照试验中，研究人员将酒精依赖受试者随机分配接受大剂量苯海拉明（Benadryl，作为活性对照组）或高纯度裸盖菇素，并在专业心理治疗师的全程引导下进行长达8小时的辅助体验。随访数据显示，接受裸盖菇素干预的组别在饮酒量和复发率上均呈现出断崖式下降。其药理学机制在于，迷幻药能够显著增强大脑的神经可塑性（Neuroplasticity），重塑神经突触连接，帮助大脑打破长期固化的成瘾犒赏回路并构建全新的认知通道。 关于常被用于阿片类成瘾治疗的另一种迷幻成分伊博格碱（Ibogaine），韦克曼医生则持审慎态度。目前针对伊博格碱的高规格循证研究相对匮乏，且现存证据的说服力不及裸盖菇素。更重要的是，医学界在阿片类药物依赖领域已经拥有非常成熟且能直接显著降低死亡率的维持治疗药物（如美沙酮、丁丙诺啡等），因此替代疗法若想在临床上确立地位，必须展现出更为严苛的疗效和安全性优势。紧接着，她将目光引向了成瘾医学领域更具普适潜力的一类全新药物分子。 ### [57:59](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3479s) GLP-1 药物在戒酒与成瘾治疗中的惊人潜力 人们熟知的减重药物（如 Wegovy、Ozempic 等 GLP-1 受体激动剂类药物）在临床与现实中展现出了意料之外的作用：它们似乎能够显著减少酒精摄入。Dr. Sarah Wakeman 指出，在 Reddit 等网络社区中，最初为了治疗糖尿病或减肥而使用这些药物的用户纷纷报告，自己突然不再想抽烟或喝酒，那种强烈的冲动完全消失了。对一些长期挣扎于戒酒的人来说，这种改变堪称“奇迹”，因为多年来他们首次摆脱了那种深层的渴望与渴求感（craving）。 不仅是用户自发的反馈，近期的临床双盲安慰剂对照试验也证实了 GLP-1 药物确实能有效减少饮酒量。Dr. Wakeman 解释道，这一领域目前非常引人注目，因为这类药物似乎不仅在调节对食物的饱腹感，而是从更广泛的神经机制上重置了人脑的渴望与食欲系统。随后，主持人插入了一段关于赞助商 Extra 行李箱的宣传，提到轻装出行与真空压缩收纳技术。 ```mermaid flowchart LR accTitle: GLP-1 药物抑制渴望机制 accDescr: 展示 GLP-1 药物从原本治疗糖尿病和肥胖扩展到更广泛大脑欲望抑制的路径。 subgraph Origin["初始医疗适应症"] D["糖尿病管理"] W["体重减轻 (Wegovy / Ozempic)"] end subgraph Brain["大脑奖赏机制重置"] GLP["GLP-1 受体激动剂"] Reset["广泛重置中枢神经渴望与欲望"] end subgraph Effect["行为转变表现"] Food["食物渴望下降"] Alc["酒精摄入欲望消退"] Nic["吸烟冲动减弱"] end Origin --> GLP GLP --> Reset Reset --> Food Reset --> Alc Reset --> Nic ``` --- ### [59:48](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3588s) 名人成瘾悲剧与可预防的死亡 公众通常通过荧幕上的榜样和流行文化来认识成瘾。大众看着舞台上的明星在聚光灯下一步步走向恶化与衰退，最终往往以 TMZ 上令人心碎的死讯头条收场——例如惠特尼·休斯顿（Whitney Houston）、迈克尔·杰克逊（Michael Jackson，死因与止痛药成瘾相关）、王子（Prince）、埃尔维斯·普雷斯利（Elvis Presley）、麦克·米勒（Mac Miller）以及安娜·妮可·史密斯（Anna Nicole Smith）。如今，社交媒体上仍能看到一些公众人物表现出行 erratic 的反常举止，引发公众议论。 Dr. Sarah Wakeman 表示，每次看到这类头条，她内心都感到被掏空般的极度心碎。成瘾导致的死亡是一场场“完全可以预防的悲剧”。现代医学已有成熟的工具来治疗成瘾、预防药物过量致死，但社会现实与科学界已被证实的有效手段之间存在巨大的脱节。成瘾的改变不是像搞一次突击干预（intervention）后把人送进康复机构就能一劳永逸的魔法，而是一场漫长的心路历程。关键在于去探寻：物质使用究竟如何阻碍了当事人追求自己想要的生活，以及改变现状会带来怎样的不同。 --- ### [01:02:14](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3734s) “不是他失败了，而是治疗辜负了他”：成瘾污名化 主持人分享了自己的一段亲身经历：他曾有一位朋友，平时是聚会上的焦点、永远挂着灿烂笑容，但某天却在一次活动中坐下来，悄声对他耳语道：“我痛苦万分（I'm in so much pain）。”那位朋友坦白了康复机构并没有解决他的困境。社会随后因他的异常行为对他进行苛责与网暴，但主持人因听到了那声低语，深刻体会到了对方内心的煎熬与挣扎。 Dr. Sarah Wakeman 敏锐地指出了主持人用词中的关键变化——“治疗辜负了他（the treatment failed him）”，而不是“他未能完成治疗（he failed treatment）”。社会习惯于将康复失败归咎于患者个人意志薄弱；如果一个癌症患者化疗后复发，没有人会说“这人失败了”，而是会探讨下一阶段换什么疗法、看哪个专家。然而在成瘾领域，强烈的污名化（stigma）让患者承受着巨大的个人道德指责： - **孤立无援的恐惧**：成瘾在全球范围内都是最受污名化的社会健康问题之一。 - **求助的高昂代价**：一旦承认自己有问题，人们不仅担心遭受道德审判与标签化，更面临实际风险——例如失去抚养权、失去住房或丢掉工作。 - **无处安放的信任**：那位朋友之所以只能向主持人用耳语的方式倾诉，正是因为社会污名构筑的无形高墙，使得吐露实情需要极大的信任与勇气。 --- ### [01:04:30](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3870s) 令人心碎的真实案例：制度断裂下的无辜牺牲 当被问及职业生涯中是否有令她深感心碎并改变了她的病例时，Dr. Sarah Wakeman 讲述了一位长年与海洛因成瘾抗争的男性的故事。该患者将成瘾作为一种慢性病来管理，曾有过长期状态良好的时期，也有过挣扎反复，但他始终努力保护自己的安全。他生命中唯一的精神支柱是与他同住的母亲。 两人原本相依为命租住在廉租公房（public housing）中，饱受经济脆弱性的困扰。然而，有人发现他违规住在母亲处，这威胁到了母亲继续保留公租房的资格。为了不连累母亲失去唯一的容身之所，他毅然搬了出去，瞬间陷入无家可归的境地。失去住所的巨大压力和孤立感彻底击垮了他，即便此前他有稳定的治疗和亲情联结，不久后他依然被发现独自死在两辆停放的汽车之间，因药物过量离世。Dr. Wakeman 动情地表示，成瘾导致的连锁社会反应夺走了这条本不该逝去的生命，这种深层的制度性无力感，正是驱使她持续为打破壁垒而奋斗的动力源泉。 ### [01:06:16](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3976s) 从源头重塑社会：成瘾预防的关键不在说教，而在韧性与联结 主持人提出一个假设性问题：如果萨拉·韦克曼医生（Dr. Sarah Wakeman）担任美国总统，拥有改变社会结构设计的绝对权力，她会采取哪些“上游”举措来从根本上缓解下游的成瘾症状？韦克曼医生明确指出，最核心的改革必须从生命早期开始，即建立心理韧性与人际联结。长期以来，传统的药物预防往往停留在空洞的宣教层面——例如简单粗暴地告诉孩子“毒品有害”，但事实证明这种恐吓式说教毫无效果。真正行之有效的预防，在于帮助年轻人建立应对逆境的韧性与紧密的情感纽带。 从根本上干预不良童年经历（Adverse Childhood Experiences, ACEs），意味着需要将资源投向那些看似与成瘾毫不相关的社会基础设施。这包括保障经济适用房、修建让青少年能够走出户外运动和社交的公园绿地，以及为面临困境的家庭提供全方位支持，以保障家庭完整与早期健康依恋关系的形成。韦克曼医生强调，唯有通过这种最基础的社会支持，才能打破代际创伤、贫困与物质滥用的恶性循环，这才是真正意义上的源头预防。 ### [01:07:30](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4050s) “老鼠乐园”实验与现代成瘾机制的社会隐喻 谈及环境对成瘾的决定性影响，主持人联想到了著名的“老鼠乐园”（Rat Park）实验。韦克曼医生详细解释了这一经典实验：研究人员最初将大鼠单独关在狭小、贫瘠的铁笼中，剥夺它们的一切社交互动和生活乐趣，笼内设有可自行按压获取吗啡或可卡因溶液的杠杆。在极度孤独与无所事事的绝望环境中，大鼠会频繁按压杠杆疯狂摄入药物，以此寻求短暂的快感与痛苦解脱。 然而，当研究人员将这批大鼠转移到一个设施完善的“乐园”——里面有丰富的游乐设施、攀爬轮、充足的活动空间以及大量同伴时，同样的动物却几乎不再去触碰毒品杠杆。尽管这个实验模型在某些方面被简化了，但它深刻揭示了成瘾的本质：成瘾的核心不仅是生物化学的驱动，更是环境与联结的匮乏。重塑成瘾者周围的社群生态、人际纽带、生活目标感与希望，才是彻底逆转成瘾行为的关键所在。 ```mermaid flowchart TD accTitle: 老鼠乐园实验与现代成瘾对照 accDescr: 对比孤立绝望环境与富足联结环境对成瘾行为的不同影响 subgraph EnvironmentA ["贫瘠孤立环境 (传统笼子 / 现代原子化生活)"] A1["孤立隔绝、缺乏活动"] --> A2["无聊、创伤与情感空虚"] A2 --> A3["频繁按压杠杆/滥用物质寻求代偿"] end subgraph EnvironmentB ["老鼠乐园 (丰富社群 / 情感支持生态)"] B1["宽敞空间、社交同伴与游乐"] --> B2["获得归属感、意义与真实联结"] B2 --> B3["物质需求显著下降、自发停止滥用"] end ``` ### [01:08:42](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4122s) 医疗体系重构：终结惩戒，视成瘾为同等健康问题 针对那些已经陷入物质滥用困境的人群，韦克曼医生提出医疗救治模式必须迎来颠覆性改变。首先，成瘾治疗应当具备高度的即时性与可及性。患者在踏入全科医生诊所或急诊室的那一刻，就应得到基于循证医学的科学治疗和饱含共情的关怀。医护人员应该主动询问“我们能为您提供什么帮助”，并提供立竿见影的干预方案，其接诊流程与关怀标准应当完全等同于面对心血管急症或癌症初诊患者。 与此同时，社会必须彻底终结针对物质使用者的惩罚性司法机制。韦克曼医生直言，当前社会体系存在着严重的认知撕裂：官方话术一边宣称物质成瘾是一种脑部疾病与健康问题，另一边却仍在以吸毒罪名将他们逮捕并送入监狱。将病患关入牢狱与医学救治的逻辑完全背道而驰，这种自相矛盾的制度不仅加剧了社会污名，也进一步摧毁了康复所需的社会联结。 ### [01:09:31](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4171s) 现代都市的“笼中困境”与社群联结的失落 主持人指出，当代都市人其实正普遍生活在“老鼠乐园的第一种模型”之中：人们离乡背井来到大城市，远离原生家庭与亲友，独自居住在狭小的公寓里，从事着高压而异化的工作，身体活动量前所未有地下跌。在这种孤独绝望的环境刺激下，不仅酗酒问题滋生，社交媒体成瘾、暴饮暴食、色情成瘾等不良代偿行为也随之泛滥；反之，健身、健康饮食等积极习惯却难以维持。 韦克曼医生对此表示强烈认同，直言“人类天生就不适合以这种方式生活”。人类演化历程中绝大部分时间都生活在多代同堂的村落与紧密部落之中。她分享了自己养育幼儿的体会：在拥有孩子后，她彻底理解了过去几代人住在一起互帮互助的必要性。而现代社会不仅拆解了大家庭结构，连传统的宗教社群纽带也在逐步消退。她呼吁人们必须主动建立属于自己的“新型部落”，无论通过志愿服务、兴趣社团还是参与体育运动，通过共同热爱的事物重建与陌生人的真实联结，并像重视日常身体健康一样优先捍卫这种情感支持网络。 ### [01:11:20](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4280s) 心理创伤疗愈与“治疗师共情度”的硬核科学 针对早期童年创伤，韦克曼医生坚决支持采用心理治疗，但前提是抛弃以往强制施压的粗暴做法，转向主动建立安全、包容且高质量的治疗环境，以帮助患者剖析最初使用物质的根本原因并抚平深层伤口。更为关键的是，治疗师的专业素质与共情能力直接决定了戒瘾的成败。 韦克曼医生援引了多项严谨的临床研究指出，治疗师是否具备高度的共情心，实际上是预测患者能否成功减少或戒断酒精及毒品的“最强单一预测因子”。许多人常把共情视作可有可无的“软技能”，但数据表明：当患者遇到一位缺乏共情、态度冷漠甚至具有批判倾向的治疗师时，他们在完成整个疗程后的物质滥用量往往反而会上升。因此，建设一支训练有素、具备高度同理心且恪守循证医学的专业心理咨询队伍，在戒瘾防治中具有不可替代的战略价值。 - 研究证实：治疗师的共情程度不仅影响治疗体验，更是决定患者能否减量或停止物质滥用的决定性生物/心理标志。 - 面对低共情度的治疗人员，患者由于感到未被接纳，其复吸或加重滥用的风险会显著上升。 ### [01:12:32](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4352s) 共情是“纵容”还是救赎？爱与支持的真正力量 主持人随后抛出了一个困扰许多亲友的尖锐问题：社会上常有人担忧，过度给予成瘾者无条件的爱、关怀与同理心，会不会演变成一种“病态纵容”（enabling），反而在无形中对成瘾恶习提供了正向强化，导致当事人继续沉沦？ 韦克曼医生对此给出了极具力量的专业澄清：虽然家庭边界与“纵容”概念在某些特定情境下值得探讨，但“爱与支持会导致伤害”这一核心假设本身是极其错误的。在临床一线接触的大量成瘾者中，真正促使他们迈出求医改变第一步的，几乎从来不是某些灭顶之灾般的惩罚后果，而是在他们彻底厌弃自我、陷入无尽绝望的深渊时，依然有人愿意相信他们、关怀他们并施以援手。 韦克曼医生动情地分享了一个真实的病房案例：多年前团队曾救治过一名因注射吸毒而罹患致命严重感染的住院患者。在生死边缘，医护团队没有戴着有色眼镜排斥他，而是每天坐在病床边陪伴他、平等地与他交谈。整整一年后，这名彻底摆脱毒瘾的患者给医疗团队写来了一封真挚的感谢信，并在信中写道，自己永远无法忘记那些身处至暗时刻却被当成正常人对待的对话瞬间。自此之后，每年出院纪念日，他都会向团队发送一封汇报近况的电子邮件。正是这些源自人性的细微善意与深刻联结，给予了绝望者重生的希望，并成为驱动人生彻底转折的核心催化剂。 ### [01:14:04](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4444s) CRAFT模式与积极强化：摒弃对抗式干预 针对家庭成员如何面对成瘾者，莎拉·韦克曼（Sarah Wakeman）介绍了一种极为有效的现代干预工具——CRAFT（Community Reinforcement and Family Training，社区强化与家庭培训）。许多人受到影视作品的影响，总以为干预就该是召集亲友搞一场戏剧性的“摊牌式对质”，逼迫当事人二选一。然而，CRAFT 的逻辑截然不同：它首先帮助家属理解成瘾背后的脑科学机制；其次教会家属如何先照顾好自己、寻求个人支持，因为与成瘾亲人共处极其消耗心力；最后，它指导家属学会建立不同层级的“行为后果”。比如，如果孩子因为吸毒或酗酒而逃学，家长不应为他们撒谎掩盖、变相纵容其行为模式，但也完全不必直接将其扫地出门，合理分级的后果机制才是促成转变的有效杠杆。 促使人类行为改变的最强动力之一往往是“积极强化”（Positive Reinforcement），即对期望看到的健康行为给予及时肯定与奖赏。在成瘾治疗领域，这种方法被称为“相依性管理”（Contingency Management）。韦克曼指出，商业机构与健康保险公司早就深谙此道——比如会员坚持去健身房就能获得现金返还，人们自然会更积极地维持健康生活。人类的行为逻辑在成瘾问题上亦完全适用，但现实中社会与家庭却常常背道而驰，试图通过严酷的惩罚与指责把患者“逼”好，而非奖励并强化那些健康的微小转变。 - **CRAFT 核心三部曲**：科学理解成瘾机制、家属优先自我关怀、设立清晰且有分寸的行为后果。 - **相依性管理（Contingency Management）**：通过具体奖励正面健康行为，以正向反馈替代惩罚式教育。 --- ### [01:15:24](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4524s) 划定边界与自我保护：何时该说“够了” 主持人史蒂芬（Steven）提出了听众中最痛切的疑问：如果身边有人深陷成瘾，家属已经倾注了同理心、提供了无条件支持，甚至联系了戒瘾互助会和心理咨询师，但对方依然顽固拒绝就医，甚至在同住期间偷钱、家暴、破坏生活，家人难道不能说一声“我受够了”吗？韦克曼对此表达了深切的共情，坦言自己作为亲历者完全体会过那种绝望，家属必须先宽容对待自己。她明确强调：**保护自己与放弃幻想是两回事**。 当成瘾者的行为已经对家庭成员的人身安全与心理健康造成严重伤害时，将其请出家门或切断经济支持是完全正当的自我防卫决策。但家属切忌自我欺骗，误以为“把他赶出去露宿街头就能让他痛改前非”。韦克曼剖析了临床医生与家庭成员的本质区别：医生可以做到完全无条件的接纳，无论患者今天是否复吸海洛因或酗酒，医生都可以维持专业诊疗；但作为配偶或依赖父母的孩子，这种无条件接纳不仅不现实，而且可能带来毁灭性的二次创伤。改变永远源于当事人自身坚信“做出改变能让我的生活变得更好”，旁人强加的期望永远无法成为其内驱力。 ```mermaid flowchart TD accTitle: 面对成瘾亲人时的边界设立逻辑 accDescr: 区分自我保护与惩罚性干预的不同出发点及最终应对路径 subgraph Boundaries ["边界决策的本质区分"] A["成瘾者出现攻击、盗窃或持续侵害行为"] --> B{"采取驱逐或物理隔离"} B --> C["自我保护决策<br/>（捍卫自身与家人底线，合理正当）"] B --> D["惩罚改造幻想<br/>（妄图通过制造痛苦逼其清醒，通常失效）"] end subgraph InternalDrive ["改变的底层驱动力"] E["外部强加要求与说教"] -->|引发防御机制| F["抗拒与对抗加剧"] G["发掘自身对更好生活的渴望"] -->|激活内生动机| H["自发启动康复行为"] end ``` --- ### [01:17:48](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4668s) 纠正反射与说教陷阱：为什么好心建议总被抗拒 照顾者和父母往往极易陷入一种名为“纠正反射”（Writing Reflex）的本能反应：自认为拥有更明智的认知和无懈可击的医学建议，忍不住苦口婆心地对患者讲大道理：“你难道看不出这在毁掉你吗？你必须改变！”然而人类的天性对被动接受指令极度排斥，无论建议本身多么正确，只要采用强行灌输的方式，对方的第一反应必然是抵触与防御。韦克曼形象地打了个比方：“就算你非常喜欢吃冰淇淋，如果有人突然把一个冰淇淋硬往你脸上、嘴里怼，你也会本能地后退说：‘等等，我不确定我现在想不想吃这个。’” 因此，有效的沟通必须从“居高临下的教导者”转变为“站在同一战线的盟友”，不再强行拽着马匹去喝水，也不把个人的胜负欲和情感寄托捆绑在对方的每一个选择上。沟通的核心应聚焦于：倾听成瘾究竟给当事人自身带来了哪些切身困扰，并帮助他们看清，一旦改变饮酒或用药习惯，他们自己的现实生活将如何变得更加美好。 --- ### [01:18:46](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4726s) 动机式访谈实战：用倾听撬动改变的“绝地心法” 在临床心理学中，这一转变被称为“动机式访谈”（Motivational Interviewing）。它并非将外界观点强加于人，而是像镜子一样，精准捕捉并提炼对方话语中自发流露的改变意向，将其放大并温和地反馈回去，最终将选择权交还给当事人。为了具象化这种沟通技术，韦克曼与史蒂芬在现场展开了一场生动的即兴角色扮演： 史蒂芬扮演一名起重机操作员，坚称自己早晨喝酒也完全没问题：“我每天都去上班，虽然吃了几次违纪处分，伴侣也离开了我，但我完全掌控得了。”韦克曼没有反驳或指责，而是平静地提炼关键信息反馈给他：“听起来饮酒已经开始给你的工作和亲密关系带来麻烦了。”史蒂芬随即卸下防备，承认自己在吊车上醉酒打瞌睡有多么危险，担心一旦发生严重事故被吊销执照，自己将永远失去这份赖以生存的工作。 韦克曼层层递进地共情其恐惧，强调工作对其人生的重要价值，并引导他展望未来：“对于工作和感情，你接下来的目标是什么？”最终，史蒂芬自发说出了关键转变：“我真的必须把酒戒掉，我渴望找到伴侣并组建家庭，而酗酒正在毁掉这一切。”史蒂芬在复盘时惊叹这种技巧就像“绝地武士的心灵感应（Jedi Mind Trick）”，不着痕迹地把人引向清醒思考；韦克曼微笑着承认，初学者掌握这种不加评判、仅做精准镜像反射的技术确实非常微妙。 - **动机式访谈要诀**： 1. **不反驳防御**：不直接指责对方否认现实，而是倾听弦外之音。 2. **精准镜像反射**：提炼并复述对方所面临的实际危机（如职业安全、关系破裂）。 3. **探寻内在愿景**：引导患者自主陈述核心人生追求（如保住饭碗、组建家庭），让改变的动力完全出自其本心。 ### [01:21:29](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4889s) 动机式访谈的核心技巧：捕捉“改变谈话”与巧妙绕开阻抗 在临床戒瘾与沟通干预中，萨拉·韦克曼博士（Dr. Sarah Wakeman）详细拆解了动机式访谈（Motivational Interviewing）的操作精髓——训练自己的耳朵去识别来访者口中的“改变谈话”（Change Talk）。所谓的改变谈话，就是当事人透露出的任何想要做出调整的微小火花。例如，当事人随口提到“工作上开始收到过失警告了”、“我开始担心在工作场所的安全隐患”，或者“我其实很渴望能有一段稳定的恋爱伴侣”。这些零散的念头，在医生眼中就是极具价值的“金矿”。与此同时，咨询师必须学会完全忽略当事人的“维持现状谈话”（Sustain Talk）——比如“其实没什么大不了的”、“喝酒根本没那么严重”、“我就是改不掉”这类为现状辩护的话语。 韦克曼博士指出，人类大脑存在天然的负面偏见，就像在职场进行绩效考核或收到反馈时，人们往往会死死记住那唯一一条负面批评，而忘掉成百上千句赞美。因此，专业人员必须经过刻意反向训练，过滤掉消极辩解，专心捕捉微小的改变火星。在回应方式上，咨询师充当的不是说教者，而是一面“放大镜式的镜子”：将对方自己说过的话重新反射回去。例如，绝不能直斥“由于工作不安全，你必须戒酒”，而是温和地反映：“你刚才提到，自己开始担心在工位上发生意外事故，这对你而言是一件非常严肃且沉重的事。”通过当事人自己的语言来推动认知前移。 这一策略的另一个关键铁律是“遇到阻抗立即转向”（Pivot）。无论是在诊室讨论戒瘾，还是在日常生活中争论政治或生活琐事，一旦双方陷入正面对峙与争吵，对方就会彻底筑起心防并深挖立场防御。争论的本质很快会演变成“赢得输赢辩论”，而非“寻求共同前进”。因此，一旦察觉对方在抵抗，唯一的做法就是立刻放弃正面交锋，调整战术切入点，绕道而行。 ```mermaid flowchart TD accTitle: 动机式访谈与行为改变路径图 accDescr: 展示如何通过捕捉改变谈话、避开正面阻抗、锚定内在Why并构建上游健康支撑体系 subgraph MI["动机式访谈策略"] A["倾听来访者表述"] --> B{"辨析话语性质"} B -- "维持现状谈话 (Sustain Talk)<br/>'其实没多大影响/我改不了'" --> C["淡化处理 / 不辩论<br/>遇阻抗立刻变轨 (Pivot)"] B -- "改变谈话 (Change Talk)<br/>'担心工作安全/想找伴侣'" --> D["镜态反射与放大<br/>(用当事人原话加深共情)"] end subgraph SelfDrive["行为重塑与锚定"] D --> E["确立核心目的 (Your 'Why')<br/>超越转瞬即逝的表层动力"] E --> F["切分为微观生活目标<br/>(提升晨起精力/高质量陪伴家庭)"] end subgraph UpstreamHabits["上游生态与奖赏替代"] F --> G["筑牢身体基石<br/>(睡眠充足、营养、体能训练)"] G --> H{"健康多巴胺重构"} H -- "积极健康通道" --> I["瑜伽、社交、正念、兴趣爱好"] H -- "警惕替代陷阱" --> J["避免滑入暴饮暴食或换药依赖<br/>(如‘干燥一月’变‘嗨翻一月’)"] end ``` --- ### [01:22:52](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4972s) 自我改变的法则：从抽象动机到具象的“Why”与个性化微目标 面对主持人关于“如果一个人想要自发做出改变，是否存在一套系统方法来确立行为、找到内在动力”的提问，韦克曼博士将重心放在了核心动机——“你的Why（为什么而做）”上。她直言，人们常常把“动力”（Motivation）挂在嘴边，但动力极其善变脆弱，往往在一天之内就会大起大落。以健身为例，一个人前一天晚上可能雄心勃勃、动力爆棚，但第二天清晨5点闹钟响起时，被窝温暖舒适，前一晚又睡得偏晚，那一刻所谓的动力就会荡然无存。如果缺乏真正根植于心底的终极目标或核心原因，根本不可能调动起身心能量去执行改变。 在重塑习惯时，空洞宏大的目标（如“医生说喝酒有害健康，所以我应该戒酒”）几乎注定会失败，因为这种抽象建议与个人的实际生活毫无情感连接。有效的改变需要将“Why”拆解为极其具体、能带来即时正反馈的微观目标： - 意识到每晚饮酒会导致晚餐后昏昏欲睡，无法完成当天预期的工作。 - 饮酒严重破坏睡眠质量，导致次日清晨头脑昏沉、缺乏活力。 - 宿醉让人无法在清晨按计划起床进行跑步或马拉松训练。 - 饮酒夺走了晚餐后全心全意陪伴家人与孩子的高质量时间。 当一个人把目标细化为“为了工作更有成效、为了晨跑更有活力、为了早晨醒来精神饱满，我决定每周只喝两天，且严格限制饮用量”时，他在清晨醒来感到神清气爽的那一秒，目标就已经得到了即时正向强化，而不是在为了遥不可及的体检指标受折磨。 韦克曼博士还特别提到了个体差异的客观存在： - **“薯片效应”**：有的人打开一包薯片，只吃两片就能从容封上放回柜子；但有的人只要撕开包装，就必然会把整包吃光。对于后者而言，逼迫自己“只吃两片”是对意志力的残酷消耗，最轻松的策略是干脆不买、不把薯片带回家。 - **酒精环境控制**：对待酒精也是同理。部分人一旦开了一瓶红酒或家里有存酒，就很难浅尝辄止。对于这类人群，试图练习“微量自律饮酒”极其费力，完全戒断或将饮酒场景严格限定在无存酒诱惑的餐馆聚会，反而是阻力最小的明智方案。 --- ### [01:25:52](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5152s) 行为改变的上游习惯：填补奖赏真空与警惕“替代性成瘾” 主持人引入了“河流上下游”的比喻：如果将饮酒视为最下游的表现，那么在河流的上游，究竟有哪些习惯和绝缘层（如社交连接、压力缓冲）是发起生活变革前必须提前布局的？ 韦克曼博士强调，任何重大行为决策的改变都不能在“能量耗尽”（Depleted）的状态下进行。没有人会在极度疲惫、焦虑缠身、身心处于最差状态的那天，去成功启动换工作、开始高强度锻炼或结束一段不合适恋情的计划。改变本身需要消耗大量心理与生理资源，因此在上游必须首先筑牢身体基础：保证充足睡眠、摄入均衡营养、开展规律运动，让自己维持在精力充沛的峰值状态。 从神经生物学角度看，酒精与成瘾性药物往往劫持了人类的奖赏回路，被很多人下意识当成辛苦工作一天后“犒劳自己、缓解压力”的捷径。因此，戒除饮酒绝不能靠“硬抗咬牙”（White-knuckling）生熬——如果只是强行拿走酒精，下班后留在空荡荡房间里承受孤立无援的压力，改变注定无法持久。大脑的天然多巴胺释放源自运动、健康美食、性与人际连接。真正的解决策略是在抽走酒精的同时，主动“填满留下的真空”： - 约朋友去上一节瑜伽课 - 享受一段高质量的家庭时光 - 进行冥想、做一次身体按摩，或是沉浸式看一部喜欢的剧集 针对主持人调侃“如果我用哈根达斯（Häagen-Dazs）冰淇淋和汉堡来替代酒精获取多巴胺是否可行”时，韦克曼博士提出了对“行为替代陷阱”的警示。临床上最典型的例子就是流行于欧美社会的“干燥一月”（Dry January，倡导整个1月不饮酒）：近期许多调研报道显示，“干燥一月”在很多人身上悄然变成了“嗨翻一月”（High January），因为他们只是把酒精替换成了大量吸食大麻。 韦克曼博士总结道，偶尔吃个冰淇淋作为犒赏、替代酒精空热量本身无伤大雅，但必须警惕从一种损害健康的成瘾习惯滑入另一种同样带来健康风险的物质滥用。人类对待酒精的态度，应当像对待甜点、日光浴或加工肉类一样客观看待：明确认识到它们兼具短暂的愉悦与实质的健康风险，在充分权衡利弊后做出清醒自主的选择，而非逃避现实的无意识代偿。 ### [01:28:43](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5323s) 破除酒精“促进健康”的迷思与商业决策聚焦 莎拉·韦克曼医生（Dr. Sarah Wakeman）指出，公众在饮酒问题上走入的最大误区，就是把饮酒当成一种“能够促进健康的行为”（health-promoting behavior）。她直截了当地强调，人们绝对不应该为了身体健康去喝酒，酒精绝不会让身体变得更健康。然而，就像生活中许多不利于健康但大家依然会做的事情一样，医学界的目标是帮助人们找到减少伤害的方法，使其在微量摄入时对生活的影响处于可接受范围内。 ```mermaid flowchart LR accTitle: 创伤、保护因素与大脑康复机制 accDescr: 展示童年经历、神经反应差异以及长期康复如何塑造大脑并最终重塑成瘾风险的路径图。 subgraph EarlyStage["早期经历与生理易感性"] A["童年逆境经历 (ACEs)"] --> B{"保护因素介入"} B -- "缺乏支持 / 神经回路改变" --> C["高成瘾易感性"] B -- "积极童年经历 (PCEs)<br/>如单一关爱成年人" --> D["显著阻断成瘾风险"] C --> E["初次摄入物质产生极强快感<br/>（如‘坠入爱河’般温暖）"] end subgraph RecoveryStage["戒断与大脑重塑"] E --> F["多次反复与渐进式断瘾<br/>('Progress not perfection')"] F --> G["神经可塑性修复回路"] G --> H["持续康复满 5 年<br/>复发风险降至常人水平"] end ``` 随后节目切入赞助商环节，史蒂文·巴特利特（Steven Bartlett）分享了自己在 B2B 营销中汲取的教训。他谈到，许多营销人员常犯的错误是“一味追求曝光量而非精准质量”，试图触达更多人却忽略了找对人，最终只是制造了昂贵的行业噪音。巴特利特以自身经历为例，推荐了职场社交平台 LinkedIn 广告，指出该平台汇聚了真正拥有决策权和购买力的高管，支持按职位头衔、行业及公司规模进行精准触达，并为听众提供了 100 美元的广告体验金。 ### [01:30:07](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5407s) 大脑的可塑性与康复奇迹：五年后风险降至普通人水平 史蒂文顺着前文的讨论抛出一个普遍的困惑：如果一个人的童年创伤已经从物理和生理结构上改变了大脑，导致其年轻时酗酒成瘾，即便后来成功戒酒，大脑是否仍然是一颗“处于成瘾状态的大脑”？这是否意味着他终究会不可避免地转向另一种能够带来多巴胺刺激的成瘾物？韦克曼医生的回答给出了强有力的科学希望——人类大脑具备极强的大脑神经可塑性（neuroplasticity），它会随着时间和经历不断重塑，早期的创伤绝非终身不可逆转的判决。 韦克曼医生特别强调，医学界不仅要关注“童年逆境经历”（ACEs, Adverse Childhood Experiences），更要关注“积极童年经历”（PCEs, Positive Childhood Experiences）。临床数据显示，即便孩子遭受了极度严重的变故（如父母离世、亲人入狱或家庭成员成瘾），只要童年期能有“哪怕一位真正关心他们的成年人”，就能形成强大的心理缓冲，大幅扭转神经发育轨迹，降低未来发生物质使用障碍的概率。针对已经确诊物质使用障碍的人群，科学界已有确凿的长期追踪与脑功能成像研究：戒瘾并非一蹴而就的“全有或全无”，而是一个充满反复但螺旋上升的过程。只要坚持迈进，数据证明在进入康复状态满 5 年后，该个体未来再次发生成瘾的风险将回落到与普通大众完全相同的基准水平。 - **阶段性进步而非完美主义**：戒瘾过程往往充满停滞与反复（fits and starts），患者可能先是戒断 1 个月，下一次达成 3 个月，再迈向 1 年，关键在于坚持“进展而非完美”（progress not perfection）的心态。 - **5 年康复分水岭**：脑功能成像与纵向队列研究证实，经过 5 年的持续康复，成瘾重塑的神经环路完全能够重新平衡，成瘾易感性不再高于未曾成瘾的普通人群。 - **保护性纽带的力量**：单单一笔来自成年人的真诚关爱，就足以在儿童面对严重创伤时构成抵御神经损伤的核心屏障。 ### [01:32:12](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5532s) 真的存在“成瘾性人格”吗？神经生物学带来的感受差异 许多习惯自我贴标签的人常挂在嘴边一句话：“我天生就是成瘾性人格（addictive personality）”，甚至坚信自己的大脑天生就对各种事物容易上瘾。韦克曼医生澄清，严格从医学角度来看，并不存在所谓的“成瘾性人格”，真正起决定作用的是每个人面对外界化学物质时截然不同的“神经生物学反应”（neurobiology）。 这种生物学差异往往在人生中第一次尝试某种物质时就暴露无遗。韦克曼医生分享道，那些后来深陷成瘾泥潭的患者在回忆初次接触酒精或阿片类药物时，通常会描绘出极为惊艳的体验——有人形容那感觉就像“坠入爱河”（falling in love），有人觉得像“被温暖地拥抱”（a warm hug），或如同泡在彻底放松的热水澡里，带来无与伦比的心灵慰藉。相反，普通人因拔牙被开具阿片类止痛药时，往往只会感到恶心头晕、浑身不适，迫不及待想要停药。基因与脑回路构造确实让一部分人天生处于成瘾的高危区，但这并不是一种性格缺陷，而是一份生理健康警报。认清自己的这种生理特质，能帮助个体在日常生活中做出更有防御性的决策，例如坚决不在家中存放任何酒精。 ### [01:33:20](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5600s) 行为成瘾与不可言说的创伤：深渊般的童年秘密 史蒂文将话题引申至当下席卷现代社会的非物质成瘾现象，如社交媒体成瘾、色情成瘾、暴食、性瘾以及赌博成瘾。韦克曼医生指出，尽管行为成瘾并非她的主要研究专项，但两者的底层神经机制高度重合。无论是刷手机还是滥用药物，一方面是外源性刺激对多巴胺奖赏回路的劫持，另一方面则是人们试图借此外在手段填补内心的巨大空洞——那些未经处置的心理创伤、未被治疗的精神疾患，以及意义感、奖赏机制与人际联结的彻底缺位。 当史蒂文询问在过往临床经历中，是否有患者深藏的创伤根源彻底出乎意料时，韦克曼医生讲述了一位令她心碎的病患案例。这位男性患者一生都在与严重的阿片类药物、酒精和可卡因滥用作斗争，曾经历过父母双亡和铁窗生涯。韦克曼医生为他诊治多年，深知他经历坎坷，却始终未能触碰其痛苦的真正核心。直到相识数年后的一天，这名男子在诊室里彻底崩溃大哭，终于吐露了尘封几十年的秘密——他在幼年时期曾遭受严重的性侵犯（molested as a young kid）。韦克曼医生动容地表示，这种一辈子不敢对任何人言说的秘密，不仅带来了童年创伤本身的撕裂，更让患者长期背负着“自己是残缺损坏的”耻辱感，在内心深处汇聚成无法愈合的痛苦深渊。遗憾的是，这位背负沉重秘密的患者最终未能战胜成瘾，因物质滥用过量离世。 ### [01:35:24](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5724s) 在频繁的告别中坚守：全美2400万康复者的希望之光 史蒂文敏锐地捕捉到了成瘾医学医生的职业重负：面对的几乎全是坏消息，更残酷的是，许多走向生命终点的患者所面临的死亡，在医学上本都是完全可以预防的。面对这种常人难以承受的心理耗竭，韦克曼医生坦言支撑自己日复一日重返临床一线的，恰恰是医学中极其罕见的巨大希望与生命逆转。 韦克曼医生指出，她的脑海中不仅有那些逝去的身影，更有大量正在过着精彩、充满活力生活的康复者。仅在美国本土，目前就有高达 2400 万人处于长期康复状态（living in recovery）。这些从家庭分崩离析、身体机能衰竭的绝境中挣脱出来的人，如今重新成为尽职的父母、出色的职场骨干，平静地融入日常社会。韦克曼医生感慨道：“在整个医学领域中，没有任何一门专科能让我见证如此具有戏剧性、如此翻天覆地的转变。”看到一个人从面临全身脏器衰竭、家庭破裂的谷底一步步康复，重获新生，是行医过程中最美丽、最动人的体验，正是这份蕴藏在绝望之中的坚韧生机，支撑着她抵御所有的阴霾。 ### [01:36:46](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5806s) 医者的自我关怀与被忽视的核心议题：语言的力量 在谈及如何应对高压且沉重的成瘾临床工作时，萨拉·韦克曼（Dr. Sarah Wakeman）分享了自己保持内心完整与韧性的方式。她通过家庭陪伴、人际联结、跑步锻炼和写作来照顾自己的身心状态；而从患者身上看到康复的希望，则是她职业生涯中源源不断的动力来源。 紧接着，主持人史蒂芬·巴特利特（Steven Bartlett）抛出了一个关键问题：“在今天的所有讨论中，有什么最重要但我们尚未触及的话题？”萨拉毫不犹豫地指出了“语言”（Language）。她强调，社会上普遍使用的成瘾词汇，表面看似只是文字游戏或政治正确（politically correct），实则在潜移默化地加剧针对成瘾者的社会污名化，甚至直接影响到专业临床决策与司法干预。 ### [01:37:24](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5844s) 语言对成瘾污名化与临床决策的实证影响 萨拉指出，“物质滥用”（Substance abuse）中的“滥用”（abuse）一词在古英语中意为“蓄意的恶行”（a willful act of misconduct）。在现代语境下，它几乎专门用于“虐待儿童”（child abuse）、“性侵/虐待”（sexual abuse）或“家庭暴力”（domestic abuse）等极具暴力色彩、带有强烈道德谴责的故意犯罪行为。然而，当医学界和公众将成瘾这一健康疾病称为“滥用”时，便在潜意识中将其等同于故意作恶。 实证研究深刻揭示了这种用词的破坏性： - **针对专业临床医生的研究**：在向受过高度专业训练的心理学博士和资深临床医生呈现虚构患者病例时，仅仅改变描述用词——一组称为“物质滥用者”（substance abuser），另一组称为“患有物质使用障碍的人”（person with a substance use disorder）——结果显示，看到“物质滥用者”标签的医生更倾向于推荐具有惩罚性质的处理方式（如送往禁毒法庭或关入监狱），而非提供科学有效的外部门诊治疗。 - **针对普通公众的研究**：当被告知对方是“吸毒成瘾者”（drug addict）时，公众的负面态度显著高于被告知对方是“患有成瘾症的人”（person with addiction）。 ```mermaid flowchart LR accTitle: 语言标签对临床决策与公众态度的影响 accDescr: 对比传统贬抑标签与以人为本语言在专业决策和公众态度上的不同后果。 subgraph Stigmatizing["贬抑性标签"] A1["'物质滥用者'<br/>(Substance Abuser)"] A2["'吸毒成瘾者'<br/>(Drug Addict)"] end subgraph PersonFirst["以人为本语言"] B1["'物质使用障碍患者'<br/>(Person with substance use disorder)"] B2["'患有成瘾症的人'<br/>(Person with addiction)"] end subgraph Impact["现实后果"] C1["倾向惩罚手段<br/>(入狱/惩罚性司法)"] C2["医学同理心与支持<br/>(科学门诊治疗/包容)"] end A1 --> C1 A2 --> C1 B1 --> C2 B2 --> C2 ``` ### [01:38:44](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5924s) “以人为本的语言”：从“成瘾者”到“患有成瘾的人” 萨拉指出，现代医学正全面转向“以人为本的语言”（Person-first language）。在过去的医疗环境中，医生常犯下以疾病代指人的错误，例如粗暴地称呼患者为“那个精神分裂症患者”（the schizophrenic），甚至在交接班时说“去看看204病房的肺癌”。文明与医学的进步让人们认识到：患者首先是一个人，其次才是患有某种疾病。正确的表达应该是“患有肺癌的史密斯先生”。 成瘾领域同样亟需这种转变，应当淘汰“成瘾者”（addict）或“酗酒者”（alcoholic）等将疾病直接标签化为人格的词汇，改用“患有成瘾的人”（person with addiction）或“酒精使用障碍患者”（person with alcohol use disorder）。 此外，成瘾康复领域常用的“干净”（clean）与“肮脏”（dirty）同样具有极强的隐形羞辱： - 当赞扬某人“你现在变干净了（戒断了）”时，反面潜台词即是“你过去受成瘾折磨时是肮脏的”。 - 萨拉分享了一位处于康复期的朋友在求职时的幽默回击：当面试官询问“你干净多久了？”时，他回答：“我从刚出生就开始洗澡，所以我这辈子一直很干净；至于康复阶段，我已经持续五年了。” - 史蒂芬坦言，尽管自己深知这一道理，在日常交流中仍会不自觉脱口而出“abuse”或“addict”等词，这表明打破旧有语境惯性需要极大的警惕与持续练习。 ### [01:41:30](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=6090s) 标签如何囚禁个人潜能与成瘾的多样结局 史蒂芬将这一现象延伸至日常生活中的自我暗示。他分享了前一晚与团队聚餐时的亲身经历：他脱口说出“我不擅长那个”或“我是一个没有条理的人”，但随即意识到这种言语是在将自己本质化地定义为“无能”，于是立刻纠正为“我目前正在努力提升条理性”。他提出：当我们用“成瘾者”去定义一个人时，是否同样是在用一种永久性的缺陷囚禁了对方的完整人格？ 萨拉对此深表赞同。将某人固化为“成瘾者”，等于宣判他永远只能是这样。她引用了曾有成瘾经历的著名记者兼作家玛雅·扎拉维茨（Maia Szalavitz）在《纽约时报》上发表的观点——“成瘾并不总是伴随一生”（Addiction doesn't always last a lifetime）： - 公众普遍存在一种认知偏差，认为成瘾是一旦患上就终生无法摆脱、绝无可能治愈的死刑。 - 实际上，成瘾的轨迹各不相同：对一部分人来说，它是一段通过治疗与应对后即可彻底走出的生命阶段；对另一些人而言，它需要长期的主动管理。但无论如何，如果一个人在世上的全部身份被简化为“成瘾者”，其发展其他潜能的空间就会被彻底扼杀。 ### [01:43:05](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=6185s) 前任嘉宾提问：重温成就与“活在当下”的医者感悟 节目录制尾声，史蒂芬提出了节目的传统压轴环节：由上一位匿名嘉宾留给下一位嘉宾的问题——“如果你可以重新经历或修正一项你已经成功实现的事情，那会是什么？为什么？” 萨拉给出了一个充满深情的答案：**重新经历她的医学规培与训练生涯（Medical Training）**。 - 她坦言，在追求成功的过程中，人们往往全力以赴冲向终点线、忙于应付下一场考试或达成下一个目标，却忽视了旅程本身的壮美。 - 萨拉回忆道，尽管她从未打算成为一名心脏外科医生，但年轻时站在手术室里、亲眼望进打开的胸腔观察一颗活生生跳动的心脏，是此生不可多得的震撼体验。 - 她感慨，若能重来，她希望能更加“身临其境”（be more present），不因一味赶路而错过眼前真实发生的生命奇迹。这一感悟让史蒂芬深感共鸣，直呼“这也正是对我们所有人的当头棒喝”。 ### [01:44:19](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=6259s) 厘清酒精真相与应对未来的成瘾危机 主持人对莎拉·韦克曼医生（Dr. Sarah Wakeman）的卓越贡献表达了由衷的敬意与感谢。他坦言，在过去的五到十年中，公众领域充斥着各种彼此矛盾的信息，特别是关于酒精对人体到底有何影响。主持人提到，自己过去曾坐在录音室里与多位嘉宾对谈，其中甚至有人坚信“适量饮酒对身体有益”。但在读过莎拉医生的研究和著述之后，他终于看清了这一领域的科学真相。他指出，随着当前社会孤独感蔓延成灾（loneliness epidemic）、数字设备的无孔不入，以及人们能够以极低成本轻易接触到各类成瘾物质，未来成瘾问题只会变得愈发严峻，而莎拉医生所做的工作也将发挥越来越关键的作用。 莎拉医生随后透露了自己的新书计划。主持人原本以为新书将在下个秋天面世，莎拉医生纠正道，该书预计于2027年春季出版。当被问及新书的核心主题时，莎拉医生表示，该书旨在“彻底改变围绕成瘾的社会叙事”，重构公众对成瘾的认知框架——让大家意识到这其实是一种“可治愈、预后良好（treatable good prognosis）的疾病”。她将通过讲述自己有幸接触并结识的患者故事，帮助大众从全新的视角来看待这一疾病与受其困扰的人群。 - **获取科学真相**：澄清了坊间关于“适量饮酒有益健康”的流行误区，以扎实的医学依据揭示酒精的真实危害。 - **时代背景的紧迫性**：全球性的孤独流行病与廉价成瘾物、数字设备的普及，使成瘾防治面临前所未有的挑战。 - **新书展望（2027年春季）**：打破污名化，通过真实患者的经历与医学观察，展现成瘾作为一种可治疗疾病的希望与可能性。 ### [01:45:33](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=6333s) 建立联结与结语 在访谈的尾声，主持人询问听众如何能够联系到莎拉医生或了解更多信息。莎拉医生表示非常乐意与大家交流，听众可以通过 LinkedIn、Instagram 关注她，也可以直接通过电子邮件进行沟通，并表示非常期待新书出版后再回访节目。主持人确认会将她的社交媒体主页链接附在节目说明中，并坦言由于成瘾问题在许多人的生活中既沉重又充满强烈的情感冲击，莎拉医生的收件箱大概率会被大量求助和咨询信息填满。主持人代表全体听众由衷感谢莎拉医生今天倾囊相授的智慧与慷慨分享。 访谈结束后，主持人面对镜头向长期收听节目的听众分享了一组数据：常听节目的听众中有 53% 尚未点击订阅。他真诚地请求大家举手之劳支持播客——只需点击免费的“订阅”按钮，而他和团队的承诺则是全力以赴持续提升每周节目的品质，认真倾听听众的反馈，邀请大家渴望听到的各领域专业嘉宾，不断产出深度内容。 ## Notable quotes > [03:29](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=209s) 如果你认为他们只是在做坏事，你又怎么会认为他们理应获得医疗照顾，或者用善意与同理心去对待他们？ — 萨拉·韦克曼 > [10:11](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=611s) 创伤才是真正的入门毒品。 — 萨拉·韦克曼 > [14:19](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=859s) 成瘾的反义词不是清醒戒断，而是联结。 — 萨拉·韦克曼 > [20:32](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1232s) 如果家人生了癌症，你绝不可能因为他们生病就拒绝花时间陪伴他们……在那种非黑即白的模式下，我们忘却了与成瘾搏斗的人本质上依然是风趣、善良、充满爱意的鲜活个体，他们只是生病了。而那些失去的时光，我再也无法找回了。 — 萨拉·韦克曼 > [22:47](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1367s) 唯有当保持现状的痛苦超越了做出改变的痛苦时，改变才会真正发生。 — 史蒂芬·巴特利特 > [28:05](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=1685s) 我绝不会说饮酒对你的健康有益。 — 萨拉·韦克曼 > [38:43](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2323s) 这就像烤松饼或做蛋糕。如果你在把面糊推进烤箱前发现自己忘了加鸡蛋，你随时可以补打鸡蛋搅拌均匀，烤出来的蛋糕依然完美；但如果松饼已经在烤箱里烤熟定型了，你才想起来没放鸡蛋，这时候把生鸡蛋浇在烤熟的松饼表面，就无论如何也回天乏术了。 — 萨拉·韦克曼 > [48:57](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=2937s) 这就像拿一杯水往里面滴红墨水。体内的水分越多，酒精扩散稀释的范围就越广，血液酒精浓度也就越低。 — 萨拉·韦克曼 > [01:02:14](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=3734s) 不是他失败了，而是治疗辜负了他。 — 萨拉·韦克曼 > [01:17:48](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=4668s) 就算你非常喜欢吃冰淇淋，如果有人突然把一个冰淇淋硬往你脸上、嘴里怼，你也会本能地后退说：‘等等，我不确定我现在想不想吃这个。’ — 萨拉·韦克曼 > [01:35:24](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5724s) 在整个医学领域中，没有任何一门专科能让我见证如此具有戏剧性、如此翻天覆地的转变。 — 萨拉·韦克曼 > [01:38:44](https://www.youtube.com/watch?v=Fg7U-BhiZGE&t=5924s) 我从刚出生就开始洗澡，所以我这辈子一直很干净；至于康复阶段，我已经持续五年了。 — 萨拉·韦克曼 ## Mentioned 萨拉·韦克曼 (Dr. Sarah Wakeman), 史蒂芬·巴特利特 (Steven Bartlett), 哈佛医学院 (Harvard Medical School), 麻省总医院布莱根医疗系统 (Mass General Brigham), 精神疾病诊断与统计手册 (DSM), 不良童年经历研究 (ACEs), 老鼠乐园实验 (Rat Park), 辛克莱方法 (The Sinclair Method), CRAFT模式 (社区强化与家庭培训), 相依性管理 (Contingency Management), 动机式访谈 (Motivational Interviewing), GLP-1 受体激动剂 (Ozempic / Wegovy), 纳曲酮 (Naltrexone), 裸盖菇素 (Psilocybin), 伊博格碱 (Ibogaine), 利亚姆·佩恩 (Liam Payne), 大卫·辛克莱 (David Sinclair), 玛雅·扎拉维茨 (Maia Szalavitz), 纽约时报 (The New York Times), 领英 (LinkedIn) ## Video description Are you unknowingly damaging your brain and raising your cancer risk with just one drink? Discover the alarming truth about alcohol from Dr. Sarah Wakeman, what every adult needs to know now. Dr. Sarah Wakeman is a senior medical director for substance use disorder at Massachusetts General Brigham Hospital, the number one research hospital in the world. She is also the Medical Director of the Mass General Hospital Addiction Consult Team and Assistant Professor of Medicine at Harvard Medical School.  She explains:  ▫️How alcohol is hijacking your dopamine system. ▫️Why no amount of alcohol is good for your brain. ▫️The shocking truth about moderate drinking. ▫️How doctors are failing addiction patients on a daily basis. ▫️Why 1 in 3 people will struggle with alcohol. 00:00 Intro 02:13 Sarah's Mission 02:42 Sarah's Education and Experience 03:29 Issues With Addiction Treatment in the Modern World 04:20 What Is Addiction? 05:37 What Things Are Capable of Being Addictive? 06:36 Physiological Dependence vs. Addiction 07:15 Scale of the Problem: Why Should People Care? 08:49 Is Society Getting Better or More Addicted? 09:22 Substance-Related Deaths During the Pandemic 10:11 What Drives People to Use Substances? 12:13 Substances' Effects on the Brain 14:19 Does Trauma at a Young Age Increase Addiction Risk? 16:26 The Opposite of Addiction Is Connection 18:01 Why Addiction Matters to Sarah 18:51 Living With a Family Member Struggling With Addiction 20:33 Who Is Sarah Trying to Save? 22:47 Change Happens When the Pain of Staying the Same Is Greater Than the Pain of Change 25:42 Misconceptions About Alcohol 28:05 Is There a Healthy Level of Alcohol Consumption? 28:40 Is One Drink a Day Safe for Health? 30:28 Link Between Moderate Drinking and Cancer 33:13 Types of Cancer Linked to Alcohol Consumption 34:41 Cancer Risk Among Heavy Drinkers 35:21 Heavy Drinking and Comorbidities as Cancer Risk Factors 36:10 How Alcohol Drives Cancer Mechanisms 37:49 Alcohol and Weight Gain 38:43 The Role of the Liver 41:57 Liver's Ability to Regenerate 43:42 What Else Damages the Liver Besides Alcohol? 44:21 How Much Alcohol Causes Liver Damage? 45:17 Alcohol's Impact on the Brain 46:27 How Alcohol Causes Brain Deterioration 47:13 Other Organs Affected by Alcohol 47:50 Alcohol's Impact on the Heart 48:57 Body Fat Percentage and Alcohol Tolerance 49:55 Does High Alcohol Tolerance Prevent Organ Damage? 50:36 What Is a Hangover? 52:03 Balancing the Risks and Benefits of Alcohol 53:36 Is Rehab Effective for Addiction? 56:40 Psychedelic Therapy for Addiction 57:26 GLP-1 Medications for Addiction Treatment 58:52 Ads 59:49 Sarah's Reaction to Celebrity Addictions 1:02:14 Stigma Around Addiction 1:04:30 Addiction Cases That Broke Sarah's Heart 1:06:16 How Society Should Change to Reduce Addiction 1:07:30 What Is Rat Park? 1:12:32 Is Empathy Positive Reinforcement for Addicted Individuals? 1:15:24 Setting Boundaries With an Addicted Person 1:18:46 Motivational Interviewing to Support Recovery 1:22:08 Finding Motivation for Positive Change 1:25:52 Habits to Support Addiction Recovery 1:29:02 Ads 1:30:07 Can the Brain Recover From Addiction? 1:33:59 Non-Substance Addictions 1:34:45 Unexpected Sources of Addictive Behavior 1:35:24 How Sarah Copes With Difficult Addiction Cases 1:37:00 Importance of Language Around Addiction 1:41:30 How Labels Limit People's Potential 1:43:47 Question From the Previous Guest You can find out more about Dr. Sarah’s profile, here: https://bit.ly/4mxu191 👀 28.05.2025. Be the first to know: https://bit.ly/circle-youtube Ready to think like a CEO? Gain access to the 100 CEOs newsletter here: bit.ly/100-ceos-newsletter The 1% Diary is back - limited time only: https://bit.ly/3YFbJbt The Diary Of A CEO Conversation Cards (Second Edition): https://g2ul0.app.link/f31dsUttKKb Get email updates: https://bit.ly/diary-of-a-ceo-yt Research document: https://stevenbartlett.com/wp-content/uploads/2025/05/DOAC-Dr-Sarah-Wakeman-Independent-Research-further-reading.pdf Follow Steven: https://g2ul0.app.link/gnGqL4IsKKb Sponsors: Ekster - https://partner.ekster.com/DIARYOFACEO with code DOAC Linkedin Ads - https://www.linkedin.com/DIARY [Source](https://www.youtube.com/watch?v=Fg7U-BhiZGE)

[3:29] 萨拉·韦克曼: 如果你认为他们只是在做坏事，你又怎么会认为他们理应获得医疗照顾，或者用善意与同理心去对待他们？ [10:11] 萨拉·韦克曼: 创伤才是真正的入门毒品。 [14:19] 萨拉·韦克曼: 成瘾的反义词不是清醒戒断，而是联结。 [20:32] 萨拉·韦克曼: 如果家人生了癌症，你绝不可能因为他们生病就拒绝花时间陪伴他们……在那种非黑即白的模式下，我们忘却了与成瘾搏斗的人本质上依然是风趣、善良、充满爱意的鲜活个体，他们只是生病了。而那些失去的时光，我再也无法找回了。 [22:47] 史蒂芬·巴特利特: 唯有当保持现状的痛苦超越了做出改变的痛苦时，改变才会真正发生。 [28:05] 萨拉·韦克曼: 我绝不会说饮酒对你的健康有益。 [38:43] 萨拉·韦克曼: 这就像烤松饼或做蛋糕。如果你在把面糊推进烤箱前发现自己忘了加鸡蛋，你随时可以补打鸡蛋搅拌均匀，烤出来的蛋糕依然完美；但如果松饼已经在烤箱里烤熟定型了，你才想起来没放鸡蛋，这时候把生鸡蛋浇在烤熟的松饼表面，就无论如何也回天乏术了。 [48:57] 萨拉·韦克曼: 这就像拿一杯水往里面滴红墨水。体内的水分越多，酒精扩散稀释的范围就越广，血液酒精浓度也就越低。 [62:14] 萨拉·韦克曼: 不是他失败了，而是治疗辜负了他。 [77:48] 萨拉·韦克曼: 就算你非常喜欢吃冰淇淋，如果有人突然把一个冰淇淋硬往你脸上、嘴里怼，你也会本能地后退说：‘等等，我不确定我现在想不想吃这个。’ [95:24] 萨拉·韦克曼: 在整个医学领域中，没有任何一门专科能让我见证如此具有戏剧性、如此翻天覆地的转变。 [98:44] 萨拉·韦克曼: 我从刚出生就开始洗澡，所以我这辈子一直很干净；至于康复阶段，我已经持续五年了。

[0:00] Dr. Sarah Wakeman: The amount of alcohol it takes to begin to cause health-related problems is much lower than you think. [2:13] Dr. Sarah Wakeman: My mission is really to change the way people think about and understand alcohol and drug problems, and also to give people the evidence and the facts. [27:38] Dr. Sarah Wakeman: Don't fool yourself into thinking that drinking that glass of wine is like going to exercise for 30 minutes. 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. [30:28] Dr. Sarah Wakeman: There's really sort of no safe amount of alcohol when it comes to breast cancer. [41:38] Dr. Sarah Wakeman: You could actually cut out 80% of the liver and it would regrow itself... But once you pass that point into scar tissue, the liver can't regenerate anymore... We're seeing younger and younger people coming in in liver failure. People in their 20s coming in in fulminant liver failure from alcohol and then dying in the hospital. [48:57] Dr. Sarah Wakeman: A hangover isn't just about being dehydrated... It is sort of that sequelae of your brain essentially being bathed in this ethanol, and then as it leaves, you just feel totally crappy. [52:03] Dr. Sarah Wakeman: a molecule of ethanol is not more moral or immoral than a molecule of glucose [59:49] Dr. Sarah Wakeman: When I read the headlines of someone dying, to me, it's gutting and heartbreaking... mostly that it was a totally preventable death. Really, no one should die from a substance-related death. [62:14] Friend of Steven Bartlett: I'm in so much pain [81:34] Dr. Sarah Wakeman: Man, your job sounds really important to you, and alcohol's starting to get in the way of that. [97:00] Dr. Sarah Wakeman: Words actually influence how we think, even how we make clinical decisions.

[0:00] the amount of alcohol it takes to begin [0:01] to cause health rellated problems is [0:03] much lower than you think. Okay. So, if [0:04] I have this glass of wine every day, [0:07] you'd be in what we call moderate risk, [0:08] which is associated with pretty much [0:10] every form of cancer. So, say that I'm [0:12] drinking If you're drinking two of those [0:13] glasses, we're talking like a 40% [0:15] increase. But even drinking that amount, [0:17] your risk of breast cancer would [0:18] increase by about 5%. This amount. Mhm. [0:20] Which for many people is very normal. [0:22] So, there's a lot of misinformation out [0:24] there about how much should you drink, [0:25] which I think people don't know, but I [0:27] can take you through everything. So, Dr. [0:29] Sarah Wakeakeman is a Harvard professor [0:31] and addiction expert leading the charge [0:33] against one of the biggest public health [0:34] crises of our time, addiction. Bringing [0:36] facts, empathy, and hard-earned truth. [0:38] One in three people may have a problem [0:40] with alcohol at some point in their [0:41] lives. And globally, 2.6 million people [0:43] every year die from alcohol-related [0:45] causes because pretty much every organ [0:47] in the body is impacted by it. You can [0:49] see here, this is a 43year-old person [0:51] where their brain looks the way a [0:52] 90-year-old with dementia would look [0:54] because of that brain damage over time [0:56] from alcohol use. But what drives people [0:58] to use substances? It's probably the [0:59] most important question and if we look [1:01] at studies, one is about 40 to 60% [1:03] genetics. And the other half of the [1:05] equation is trauma. And so we hear [1:07] someone talk about alcohol gives them [1:08] pain relief, whether that's emotional or [1:10] physical. That's a very real thing. [1:12] That's because your sort of natural [1:13] painkiller system is activated by [1:15] drinking. It's an anti-anxiety and a [1:17] pain medication sort of allin-one. So [1:19] when you think about how we treat [1:20] addiction, where are we going wrong? The [1:22] biggest problem is that people haven't [1:24] been given the evidence and tools to [1:25] understand addiction. But also many [1:27] rehabs don't offer the things that we [1:29] know are actually effective. And what is [1:30] it that people need? Great question. One [1:32] of the most effective tools we teach [1:34] people is something called and they [1:36] found that people drink much less after [1:38] it. Yeah. Wow. [1:41] This has always blown my mind a little [1:42] bit. 53% of you that listen to this show [1:45] regularly haven't yet subscribed to the [1:47] show. So, could I ask you for a favor [1:49] before we start? If you like the show [1:50] and you like what we do here and you [1:51] want to support us, the free simple way [1:53] that you can do just that is by hitting [1:55] the subscribe button. And my commitment [1:56] to you is if you do that, then I'll do [1:58] everything in my power, me and my team, [2:00] to make sure that this show is better [2:01] for you every single week. We'll listen [2:03] to your feedback. We'll find the guests [2:05] that you want me to speak to, and we'll [2:07] continue to do what we do. Thank you so [2:09] [Music] [2:11] much, Dr. Sarah Wakeakeman. With all the [2:15] work that you [2:16] do, what is the mission that you are on? [2:20] My mission is really to change the way [2:22] people think about and understand [2:23] alcohol and drug problems and also to [2:25] give people the evidence and the facts [2:27] both to understand addiction, which are [2:29] sort of problems related to alcohol and [2:30] drug use, but also to just understand [2:32] the science around, for example, how [2:34] much should you drink? Is drinking [2:35] healthy? Is it not healthy? There's a [2:37] lot of misinformation out there, and I [2:39] want to give people the tools to make [2:40] the right decision for them in their [2:41] lives. And who who are you and what what [2:44] is your sort of body of [2:45] experience education? So I'm a medicine [2:48] doctor by training. So I still do some [2:50] general medicine like in the hospital [2:52] take care of pneumonia and heart failure [2:53] and in the outpatient setting take care [2:55] of people's diabetes and um depression [2:58] but I train especially in addiction [3:00] medicine. So I'm board certified in [3:01] addiction medicine and that's been kind [3:02] of my life's work. I work in a big [3:05] academic medical center in Boston, [3:07] Massachusetts, where I would say my kind [3:09] of focus professionally has been [3:11] thinking about how do we bring addiction [3:12] care back into the medical system so [3:14] that it's not this separate and unequal [3:17] and often very poorly done sort of [3:20] siloed system, but actually just a part [3:22] of the health care that people get. And [3:24] then I train people so I'm um program [3:25] director of our fellowship program. So I [3:27] train doctors who want to be specialists [3:28] in addiction medicine. When you think [3:30] about how we treat addiction in the [3:32] modern world, what are some of your [3:34] gripes? Where are we going wrong? Oh, [3:37] how much time do we have? [3:39] Where do we begin? I mean, I think at [3:41] its core, the biggest problem is that [3:43] we've all been taught and sort of [3:45] infused in this idea that addiction is [3:48] an issue of behaving badly, that it's an [3:50] issue of morality, that people really [3:52] need to kind of knock it off and pull [3:54] themselves up by their bootstraps, and [3:55] that this is like a criminal legal [3:57] issue, that um it's an issue of [3:59] willpower. And so, if you believe those [4:01] things, then why would you think that [4:02] someone should get medical care or why [4:04] would you treat them with compassion and [4:06] kindness if you think that they're doing [4:07] something wrong? And so really reframing [4:10] how we think about addiction based on [4:12] all of the science we have and what [4:14] effective treatment looks like, which [4:15] often is very different than what people [4:17] may have experienced if they were trying [4:18] to access care for themselves or a loved [4:20] one. And what is an addiction? What what [4:23] falls into the the bucket of addiction? [4:26] You know, because I'm I use my iPad a [4:28] lot. I use my phone a lot. Um is that is [4:31] that an addiction? Yeah, it's a great [4:33] question because we use that term [4:34] colloially a lot. You know, I'm addicted [4:36] to Netflix or whatever. Um, so addiction [4:39] is really defined by use despite [4:40] consequences. So continuing to do [4:42] something in your life despite bad [4:44] things happening to you because of it. [4:46] So we talk of addiction, we talk of the [4:47] four C's is a way to remember it. So one [4:50] C is loss of control, meaning like [4:52] you've tried to change and you haven't [4:53] been able to. So you've tried to cut [4:54] back or you've tried to stop and you [4:56] couldn't. The other is compulsive use. [4:58] So your use is like spiraling out of [5:00] control that you're kind of using in a [5:02] way that isn't really attached to your [5:03] rational thinking. The next is [5:05] consequence. So continued use despite [5:07] negative consequences either in your [5:09] life, your job, your relationships, your [5:11] health. And then the last C is craving, [5:14] which is this sort of strong [5:15] psychological urge to want to use. Like [5:17] you can't get the idea of having a drink [5:18] out of your mind. And so it's really [5:20] those four C's that we think about. And [5:22] then we make the definition based on how [5:24] many criteria people meet out of this 11 [5:26] list of different criteria. And then [5:28] based on that, people can have a mild, [5:30] use disorder, moderate, or severe. And [5:32] so moderate, severe is really what we [5:34] think of as addiction. But it's that use [5:36] despite bad things happening to you. And [5:37] what things are capable of being [5:39] addictive? Yeah, lots of things. I mean, [5:42] um, I focus mostly on alcohol and drugs. [5:44] So, alcohol obviously probably most [5:47] common. I think we'll talk about that a [5:49] lot today, which I'm excited about. And [5:50] certainly when we look worldwide, 400 [5:53] million people have an alcohol use [5:54] disorder, meaning addiction alcohol. [5:56] It's a lot of people. The other are [5:59] drugs. So, that can be, you know, [6:01] opioids like heroin or pain pills or [6:03] fentanyl. can be cocaine or stimulants [6:05] like methamphetamine or prescription [6:07] stimulants, sedatives that people may [6:09] take for anxiety like bzzoazipines, [6:11] cannabis. And so there's a whole sort of [6:14] range of substances that can be [6:15] addictive and how addictive a substance [6:17] is um is really related to sort of how [6:19] much dopamine is released in the brain. [6:21] I know you've had a wonderful episode [6:22] with Dr. Lumpkkey about dopamine, so [6:24] you've talked about that a bit. Um and [6:26] there are different sort of addictive [6:28] indices of different substances. So [6:30] cannabis is less addictive than [6:32] methamphetamine for example, but all of [6:34] those substances can cause addiction in [6:36] people. Even beyond that, I wonder [6:37] sometimes in my life if I'm addicted to [6:39] other things like I mean I drink coffee [6:40] every day. Certainly get a craving to [6:42] drink it now. Yeah. Well, there's, you [6:45] know, a couple important pieces there. [6:46] Is your coffee drinking causing harm in [6:48] your life in any way? No. I think it's I [6:50] think it helps. It may be helping you, [6:52] right? Okay. So, it's not Yeah. So, it's [6:53] not addiction. So, there's a difference [6:54] between physiologic dependence, meaning [6:56] like if you don't drink your cup of [6:58] coffee, you're going to get a headache, [6:59] and addiction, meaning that you're [7:01] spending all your day and all your money [7:03] buying more and more coffee. We don't [7:04] really see this, but um buying more and [7:06] more coffee despite, you know, your [7:08] girlfriend nagging you about it and you [7:10] you're late to work cuz you're [7:11] purchasing coffee. We don't really see [7:12] that so much with coffee, but that would [7:14] be sort of addiction. And how big is the [7:16] problem? So, if you were to frame like [7:18] why should we care? Why should the [7:19] person listening to this care? Because I [7:21] imagine it's the case that many people [7:23] here don't have an addiction that fits [7:26] into the category of having severe [7:27] consequence for their life. I also [7:29] imagine some people are under the [7:30] impression that addiction is something [7:31] that happens to other people. Yeah. So c [7:35] can you frame the situation for me and [7:37] explain to me why we should all care [7:38] about this and the I guess the scale of [7:41] the impact it's having? Well, I [7:43] guarantee that many people listening [7:44] have been touched by addiction either [7:46] personally or in their lives. Because of [7:48] stigma, we tend not to talk about that. [7:50] But the scale is huge. So globally 2.6 [7:53] million people every year die from [7:54] alcohol-related causes. So that's 7,000 [7:57] people today will die from an [7:58] alcohol-related death. Another 600,000 [8:01] people die from drugrelated deaths [8:03] annually. So that's like 1,600 deaths [8:06] today from drugrelated causes. And then [8:08] when we look at the criteria of sort of [8:10] meeting criteria for a substance use [8:12] disorder or addiction, it's about 400 [8:14] million people worldwide for alcohol and [8:16] 80 million people for drug use. So it's [8:18] incredibly common. If you think about [8:20] alcohol, some studies estimate that the [8:22] lifetime prevalence, meaning in over the [8:24] course of your life, how likely are you [8:26] to at some point develop alcohol [8:27] addiction? Somewhere between 15 and 30% [8:30] in some studies. So one in three people [8:33] may have a problem with alcohol at some [8:34] point in their life. So this touches all [8:36] of us. We just don't talk about it [8:37] because of stigma and because of these [8:38] mental images of kind of othering that [8:41] you know it's only those people who are [8:42] injecting heroin who have addiction or [8:44] that person who you know has the shakes [8:46] every morning and is drinking as soon as [8:47] they wake up who has a problem with [8:48] alcohol. In which direction are we going [8:50] in as a society? Are we getting better [8:53] or are we getting more addicted? Yeah, [8:55] great question. Um the pandemic was not [8:57] kind to addiction. So we saw rates of [9:00] alcohol and drug use and deaths related [9:02] to those increase significantly after [9:04] the onset of the COVID pandemic. Um that [9:07] has started to level out. So for drug [9:09] use related deaths, we're now back at [9:11] the prepandemic levels. But there was a [9:14] very significant increase during the [9:15] time of the pandemic. And that's really [9:16] not surprising when we think about what [9:18] are the things that drive people to use [9:20] alcohol or drugs in a problematic way. I [9:22] was looking at some of the some of the [9:24] life expectancy graphs and um this one [9:26] in particular I found quite shocking. [9:28] I'll throw it up on the screen but it [9:30] shows that obviously you know we would [9:33] expect that there was a drop in life [9:36] expectancy during the pandemic but even [9:39] when you compare it to other countries [9:41] it's not as significant. So I'm [9:42] wondering why in your view there was [9:44] such a significant decline in life [9:46] expectancy during the pandemic. Yeah. So [9:49] um obviously COVID was one driver. One [9:51] of the main other drivers was substance [9:53] related deaths. So actually immediately [9:54] following the onset of the pandemic, so [9:56] beginning March, April of 2020, we saw a [9:59] 23% increase in alcohol-related [10:01] mortality and we saw the highest rates [10:03] ever we've seen of drugrelated overdose [10:05] deaths. And that actually impacted US [10:07] life expectancy up until this year. This [10:09] is the first year that we've seen that [10:10] change. at the essence of what's [10:12] actually going on there because you know [10:16] addiction is downstream from something [10:18] else. Yeah. What is actually going on? [10:21] Yeah. So that's a really great question [10:23] like what drives people to use [10:24] substances. It's actually probably the [10:26] most important question even in my work. [10:28] You know if you don't understand what [10:30] someone's substance use is about or [10:32] related to how are you ever going to [10:33] address it or help them address it? Um [10:35] so trauma is probably the single biggest [10:38] driver. So, you know, you often hear [10:39] things like cannabis is a gateway drug. [10:41] I would say trauma is the gateway drug. [10:43] If we look at many, many studies, [10:46] they're kind of two different things [10:47] that drive someone's risk of addiction. [10:49] One is genetics. It's about 40 to 60% [10:51] genetics, similar to diabetes in terms [10:54] of someone's risk. That's not a done [10:56] deal. Obviously, there are people with [10:57] strong genetic risks who never develop [10:59] addiction and people without that who [11:00] do. The other half of the equation is [11:02] based on kind of your exposures and your [11:04] experiences. And one of the number one [11:06] drivers is what we call adverse [11:08] childhood experiences. So there are this [11:10] famous study called the ACES study which [11:12] is stands for adverse childhood [11:13] experience and it's been replicated. [11:15] There's a recent one done actually in [11:17] Europe as well that looks at the number [11:19] of adverse childhood experiences you [11:20] have and it's a linear track increase in [11:23] terms of your risk of substance use [11:24] disorder. So if you think about what's [11:26] happening in the brain with substances, [11:28] you know, when we use alcohol or drugs, [11:31] all sorts of feel-good hormones are [11:33] released, right? dopamine, your [11:34] indogenous opioid system, which is [11:36] literally your natural pain reliever. [11:38] And if you take someone who's [11:40] experienced trauma, there's great relief [11:42] that people can find in substance use. [11:43] And so we saw that in the pandemic, like [11:45] what was going on in the pandemic, [11:46] people were scared, they were bored, [11:48] they were lonely, they were stuck at [11:50] home, they didn't have their usual [11:51] routine, some people were losing people [11:53] that they loved. And so we saw all of [11:56] this escalating substance use. And it [11:57] was actually most pronounced in people [11:59] who are frontline workers. So that could [12:00] be a healthcare provider. It could also [12:02] be someone working in a grocery store or [12:04] a convenience store who had to work [12:05] through the scariest times of the [12:06] pandemic. And also people who are [12:08] caregivers. So those are kind of the two [12:09] groups that had the biggest increase in [12:11] their substance use during the pandemic. [12:13] What is going on in the brain? You [12:16] referenced it a little bit there. You [12:17] referenced that dopamine makes you feel [12:19] good. Um so you know very naively I [12:22] would assume a case if you feel bad [12:23] dopamine makes you feel good. You want [12:24] more dopamine. But is it is it more [12:26] complic complicated and nuanced than [12:28] that? Yeah. Yeah. Well, alcohol is a [12:29] really complicated one because alcohol [12:31] has lots of different effects on the [12:32] brain. Um, so any drug that can or [12:35] substance that can cause addiction is [12:36] going to release dopamine. That's sort [12:37] of a primary driver of many things that [12:39] we find rewarding whether it's sex or [12:41] food or alcohol or drugs. But alcohol [12:44] also so it binds to the part of our [12:46] brain um a system called GABA which is [12:48] sort of our anti-anxiety system. So it's [12:50] the same system that anxiety medications [12:52] like people may have heard of Adavan or [12:54] larazzipam or Xanax. These medications [12:56] that are kind of sedatives and anxiety [12:58] meds, alcohol acts on that part of the [13:00] brain and it actually then causes a [13:02] release of your indogenous opioids in [13:04] your brain. So like your brain's natural [13:05] painkillers. So that's actually why one [13:08] of the medications that's effective in [13:09] helping people stop drink actually just [13:11] blocks the opioid response in the brain, [13:13] which doesn't make sense when you first [13:14] hear about it until you understand these [13:16] neural mechanisms that actually your [13:19] sort of natural painkiller system is [13:20] activated by drinking. So when you hear [13:22] someone talk about alcohol gives them [13:24] pain relief, whether that's emotional or [13:26] physical, that's a very real thing. [13:28] That's a powerful system in our brain um [13:30] that gets activated when you're [13:31] drinking. Ah okay. So, if I'm having a [13:34] stressful time at work and work is [13:35] making me anxious and um is crippling [13:39] me, then I'm more likely to want to have [13:41] a big blowout on the weekend because [13:42] that's [13:44] effectively a a pain medication. [13:46] Totally. It's an anti-anxiety and a pain [13:48] medication sort of allin-one, you know, [13:50] and I think often this is part of the [13:52] area where I think just getting more [13:53] awareness and and education about [13:55] alcohol is so important because we see [13:57] that as a way of like treating [13:58] ourselves, right? And and it's very easy [14:00] to have that get out of control. And I [14:03] think especially if in your head you [14:04] think as long as I'm not like drinking [14:06] in the morning or missing work because [14:08] of drinking or you know having problems [14:10] in my relationships I'm fine. But [14:11] actually there's so many health problems [14:13] and even life problems related to [14:14] alcohol that people may make different [14:16] decisions for themselves if they had [14:17] that awareness earlier on. You know I [14:20] was thinking about a friend of mine who [14:23] is fairly well known um passed away from [14:30] issues related to his addiction. Yeah. [14:33] He had a lot of pressure on him when he [14:35] was fairly young. He wasn't [14:38] necessarily a a young child when he had [14:41] a lot of pressure put on him, but he was [14:43] young. And I was wondering as you [14:45] said childhood [14:48] experiences, what age that is? Yeah. Is [14:51] there like a certain age where those [14:52] experiences become, you know, if you [14:54] experience a certain level of trauma at [14:55] a certain age, it's harder um to recover [14:59] from that and you're more likely to be [15:00] addicted. Yeah. So, it's a great [15:02] question. Trauma at any time can put you [15:04] at risk for addiction. The earlier that [15:06] happens, the more sort of long-lasting [15:08] the impact can be. Um, so when we think [15:11] about the brain, you know, your brain [15:13] doesn't really fully form until early to [15:15] mid20s. And so both in terms of trauma, [15:18] but also in terms of early substance [15:19] exposure, you're at much greater risk [15:21] when you're younger, but that doesn't [15:23] mean that trauma in later life doesn't [15:25] um put you at risk for developing [15:26] substance use as well. So I've seen [15:28] people who, you know, their first trauma [15:30] was in their 20s or 30s or 40s and they [15:32] can still develop a substance use [15:33] disorder. It's just the risk is even [15:35] greater when you experience those [15:37] adversities as a child. And the [15:39] interesting thing is, you know, trauma [15:40] is not so much about the experience. [15:42] It's about often being left alone to [15:45] grapple with that experience by [15:46] yourself. And so what's traumatizing to [15:48] one person may not be traumatizing to [15:50] someone else. And you know, take the [15:52] pandemic for example. I've talked to [15:54] people who like being stuck at home and [15:56] alone and bored was deeply traumatic. [15:58] Other people were fine. They like were [16:00] in their living room, you know, doing [16:02] whatever and found ways to connect and [16:03] to live their lives and did okay. It was [16:05] the same experience, but it was [16:06] experienced very differently by [16:08] different people. So, it's less about [16:09] the actual experience and more about the [16:12] impact on that human, how they're left [16:13] feeling. And often it's about feeling [16:16] disconnected. Um, we often talk about [16:18] the opposite of addiction is not [16:19] sobriety, it's actually connection. It's [16:21] how do you build that connection with [16:23] other people again? My friend um that I [16:25] was referencing is is Liam Payne who's [16:26] from One Direction, the the boy band who [16:28] passed away. and he was on my podcast [16:30] and uh a few years before he passed away [16:32] and on the show he said [16:34] that much of what made his early life so [16:38] difficult as a teenager was he was [16:40] obviously thrust onto this big show and [16:42] then the way it worked was you know got [16:43] all this public spotlight and then [16:45] they'd like put him up on a stage and [16:47] he'd be in front of 100,000 people in [16:49] Dubai and then they after that [16:52] experience he was then like driven back [16:53] to a hotel room and like locked in the [16:55] hotel room because obviously you can't [16:56] go out because you're you're that famous [16:57] that if you walk out on the street the [16:58] crowds are going emerge. So he was then [17:00] locked in that hotel room and on the [17:02] show he said I was locked in there with [17:04] the mini bar which is full of alcohol. [17:06] Yeah. So I would drink and that cycle [17:08] would repeat itself and he'd be like [17:09] stage you know car hotel locked drink [17:12] stage car and that cycle repeat itself. [17:14] So when you were talking about isolation [17:15] and loneliness as well I never really [17:18] considered the fact that connection and [17:19] social [17:21] um relationships could play a role in [17:23] help in creating an addiction in someone [17:25] but it it tracks totally. I mean, it [17:28] makes me think of a patient I saw this [17:29] week who really wants to stop drinking [17:30] and is able to go for a few weeks, but [17:33] his life is pretty empty. Like, he's not [17:35] working right now. He doesn't have a lot [17:36] of relationships. So, when he's not [17:38] drinking, he's sitting at home like [17:39] watching TV by himself. And it doesn't [17:42] take very long for him to think that [17:43] like, you know, the thing that's going [17:44] to give me relief is having a drink. And [17:46] so, then the question becomes less about [17:47] the molecule of alcohol and more about [17:49] like how do we fill up people's lives? [17:51] How do we form connection and build [17:53] community and build a sense of identity [17:55] and purpose and engagement outside of [17:57] the relief of substance use? You're [17:59] you're clearly extremely smart and when [18:01] I meet people like you, I always think [18:02] to myself, you could have committed your [18:04] life to anything. You could have you [18:06] could have worked in pretty much any [18:07] field and you would have been a success [18:08] because you have what it takes to be [18:10] successful. So, why do you care so much [18:12] about this? Yeah. Um, I think like many [18:16] people, I had kind of a personal thread. [18:18] I um had a family member who was [18:20] impacted by addiction who actually died [18:21] when I was in medical school. And so [18:23] that was a sort of a pivotal moment I [18:26] think that coming at the same time that [18:27] I was learning all of this science, I [18:29] was realizing like, wow, I wish I'd [18:30] known this when I was younger and [18:33] dealing with family members and friends [18:34] who were affected by this and that we've [18:36] gotten it so wrong and most people don't [18:38] have the kind of tools and knowledge to [18:40] do things differently. And so, you know, [18:42] you sort of there's that saying when you [18:43] know better, you do better. And I think [18:45] I kind of wanted to put out into the [18:46] world what I wished was there for other [18:47] people. An immediate family member. Mhm. [18:50] And what age were you when you lost that [18:51] person? [18:53] Probably 24 or so from addiction. Yep. [18:58] When you're dealing with a family member [19:00] or someone close to you that has an [19:04] addiction. So many people listening will [19:06] be able to relate to that feeling. Yeah. [19:07] Can you can you describe that what they [19:10] feel to in I guess in attempt to make [19:12] them feel seen because sometimes [19:15] especially in hindsight if you end up [19:16] losing that person you can be filled [19:18] with lots of feelings of guilt or [19:20] misunderstanding and especially thinking [19:21] about how society's moved on. So how do [19:24] you put into words how it feels to be a [19:26] family member with someone dealing with [19:27] addiction? Yeah, I think you feel [19:29] powerless. You feel like you want to do [19:32] something and you either don't know what [19:33] to do or feel like everything you've [19:34] tried hasn't worked. Um, I think again [19:36] because people have been exposed to this [19:38] idea that it's an issue of willpower or [19:40] choice, which really implies that if [19:41] people wanted it bad enough, they could [19:43] just stop. And so if you're a family [19:45] member, then that's easy to feel like, [19:47] oh, they don't love me enough, you know, [19:49] that they're not choosing me over this [19:51] substance. And so I think often people [19:53] feel deeply hurt and they've, you know, [19:55] been through experiences that have [19:56] created trauma for themselves. There's a [19:58] lot of trauma within families who are [19:59] experiencing this. And then they're [20:01] sometimes given really bad advice, you [20:03] know, that you have to like kick someone [20:04] out or this whole concept of kind of [20:07] tough love and that people need to hit [20:08] bottom. And so sometimes people, you [20:11] know, either do that and then wrestle [20:12] with the guilt of was that the right [20:14] thing or not or they feel bad even like [20:16] being kind or loving to their family [20:18] member. So I think there's a whole mix [20:20] of feelings and of course if you lose [20:22] someone you always wonder what if like [20:23] could I have done something differently? [20:25] Could something else have changed? And I [20:27] think people can feel angry and sad and [20:28] guilty and be left with that. What did [20:32] those people in your life need that you [20:33] lost [20:35] that they didn't get? I think they [20:36] needed science-based treatment and [20:39] compassion and empathy and um and I [20:43] think they needed a world where [20:44] addiction was not seen as something to [20:46] be ashamed of or something that we judge [20:48] but rather something that is a problem. [20:51] You know, the shift from like you are [20:52] the problem to like you have a problem [20:54] and we can help you with this. And I [20:56] think too often we have approached it as [20:57] if like you the person are the problem. [21:00] Do you sometimes think back and think [21:01] you know if if [21:04] id done something differently whether it [21:07] was you or someone else around you or [21:08] the system around that individual they [21:11] would still be here today. Cuz I think [21:12] that was the first thing that sprung to [21:14] mind. I played back all the decisions [21:15] that I made and I thought okay maybe [21:18] that was bad advice that I was given. [21:19] Maybe I should have been you know maybe [21:21] I could have called more. Maybe I could [21:22] have intervened here. Maybe, you know, [21:25] maybe there's something else I could [21:26] have done. Absolutely. I mean, I think [21:29] about that all the time. And um, you [21:31] know, I think I think of a friend, I [21:32] lost overdose. I think of the family [21:33] member, I lost alcohol. And not only [21:36] things that I could have done [21:37] differently, but also, you know, those [21:39] people, they they saw their doctor, they [21:41] were in the hospital, they had all these [21:43] touch points, all of these like [21:44] reachable moments where someone could [21:46] have engaged with them and offered them [21:48] kindness and actual effective care [21:51] that's backed by science. And and they [21:52] weren't. And so there are all of these [21:54] like missed moments and missed [21:55] opportunities. But the other thing I [21:57] think about is like how much time I lost [21:59] with them because I think often in this [22:02] model of like tough love and kicking [22:04] people out or thinking like I'm not [22:06] going to see you until you stop using or [22:08] stop drinking because I think that's [22:10] going to help make them make that [22:11] change. You lose out on like all of [22:13] these moments of time with people that [22:15] you love and you you can't get those [22:16] back. And so there is this problem I [22:20] think in that binary model of like [22:22] you're either like sober in recovery or [22:24] you're actively using and this is good [22:25] and that is bad is that we lose the fact [22:29] that like people who are struggling with [22:30] addiction are amazing funny loving [22:33] people who have a problem that they're [22:34] dealing with. But if someone was dealing [22:36] with cancer, you wouldn't like not want [22:38] to spend time with them. You know, you [22:39] miss all of that time. And you know, the [22:42] both cases that I'm thinking about it, [22:43] like I'll never get that back. You know, [22:47] there's a phrase I had many years ago [22:48] which I'm now reconsidering, which is um [22:51] change happens when the pain of staying [22:52] the same becomes greater than the pain [22:54] of making a change. And that kind of [22:57] dovetales into this idea that someone [22:59] needs to hit their own rock bottom for [23:00] them to change. I think the part the [23:02] reason why that idea prevails is because [23:04] we hear so many stories. I hear them on [23:05] this podcast of someone's family [23:07] rejecting them, throwing them out on the [23:09] street and then them having that Eureka [23:11] moment that [ __ ] I need to change my [23:13] life. And people always reference that [23:15] like rock bottom moment where they took [23:16] action because you know they were at the [23:19] very bottom of the well. And um how does [23:22] that phrase sit with you? Change happens [23:24] when the pain of making a change becomes [23:25] greater than the pain of making a [23:27] change. I think that there are those [23:29] times for sure. It's not to discount [23:31] that and I hear those stories too. But I [23:33] think there are um from evidence what we [23:37] know there are probably more times where [23:39] people just endure the pain again and [23:41] again again until they never change. And [23:43] I think the part that we don't see are [23:45] are the folks who change happens when [23:48] they begin to get enough hope that [23:50] things could be better for them. That [23:52] you know someone loves them someone [23:54] cares enough that they're reaching out a [23:55] hand in the darkness that there actually [23:56] is a path forward. I think people stay [23:58] stuck when they feel hopeless, when they [24:00] feel like nothing could ever, that [24:02] they're never going to get this, they're [24:03] never going to be able to change, their [24:05] life would never get better. And so, you [24:07] know, take the example I'll often hear [24:09] from family members when their loved one [24:11] is in jail that they're like, "Thank [24:13] heavens." You know, they're they're in a [24:14] safe place at least like there's [24:16] actually this sense of relief. There's [24:17] even a term for it called a rescued that [24:19] people feel. I think it just goes to the [24:21] desperation that families are dealing [24:23] with, but this idea that like that's a [24:25] safe intervention. And you hear these [24:26] stories, right, of someone who they get [24:28] locked up and like that's their Eureka [24:29] moment. And yet, if imprisonment were an [24:33] effective intervention for addiction, [24:35] for example, we wouldn't see that [24:37] actually the time after getting released [24:39] from prison, there's 130 times increased [24:41] risk of dying from a drugrelated cause [24:44] after people leave prison. And that your [24:46] risk of dying ever from addiction is [24:48] much much higher if you've ever been [24:49] imprisoned. And so I think there are [24:51] those stories, but we tend to elevate [24:52] those like amazing narratives and we [24:54] miss the fact that so many other people [24:56] are going to die in pain and alone and [24:58] isolated because they have no hope. And [25:00] so it's not to discount those moments. [25:02] And some people are incredibly resilient [25:05] and against all odds even with the most [25:07] trauma they can, you know, make it [25:09] through and that's incredible. But that [25:12] doesn't mean that we should like create [25:13] a system that makes it as hard as [25:15] possible on people. So would you say [25:17] that if we are trying to help someone [25:19] change really it's about hope it's about [25:22] the strength of their why and it's about [25:24] love and empathy and connection [25:25] absolutely is there anything else [25:26] missing and it's about effective [25:28] treatment and treatment [25:31] okay which is subjective right which [25:33] could be depending on the situation [25:35] they're in it depends on the type of [25:36] addiction and their situation but in [25:38] most cases is some combination of [25:40] psychotherapy medication [25:43] so alcohol yes there's I I mean, [25:46] alcohol's been on a journey. Yes. It's [25:48] been on a journey in terms of society's [25:50] opinion about it. Mhm. Can you take me [25:52] on that journey and tell me where we are [25:54] now and and in ter when I'm saying that, [25:56] I'm talking about society's opinion on [25:58] its health benefits and what it is and [26:00] and then and then also what we're [26:02] getting wrong now about alcohol. Yeah. [26:04] Yeah. Um, so I mean the journey of [26:06] alcohol is fascinating. So, first I [26:08] think we think of this as a relatively [26:09] modern thing, but you know, [26:10] archaeologists have discovered like beer [26:12] making equipment in hunter gatherers [26:14] cave dwellings from 13,000 years ago. [26:17] That's wild. Like 13,000 years of people [26:20] figuring out how to make beer. You know, [26:22] you look at China 9,000 years ago, it [26:24] was really about like a spiritual [26:26] journey or a social thing. It was never [26:28] really about health. At some point, we [26:29] started talking about this as something [26:30] that is good for your health. Like drink [26:32] red wine. It's going to improve your [26:34] health. And that's where I think we got [26:36] wrong. And the reason why was actually [26:38] from how we were looking at the data. So [26:40] first if you look at only one health [26:42] condition, there are some health [26:43] conditions where a moderate amount of [26:45] alcohol actually improves your health. [26:46] But it was also how people were [26:48] conducting the studies. So in most of [26:49] those studies, what people do is they [26:50] take like a massive population, tens of [26:53] thousands of people, where we have some [26:54] data where they're reporting how much [26:56] alcohol they used. And then we look at [26:57] health risks over time. And scientists [26:59] would lump people into sort of [27:01] non-drinkers versus light drinkers, [27:03] moderate drinkers, or heavy drinkers. [27:05] And what they were finding is that [27:06] people who were drinking in the even up [27:07] to the moderate level were actually [27:09] doing better than the people who weren't [27:10] drinking at all. And so that was where [27:12] that um concept that drinking is good [27:14] for your health came from. And so people [27:16] talk about this like J-shaped curve, [27:17] meaning that moderate drinkers actually [27:20] have lower risks of health problems. And [27:22] then it's really only when you start [27:23] drinking very high levels that you start [27:25] having more risk of health problems than [27:26] people who don't drink at all. What they [27:28] realize is wrong with that is that in [27:30] the people who don't drink at all, many [27:32] of those people are not drinking because [27:33] they're actually really unhealthy for [27:34] another reason. Like they might have [27:36] heart failure and they like don't want [27:38] to drink because they don't want it to [27:38] mix with their medication or they might [27:40] have had a history of alcohol use [27:41] disorder and they're actually in [27:42] recovery. So they've already had some [27:44] damage from alcohol and they're not [27:46] drinking because of that. And so when [27:48] you change the reference group, you [27:49] actually make the the sort of group that [27:51] you compare people to to people who very [27:53] rarely drink. So, it's not that they're [27:54] not drinkers at all, but they drink, you [27:56] know, very very light levels. Then you [27:59] start to see that those like health [28:00] benefits of alcohol go away, especially [28:03] if you look across all conditions. Are [28:05] you telling me that there's no healthy [28:08] level of alcohol consumption? Yes. I [28:10] would never say drinking alcohol is good [28:12] for your health. That doesn't mean that [28:15] drinking at what we call low-risk levels [28:17] can't be a part of a healthy lifestyle. [28:19] So, it's a slight slight shift that like [28:21] don't fool yourself into thinking that [28:23] drinking that glass of wine is like [28:24] going to exercise for 30 minutes. Like, [28:26] it's not something that's going to [28:27] promote your health. I think of it more [28:29] like having dessert, eating bacon, going [28:32] out in the sun. There are risks [28:33] associated with all those activities. It [28:34] doesn't mean that I would say you can [28:36] never do any of that, but you need to [28:37] understand what the risks are and then [28:39] make choices for yourself. Say look at [28:41] this glass of wine here and this pint of [28:44] beer. Yep. If I drank one of these a [28:47] day, not a huge amount, um I think what [28:50] people tend to think is they think, [28:51] well, it's only one, so my body will [28:53] just flush it out and there'll be no [28:55] adverse health consequences. [28:57] Yep. I Is that true? Well, so part of [29:01] the challenge is what we think of as one [29:02] drink. So I think um much like, you [29:04] know, if you learn to re read the [29:06] serving size on a food, you realize that [29:08] like, oh, a serving of ice cream is like [29:09] a half a scoop. It's not like a giant [29:12] ice cream sundae. The same is true with [29:14] alcohol. So um in the UK the kind of [29:17] low-risisk drinking limits talk about [29:18] units of alcohol which is the equivalent [29:20] of 8 grams of alcohol. So how much of a [29:23] drink has eight grams of alcohol and to [29:25] be in that lowrisk category you have to [29:27] be below 14 units. The problem is that [29:29] glass of wine just eyeballing it has [29:32] several units of alcohol. So it is not a [29:34] even though we think of it as a single [29:36] drink it's probably I mean I have to [29:38] guess but it's probably like three units [29:40] of alcohol. So, if I have a glass of [29:43] wine every day, I'd be over that limit. [29:45] Then you'd be right at that limit. The [29:47] problem is most people don't drink just [29:49] one glass. If you um you know, you have [29:52] two glasses one day and then one glass [29:54] one day and then three glasses one day [29:55] cuz you're at a social function. All of [29:56] a sudden, you're actually quite a lot [29:58] over that limit. So, if you said that [29:59] this this is roughly three units roughly [30:02] and you get 14 a week. You get 14 a [30:04] week. Mhm. So, 3 * 7. Mhm. 21. Yep. So, [30:08] yes, you're over if you're drinking that [30:09] size. Yep. Okay. Okay. So, if I have [30:11] this glass of wine every day, then I'd [30:14] be over the UK limit of lower risk [30:17] drinking. Lower risk drinking. So, I'd [30:18] be medium risk drinking. You'd be in [30:20] what we call moderate risk, which is [30:22] associated with pretty much every form [30:23] of cancer, which I think people don't [30:26] know. [30:28] Okay. Cuz I was wondering why cancer has [30:31] been increasing. Yes. A variety of [30:33] different forms of cancer increasing. [30:35] You know, breast cancer is one of the [30:36] ones we always hear about that's [30:37] increasing. [30:38] So you're saying what is the data in [30:40] terms of low or moderate risk of [30:43] drinking and cancer? Yeah. So the data [30:47] is um growing and really worrisome. So [30:49] for breast cancer so there's really [30:51] there's a few cancers that even at low [30:54] risk limits you see the risk begin to [30:56] increase. So where we would say there's [30:57] kind of no healthy or there's no even [30:59] like low risk amount. So breast and [31:01] esophageal cancer are two examples of [31:03] that. So breast cancer if you were to [31:04] drink um below those low risk limits. So [31:07] in the US that would be fewer than seven [31:09] drinks but a drink in the US is 5 ounces [31:12] of wine which is smaller than that or in [31:14] the UK is below that 14 units. So it [31:16] would be you know fewer than seven of [31:17] that that size glass of wine. We still [31:20] see a slight increase in the risk of [31:21] breast cancer. It's about a 5% increase. [31:23] So that means your risk of breast cancer [31:25] would increase by about 5%. Now that's [31:27] not huge. So I think you know percent [31:29] increase is kind of hard to do the math [31:31] on but if you think in the US for [31:32] example the average woman has a 13% [31:35] likelihood of getting breast cancer in [31:36] their lifespan. 13% likelihood. Really? [31:40] Yeah. Wow. Really high. So 5% increase [31:42] would increase that to like 13.6 or so. [31:45] So that means that if there's nine women [31:48] in this room Yeah. one of them has is [31:52] going to get breast cancer [31:53] probabilistically in their life. Yep. [31:56] Damn. Yeah. Why is it is it and it's [31:59] increasing. Yeah. And so the reasons for [32:01] that are likely environmental because [32:02] your genes don't change over that time [32:04] period. So the risk factors, you know, [32:06] if you think about breast cancer, it's [32:07] alcohol, it's obesity, um it's, you [32:10] know, age when you have children or [32:12] don't have children because it's a [32:13] really hormonally driven cancer. Same [32:15] thing if you think about colon cancer, [32:16] that's a really scary one where we're [32:18] seeing more and more cases in younger [32:19] people. Some of the drivers of that [32:22] eating meat. So processed meats increase [32:24] your risk of colon cancer. So, you know, [32:26] these very sort of normal behaviors. [32:28] There's probably other environmental [32:30] things honestly that we're not yet [32:32] measuring or able to measure just given [32:34] the rate of acceleration. When I talk to [32:36] my colleagues who are oncologists, you [32:38] know, things like plastics or other [32:40] things that we don't yet know, there's [32:41] um it's clearly something in the [32:43] environment that is driving these [32:44] increased cancer risks. So, even at even [32:47] at this sort of level, if I'm drinking [32:50] that might be one unit, right? Yes. So, [32:52] that would be one unit. So, that would [32:53] be fewer than 14 of that. So you could [32:55] see like an, you know, if you had double [32:58] that, it would be a decent pour of wine. [33:00] You could not have more than seven of [33:01] those in a week to be in low risk. But [33:03] even drinking that amount, your risk of [33:05] breast cancer would go up a little bit. [33:06] Even this amount. Mhm. There's really [33:08] sort of no safe amount of alcohol when [33:11] when it comes to breast cancer. Is it [33:13] just breast cancer? So that lowrisk [33:17] category. So when we these big cancer [33:18] studies categorize people as sort of low [33:21] risk or light drinkers, moderate or [33:23] heavy. And for pretty much every cancer, [33:26] once you get to the moderate category, [33:27] we start seeing increases. And there's [33:29] what we call a dose response [33:30] relationship. So the more you drink, the [33:32] higher your risk of cancer. There's only [33:34] a few cancers that the risk seems to [33:35] increase even at that very low level. [33:37] And breast cancer is one of those. And [33:38] then esophageal cancer is one of those. [33:41] So there are certain cancers where even [33:43] a small amount of alcohol will increase [33:44] your risk. Does it have an impact on [33:47] thinking about cancers that are [33:49] prominent in men? Yeah. Um, so colon [33:52] cancer, we're seeing that in a lot of [33:53] young men. Um, liver cancer, yeah, [33:56] prostate cancer, which is obviously a [33:58] male cancer, we don't think of as much [33:59] as being sort of an alcohol sensitive [34:01] cancer, but most cancers, because the [34:04] way alcohol impacts your risk of cancer, [34:05] is not really on a specific organ [34:07] outside of the liver. It's really about [34:09] how it changes our DNA. So, it's about [34:11] inflammation and what are called [34:13] reactive oxygen um species that sort of [34:15] change our cells and increase the risk [34:18] over time of the mutations that lead to [34:19] cancer. So yeah, can you drill down on [34:21] that? So if I if I'm a heavy drinker, so [34:23] say that I'm drinking [34:25] uh let's say I'm drinking two glasses of [34:27] wine a day consistently, which I guess [34:29] would cons like if I was drinking if you [34:31] drink two of those glasses. Yeah, you'd [34:32] be in the heavy category. So two of [34:34] those a day puts me in the heavy drink [34:35] category, which would surprise most [34:37] people, right? Like that for many people [34:40] is very normal. It is very normal. Yeah, [34:43] I think it's some somewhat more [34:44] difficult for younger people to [34:46] understand because younger people drink [34:47] less. But if I think about the [34:49] generation above me, having two glasses [34:51] of wine a day is quite normal after work [34:54] on the weekends with with every meal [34:55] that you have. So that would make me a [34:57] heavy drinker. And then what are my what [35:00] are the stats saying in terms of my [35:02] cancer uh risk profile? Yeah. So it [35:05] varies by cancer, but roughly we're [35:07] talking like a 40% increase in cancer [35:09] depending on the cancer type. And the [35:11] more you drink, the more that's going to [35:12] go up. So you know these are scientific [35:14] studies where it's not precise to you as [35:16] an individual. They're based on large [35:17] populations, but definitely the more you [35:20] drink, the greater the risk. And then if [35:21] I have other sort of do they call them [35:24] comorbidities? Yeah, exactly. So other [35:26] illnesses, other diseases in my body, my [35:28] probability is going to go up further [35:29] from obese some if I'm overweight. [35:31] Exactly. If you smoke. So one of the [35:33] main drivers of alcohol too and cancer [35:35] is that it actually makes you more [35:37] susceptible to the cancer-causing [35:38] effects of tobacco. So if you drink and [35:40] smoke, your risk of cancer is going to [35:42] be even higher. [35:44] How does that work? The thought is like [35:46] if you take esophageal cancer at like [35:48] the cellular level, it makes you um more [35:51] susceptible of the carcinogens which are [35:52] kind of the cancer-causing compounds in [35:54] tobacco. And so rather than just seeing [35:56] like an additive risk, you actually [35:58] almost get a multiplied risk in terms of [35:59] the risk of cancer. So smoking and then [36:02] obesity is the other big one. So a lot [36:04] of um cancers your risk goes up if [36:06] you're if you're you know have an [36:08] increase in your body mass. What's going [36:09] on in the body then? If I drink alcohol, [36:12] how is that leading to cancer? You [36:13] referenced it slightly there, but I'm [36:15] trying to I want to make sure I'm super [36:16] clear of my brain as to like what the [36:17] the the knock-on effects are and how [36:20] that ends up as cancer. Yeah. I mean, [36:22] there's lots of different mechanisms. [36:24] So, I mean, maybe starting just with [36:25] like what does alcohol do in your body? [36:26] So, you ingest alcohol. The like fancy [36:29] name for that is ethanol. It's a [36:31] molecule and it basically gets absorbed [36:33] pretty quickly from your stomach. And [36:35] so, you know, it hits your bloodstream [36:36] usually within 10 minutes or so of [36:38] having a drink. Um, how much it hits [36:40] your bloodstream depends on how much [36:41] water you have in your body. So alcohol [36:43] doesn't penetrate into your fat. It just [36:45] kind of diffuses into the water parts of [36:47] your body. So that's actually why for [36:48] many women, they will get more sort of [36:51] drunk or more of an effect from alcohol [36:52] at a lower level than men because women [36:54] have more body fat than men. But that's [36:56] going to depend on you as an individual. [36:57] If you have more body fat, you're going [36:58] to have a different impact. So alcohol [37:00] gets in your bloodstream. Alcohol can [37:02] instantly cross across what we call your [37:04] bloodb brain barrier. So it impacts your [37:06] brain instantly and that's where you [37:07] feel the initially pleasurable effects [37:09] for many people of feeling a little [37:11] relaxed, feeling more social, feeling a [37:13] little bit, you know, less anxiety. If [37:16] you keep drinking and that level keeps [37:17] going up, then you start having impaired [37:19] judgment. You might have motor lack of [37:22] motor coordination. So we've all seen [37:23] this and many people have probably [37:25] experienced it. You know, you may be [37:26] stumbling, not able to drive safely. [37:29] You're not going to make the same [37:30] decisions you would make if you weren't [37:32] drinking. And then if you keep drinking [37:33] then you get you can actually lose [37:35] consciousness so pass out and people [37:36] have experienced that your body is going [37:38] to try to break down alcohol as quickly [37:40] as it's able to like anything we want to [37:42] kind of excrete any abnormality and get [37:44] back to our normal functioning and so [37:45] that process happens mostly in your [37:47] liver which is why the liver is so [37:48] sensitive to alcohol because your body [37:50] sees ethanol as poison. Yes. I mean you [37:54] know I know you talked about this Dr. [37:55] Lumpy but your body always wants to [37:56] restore what's called homeostasis. [37:58] You're always your body's always going [37:59] to fight to get back to what it feels [38:01] its normal is. And so ethanol is not [38:03] something that belongs in your [38:04] bloodstream. Your body's going to try to [38:05] excrete it as fast as it can and then it [38:08] converts it into something called [38:09] acetate and then you can pee that out [38:10] and breathe that out and get rid of it. [38:13] So to eliminate the alcohol in your [38:14] body, you have to go through this [38:16] process and part of that process [38:17] includes this toxic molecule that's [38:19] going to be floating around and causing [38:21] damage to your cells. So that's one way [38:23] that alcohol can cause cancer. The other [38:26] is um just general sort of inflammation. [38:28] People have probably heard that [38:29] inflammation is just not good for the [38:31] body and increases the risk of cancer [38:33] and o um alcohol generates a lot of that [38:36] inflammation in the process of getting [38:37] eliminated and so it can actually change [38:39] your cells that over time that can lead [38:41] to cancer. So I also found this graph [38:45] which shows for anyone that can't see [38:46] what we're describing at the moment. It [38:48] shows the acceleration in liver disease [38:50] uh death rates and general li liver [38:52] disease compared to other parts of the [38:55] body. Yeah. Other organs in the body. I [38:56] believe it shows y what impact does [38:58] alcohol have on the liver and we have [39:00] our little mannequin here of the human [39:02] body. Where is the liver? Yeah, great [39:04] question. So here's um our little [39:06] mannequin. So just to orient people to [39:08] the body. So we're looking at the inside [39:10] of the body. So like the ribs are gone, [39:11] the outside of the skin is gone. These [39:13] two pink things are the lungs. They kind [39:15] of encase the heart. You can see the [39:16] hearts behind the lungs pumping your [39:18] blood. The liver is this brownish organ. [39:21] It's on the right side of your body, [39:22] right under your ribs. It's quite large [39:24] and it's big. An amazing organ. It is [39:26] quite big. It processes much of what any [39:30] kind of toxins that we take in, things [39:33] that we eat, your glucose, alcohol, 90% [39:37] of it's metabolized by the liver. So the [39:39] liver is sort of the clearing house, [39:40] getting rid of byproducts in your body. [39:43] The other are the kidneys, but the liver [39:45] plays a huge role, especially in [39:46] alcohol. So, it sits right here. It [39:48] almost looks like it's as big as the [39:49] lung as one lung. Yeah. Yeah, it is. [39:51] Yeah. Really? Yeah. It's a giant organ [39:54] and it's an amazing organ. So, you could [39:55] actually cut out 80% of the liver and it [39:58] would regrow itself. So, kind of like [40:00] you know those lizards that you cut off [40:01] their tail and they regenerate a tail. [40:03] The liver is fascinating. It's why we [40:05] can do living liver um transplant. So, I [40:07] could take half of your liver and give [40:09] it to someone who needed a liver. you [40:11] would still be able to live and they [40:12] would get a second chance at life from [40:14] that part of your liver. So, it's this [40:16] really cool organ that can regenerate, [40:18] but it can only regenerate up to a [40:20] point. So, once you get to a level where [40:22] you have a lot of scar tissue in your [40:23] liver, we call that cerosis. Um, you [40:26] sort of reach a point of no return where [40:28] at that point the liver can't heal [40:29] itself. So, I sort of think of it like [40:31] to use a baking analogy. If you're [40:33] making muffins or a cake, you're going [40:36] along, you're mixing all your [40:37] ingredients, and you realize before you [40:39] put things in the oven like, "Oh, I [40:40] forgot the eggs." You can still add the [40:41] eggs in and like whisk it all together [40:43] and it's going to be okay. If the [40:44] muffins are baking in the oven and you [40:46] forgot the eggs, you can't like pour the [40:47] eggs on top and make the batter the [40:49] same. And the liver is sort of like that [40:50] that up to a certain degree, you can [40:52] actually completely repair the effects [40:55] of things like alcohol or obesity, other [40:58] things. But once you pass that point [41:00] into scar tissue, the liver can't [41:02] regenerate anymore. And so when you [41:04] think about that graph or just the [41:05] rising rates of liver disease, um the [41:08] the main drivers of liver disease are [41:10] obesity and two is alcohol. And so those [41:13] are the leading causes of of liver [41:15] transplant. And the thing that is, you [41:17] know, so sad is I mean I see this all [41:20] the time working in the hospital is [41:21] first of all, we're seeing younger and [41:23] younger people coming in in liver [41:24] failure. So people in their 20s coming [41:27] in in fulminant liver failure from [41:29] alcohol and then dying in the hospital. [41:32] And the terrible thing is that they [41:33] often didn't even know that this was [41:35] causing a problem in their health. And [41:36] by the time they get to the hospital, [41:37] they're so sick it's too late. And yet [41:40] all of that could have been prevented or [41:41] even repaired if it was caught sooner. [41:43] And so that's where I think this [41:45] education of understanding like what [41:47] really are the health harms of alcohol [41:48] and that we have normalized binge [41:50] drinking in many occasions, especially [41:52] in young people, as being totally [41:53] normal. and yet there are very serious [41:55] health consequences. [41:57] So, I've got a bunch of questions around [41:59] around the liver. Um, does that mean [42:01] that my liver can take a bit of a [42:03] beating before there's any real [42:05] problems? Should I, you know, some [42:06] someone like me, I don't drink alcohol, [42:08] I'm not engaging in anything too bad, [42:10] but sometimes I do wonder if I could [42:12] have like a blowout weekend and then my [42:14] liver would just recover to normal again [42:16] and I'd be fine. Yeah. I mean, so first, [42:18] every person is different. One blowout [42:20] weekend, you probably would be fine. [42:21] Anyone would probably be fine. The [42:23] challenge is one blowout weekend then [42:25] leads to like multiple blowout weekends [42:26] and then over time that can actually [42:28] accelerate the damage to your liver. The [42:31] up you said that my my liver regenerates [42:33] though. So I'm thinking this thing will [42:34] just pop back to normal again. As long [42:36] as you haven't gotten to that scarring [42:37] phase. So once you get too far down that [42:39] path even if you were to stop drinking [42:41] your liver won't recover. The hard thing [42:43] is that that we don't totally understand [42:46] who and why that happened so young to. [42:48] So, this is an active area investigation [42:50] because there are people who've been [42:51] drinking for 60 years and their livers [42:54] don't show signs of scarring. And then [42:55] we're seeing these young people at 25 [42:57] who come in and die in the hospital. And [42:59] so, there are individual factors that [43:01] you don't have any way of knowing that [43:03] are going to impact your risk of [43:04] developing liver inflammation and scar [43:06] tissue. And so, the safest way to [43:08] prevent that is to not drink in these [43:10] really high ways that we know are going [43:11] to lead to harm. The other way is to get [43:13] medical care because often we do detect [43:16] these things through blood tests and we [43:17] can do ultrasounds and when we see those [43:19] early phases. So what happens first is [43:22] you actually get fat deposition in your [43:23] liver. That's the first step and then we [43:26] see inflammation and fatty liver and if [43:29] you don't stop the thing that's driving [43:30] those changes over time we see the [43:32] development of what's called fibrosis [43:34] which is like scar tissue. And then that [43:36] scar tissue gets more and more advanced [43:38] to the point that your liver stops [43:39] functioning and you either die or you [43:40] need a liver transplant. What activities [43:43] outside of alcohol cause great stress on [43:45] our liver that we might not see as [43:47] obvious? Yeah. Um so obesity. Um so food [43:51] does. Yeah. Food. So your liver is very [43:53] involved in glucose metabolism. Um so so [43:57] our diet and our body weight impact our [43:59] liver health. Um the other medications. [44:01] So um acetaminophen or Tylenol, which is [44:04] a very common over-the-counter pain [44:06] reliever, um above a certain threshold [44:08] can cause serious liver damage. So [44:11] sometimes you'll see cases where someone [44:12] didn't realize that like their cold [44:13] medicine plus the Tylenol they were [44:16] taking both had that ingredient and then [44:17] they go out and drink heavily and that [44:19] kind of combination effect can cause [44:20] liver damage. How [44:23] much do you think this might be a bit of [44:25] a strange bit of an an unclear question [44:28] but how much alcohol is going to cause [44:30] liver damage? So again it varies person [44:32] to person for liver damage it does tend [44:34] to be the moderate to higher amounts [44:36] that cause damage. Um, one thing is that [44:40] you know that having these big surges, [44:41] like these massive binge episodes, is [44:44] probably more harmful than drinking like [44:45] at a moderate level for a long period of [44:47] time. Those like big surges cause a big [44:50] buildup of that toxic byproduct that [44:52] your body has to clear. And so, you [44:55] know, if you have several years of binge [44:58] drinking heavily, that actually probably [44:59] is going to cause more damage than a [45:01] longer period of time of just drinking [45:02] above the risk limits. So really trying [45:05] to minimize and avoid those very heavy [45:07] drinking episodes is incredibly [45:08] important and then keeping it to those [45:10] low-risisk guidelines which we just [45:12] learned are kind of eye opening and and [45:14] how low risk they are is going to reduce [45:15] the risk of liver damage. And does [45:17] alcohol just impact the liver? No. I [45:20] mean alcohol has effects across our [45:22] body. So many parts of the body can be [45:25] affected by alcohol. So kind of starting [45:26] from the top your brain and we can look [45:28] at this with pictures like an MRI. Oh, [45:30] I've got one actually. Yeah. I think [45:32] this is, by the way, shocking. Yes. To [45:35] me. So, when we do an MRI of someone's [45:38] brain, um, we basically, this is like a [45:40] cross slice. So, it's almost like you're [45:41] you're facing me and I'm cutting your [45:43] face off and looking at your brain [45:45] onwards. Um, healthy brain tissue is the [45:47] gray and white matter. And you want it [45:48] to be as plump and like taking up as [45:51] much space as possible because that's [45:52] where all of your brain activity is. [45:54] When people get really old or have [45:56] dementia, one thing we see is more and [45:58] more the black space is essentially [46:00] water. So we see the brain starts [46:01] shrinking and shrinking and there's more [46:03] water and less active healthy brain [46:05] tissue. That process is accelerated with [46:07] heavy alcohol use. And so you can see [46:09] here, this is a 43-year-old person with [46:11] severe alcohol use disorder where their [46:13] brain looks the way, you know, a [46:14] 90-year-old with dementia would look [46:16] because of that um brain damage over [46:18] time from alcohol use. And so we can [46:20] actually a form of dementia is related [46:22] to alcohol use. And so your brain can be [46:24] hugely impacted with alcohol. What is [46:27] going on there? like what's causing the [46:29] brain to deteriorate in such a way [46:31] because of alcohol. Yeah. Well, um [46:32] remember I said um ethanol which is the [46:34] molecule crosses the bloodb brain [46:36] barrier and so especially when you're [46:38] having these high levels of blood [46:40] alcohol that ethanol is sort of bathing [46:42] your brain and if you think about what [46:45] we talked about inflammation and changes [46:46] to cells and to DNA and proteins that is [46:49] happening at the brain level. The other [46:51] thing that can cause accelerate the [46:52] brain damage we see with alcohol is [46:54] actually nutritional deficiencies. So [46:56] people may be drinking a lot and they're [46:57] actually not getting really crucial [46:59] nutrients in their diet and that can [47:01] accelerate the process of brain damage. [47:03] We can even see a very like sudden onset [47:06] amnesia from heavy alcohol use in the in [47:09] the setting of not getting enough [47:10] nutrients in your diet. [47:12] Okay, so that's the brain. That's the [47:14] brain. So the brain for sure. The next [47:16] is the mouth and your esophagus. So [47:18] obviously you're drinking alcohol. It's [47:20] bathing your mouth. It's bathing your [47:21] esophagus and your stomach. So we do see [47:23] an increase in cancer like we talked [47:25] about and that's accelerated by smoking. [47:27] But we also see like benign but annoying [47:30] and problematic health conditions most [47:32] notably acid reflux. So heartburn. So if [47:34] you notice like I'm like always having [47:36] heartburn. I'm having to pop all these [47:37] like ant acids and take this medicine. [47:39] You might want to think like how much am [47:41] I drinking? Is that contributing to my [47:43] heartburn? So that's a very common [47:44] thing. Um the heart is affected by [47:46] alcohol. So you know the heart is an [47:48] organ where at low risk levels there [47:50] doesn't seem to be harm from alcohol. [47:52] But once you get into the moderate and [47:53] high, we see harms. And the harms can be [47:56] a couple fold. One is um something [47:59] called atrial fibrillation, which is [48:00] basically where your heart starts [48:02] beating really irregularly. Yeah. So um [48:05] in your heart, there's four chambers. [48:06] The two chambers at the top. So this is [48:08] really showing the ventricles and the [48:09] atrium. So there's two chambers that [48:11] blood flows through. And in a normal [48:14] heart, your electrical activity comes [48:15] from the top of your heart, goes down to [48:17] the bottom of your heart, and tells the [48:18] heart to pump. Mhm. And so you get a [48:20] single impulse that goes to the bottom [48:21] of the heart, says pump. And that pumps [48:23] blood out to your brain and your body [48:24] and your organs and your liver. In [48:26] atrial fibrillation, the top of the [48:28] heart is just kind of quivering with [48:29] this abnormal electrical activity. And [48:31] so the heart can't pump in a normal way. [48:33] We actually there's a a term in medicine [48:35] called holiday heart because we see [48:37] sometimes people drink a ton over the [48:39] holidays and we'll end up in this [48:40] abnormal rhythm just from that binge [48:42] drinking pattern. And then over time, if [48:44] you're drinking at high levels, your [48:45] heart actually dilates and you can end [48:47] up with congestive heart failure from a [48:49] cardiammyopathy, which means the heart [48:51] muscle gets kind of weak and thin and [48:53] floppy and can't pump the way that it [48:55] needs to. Oh, damn. Sometimes we think [48:58] that if we're good at handling our beer [49:00] or our alcohol, then it's having less [49:02] harm on us. So, I'm for whatever reason, [49:04] I've always been good at drinking quite [49:06] a lot when I used to drink. drink [49:08] anymore, but when I used to drink and [49:10] being less affected than my friend who [49:12] was a little bit bigger than me, had a [49:14] little bit more body fat, which is [49:15] really interesting because you pointed [49:16] out an association there that I was [49:17] never aware of. Just to pause on that [49:19] for a second, you're saying that if [49:20] someone has more body fat, they're more [49:22] likely to get drunk. Yeah. Because they [49:23] have less body water and alcohol doesn't [49:26] go into your body fat. So, you're [49:27] essentially it's like if you took, you [49:28] know, a glass of water and you dropped [49:30] red dye in it, you're going to diffuse [49:32] into that water. So the more water you [49:34] have, the more diffuse it'll be and the [49:36] lower your blood alcohol content. So if [49:38] you have very low body fat, you probably [49:40] have more body water. And so, you know, [49:42] two drinks for you is going to diffuse [49:43] into a larger amount of water. Ah, that [49:45] explains a lot cuz I always wondered, he [49:47] was he was so much bigger than me at the [49:48] time. He was um he had much more body [49:51] fat. And he would get drunk very very [49:53] quickly. And you always think, oh, a big [49:54] guy, they can handle their beer or [49:56] whatever, but he would get drunk very [49:57] quickly. So I used to wonder I used to [49:59] think well alcohol isn't harming me as [50:01] much because I'm not having I'm not as [50:02] drunk as he is. But but that's not true. [50:05] No. I mean so first of all I think the [50:07] interesting story there one is not just [50:08] the body fat but also that people [50:10] metabolize alcohol at different rates. [50:12] You probably I don't know if you found [50:14] this to be true. You probably had fewer [50:15] hangovers than your friend because it [50:17] hangover does seem to be related to the [50:19] amount how high that your blood alcohol [50:20] level gets. So people who don't [50:22] metabolize alcohol as quickly tend to [50:24] have worse hangovers. So that may have [50:26] been something you experienced but it [50:27] doesn't protect you from the other [50:28] health harms of alcohol like liver [50:30] damage like cancer like overtime you [50:33] know heart problems or esophageal [50:35] problems. What is a hangover? Yeah [50:37] hangover is a fascinating thing that [50:39] people are you know there's a lot of [50:41] emerging evidence about it and trying to [50:42] understand what happens. It seems to be [50:44] most related to how high the ethanol [50:46] concentration in your brain gets because [50:48] they've actually done a ton of studies [50:49] with mice and with people. It was [50:51] initially thought to be due to the [50:52] byproducts of alcohol like that acetal [50:55] aldahhide molecule we talked about but [50:57] it doesn't seem to be related to that. [50:58] that seems to be related to ethanol, but [51:00] essentially it's this syndrome where [51:02] after you drink, once your blood alcohol [51:03] content comes down to zero. You feel [51:06] sort of apathetic, you're tired, you [51:08] have a headache, you often feel [51:09] nauseous. And so it's sort of that [51:11] squelli of your brain essentially being [51:14] bathed in this ethanol and then as it [51:16] leaves you just feel totally crappy [51:18] because people think of it sometimes as [51:19] just being dehydrated. [51:21] Yeah, it it is not just being [51:23] dehydrated. There's actual sort of [51:24] effects of ethanol on your brain that [51:26] lead to the hangover. Okay. I think if [51:28] you are drinking at an amount that [51:30] you're getting a hangover, it is a good [51:31] sign that you're drinking above a limit [51:33] that would be considered okay for your [51:35] body. Cuz sometimes I remember back in [51:38] the day if I had a big glass of water [51:40] before I went to bed, if I had been [51:42] drinking, I felt better in the morning. [51:45] There is some element of dehydration, [51:46] don't get me wrong. And that's partly [51:48] because, right, if you think again, [51:49] alcohol is diffused in water. So if your [51:51] total body water is contracted because [51:53] you're dehydrated, your ethanol level is [51:55] going to be higher. So drinking is going [51:58] to help you sort of flush it out and [51:59] feel better. I'm drinking water, but [52:01] it's not only because of dehydration. [52:03] There'll be people listening to this [52:05] now. I doubt they would have got this [52:06] far, but um because if they if they did, [52:09] they probably wouldn't think this, but [52:10] there'll be some people who would have [52:11] gotten this far in the conversation and [52:13] be thinking, "Yes, but Mhm. [52:15] Alcohol helps me socialize and [52:18] socializing is really important and I [52:20] can't socialize very easily because of [52:22] the design of the modern world without [52:23] having a drink or I have great times [52:26] when I drink so I don't want to quit my [52:29] alcohol use and you know in some cases [52:31] that they will be high and medium [52:34] consumption alcohol drinkers. What do [52:37] you say to those people? Well, first [52:39] like there's no judgment here. So a [52:41] molecule of ethanol is not more moral or [52:43] immoral than a molecule of glucose. So [52:44] you could say the same thing about diet. [52:46] We have lots of awareness now about [52:48] processed foods and white flour and [52:50] white sugar. That doesn't mean that [52:51] everyone's going to live this like [52:53] aesthetic lifestyle where they never eat [52:54] dessert. So I think it really is like an [52:56] you need to go in with eyes wide open [52:58] and understand what are the risks, what [53:00] matters to you, and how do you make that [53:02] calculus. So if you decide it's a choice [53:04] you want to make, you want to set [53:05] yourself up for success. So, if you [53:07] decide like I want to cut back on how [53:08] much I'm drinking, but I'm going to go [53:09] to happy hour every night with my [53:11] friends and just try to like not drink [53:12] while I'm there, you're probably not [53:14] going to be very successful because [53:15] you're going to be in a situation that's [53:16] constantly like reminding you of alcohol [53:18] use and everyone around you is using [53:19] alcohol. So, try to make some different [53:22] sort of structural changes and how you [53:24] set up your life and your week and your [53:25] day. Um, and you may find that actually [53:27] you don't miss it that much. That you [53:28] could cut out three or four days of [53:30] drinking and still get that social [53:32] pleasure two days out of the week and [53:34] your overall health risk is going to go [53:35] down significantly. In terms of treating [53:38] someone with alcohol uh abuse disorder, [53:41] rehab is often the most widely known [53:43] form of treatment. Um, one of my friends [53:46] who struggled with addiction really, [53:48] really badly with alcohol addiction, but [53:50] also drug addiction said to me multiple [53:52] times, he said, "I've been to rehab [53:53] three or four times now, and it's just [53:54] not working." Yeah. And I think when the [53:57] most popular or the most well-known [53:58] treatment doesn't work for you, you kind [54:00] of develop an even greater sense of [54:01] hopelessness. Are you a fan of rehab? [54:04] Generally, no. Um, so you know, rehab is [54:07] this idea that you go away somewhere for [54:09] a week, a couple weeks, and then you're [54:11] kind of cured, right? It's almost like [54:13] people have thought of addiction as an [54:14] infection where you need like two weeks [54:15] of antibiotics and then you're done. [54:17] Mhm. What we really understand is that [54:18] for many people addiction is more like a [54:20] chronic illness or even like cancer [54:22] where you need a lot of treatment [54:23] upfront for the first few years and then [54:25] over time you get into stability and [54:27] remission and you're almost like a a [54:30] cancer survivor. You're in long-term [54:31] recovery. And so this idea that you go [54:33] somewhere for a couple weeks and then [54:35] you come out and you're all better [54:36] really doesn't match what we know of [54:38] addiction. The other problem is that [54:39] much of what happens in rehab is not all [54:41] that therapeutic most of the time. So [54:43] the things that we know are most [54:44] effective for addiction, one are [54:46] medications, which there's a lot of [54:48] stigma, misunderstanding about, and then [54:50] two are like evidence-based [54:51] psychotherapy. So things like cognitive [54:53] behavioral therapy, motivational [54:54] enhancement therapy, you know, working [54:57] on your underlying trauma. Often in [54:59] rehabs, the model is really built around [55:01] this idea of like you remove yourself [55:02] from this environment. You do some [55:06] groups while you're there. Sometimes [55:07] often they're based on more of like a [55:09] peer support model. Sometimes the [55:11] therapies that are offered are frankly [55:12] not very evidence-based. Like we [55:14] actually did this study, it was a secret [55:15] shopper study where we called rehab [55:17] programs across the country to like ask [55:19] about what they offered. And many of [55:20] them offer things like, you know, horse [55:22] therapy or like dolphin assisted [55:24] therapy, which like I'm sure it's very [55:26] nice to swim with dolphins and to work [55:28] with horses, but it's not something [55:30] that's been like studied and effective. [55:31] And many places don't offer the things [55:33] that we know are actually effective, [55:34] which are, you know, trained clinicians [55:36] doing evidence-based treatments or [55:38] medication treatments. So, it's a [55:40] combination of like this short-term fix [55:42] for a long-term problem and not actually [55:45] getting the treatment that you need. So, [55:46] what does work like for alcohol use [55:48] disorder, most people don't know we have [55:49] very effective medications that can help [55:51] you even if you just want to not drink [55:53] as much. So, there's this medication I [55:56] mentioned at the beginning that actually [55:57] blocks your opioid receptors. Yeah. [55:59] which seems kind of funny that it works [56:01] on alcohol, but the reason it does is [56:02] that that for people who part of the [56:04] thing that drives them to drink is that [56:06] they drink, they feel this like pain [56:07] relief pleasure sensation from the [56:10] release of opioids in their brain and [56:11] that makes them want to drink more. That [56:13] if you block that, people don't get sick [56:14] if they drink, but they just don't find [56:16] it as rewarding. And so, someone named [56:18] Sinclair actually in Europe did some [56:20] fascinating experiments of even just [56:21] using it as needed. So rather than [56:23] taking it as an everyday medication, if [56:24] you know that when you go to like a [56:27] holiday event, you're going to drink way [56:28] more than you want to drink, you take it [56:30] like 30 minutes before you go, and then [56:31] what people find is they have like one [56:33] drink and they're like, "Ah, I'm good. I [56:34] don't have that same urge to want to [56:35] drink more and more because I didn't get [56:37] the same sort of tickle of feeling [56:39] better and feeling relief." What do you [56:41] think about psychedelics as a way to [56:43] counteract addictive behaviors like the [56:45] ones we've described? Yeah, one of the [56:47] most like groundbreaking trials in the [56:49] last couple years for alcohol use [56:50] disorder was psilocybin. So there's a [56:52] big study of psilocybin assisted [56:54] psychotherapy for alcohol use disorder [56:56] which showed really remarkable effects. [56:58] So people took psilocybin they actually [57:00] compared it. Folks came in and they [57:02] either got a big dose of benadryil or [57:03] psilocybin and then they sat with a [57:05] therapist for like eight hours for this [57:07] guided um psilocybin journey and they [57:10] found that people drink much less after [57:12] it. So it does seem to have some effect [57:13] and the thought is that part of the way [57:15] psychedelics work is they imp increase [57:17] neuroplasticity meaning the ability for [57:19] the brain to form new pathways and kind [57:21] of retrain itself and so it does seem to [57:24] be a potential therapeutic for alcohol [57:25] use disorder. Psilocybin is the active [57:27] compound in magic mushrooms. Yes, [57:29] exactly. Have you heard of iberane? I [57:31] have. Yeah. Which is often associated [57:33] which is another psychedelic often [57:35] associated with addiction. Yes. People [57:37] have looked at ibagane for um opioid use [57:41] disorder. um those studies have been [57:43] less promising than psilocybin although [57:45] it hasn't been tested in the same kind [57:47] of rigorous ways recently partly for [57:49] opioid use disorder we have really [57:50] effective medications that have been [57:52] shown to improve recovery and reduce [57:54] death and so it's sort of hard to be [57:55] better than that one really interesting [57:57] like new whole class of medications for [57:59] alcohol is um medications that are being [58:01] used for weight loss that people have [58:02] probably heard of so like WGOI ompic [58:05] that whole class of GLP-1 [58:07] um medication seems to also reduce [58:09] alcohol use which is kind of interesting [58:11] Really? Yeah. Have they studied that? [58:13] Yeah. So, they Well, first of all, [58:15] there's I mean, there's whole like [58:16] Reddit threads and online communities [58:17] about this where people were prescribed [58:19] it for diabetes or for weight loss and [58:21] they all of a sudden were like, I don't [58:22] really want to smoke or drink. Like that [58:24] kind of urge has gone away entirely. And [58:26] for some people, they really describe it [58:28] as being like miraculous. They've been [58:30] trying to stop drinking for, you know, [58:31] years and years and for the first time, [58:33] they don't feel that sense of like [58:34] craving and urge. Um, and there recently [58:36] have been some actual clinical trials [58:38] where they've done, you know, placeboc [58:40] controlled blinded studies and have [58:42] shown that it does reduce drinking. And [58:44] so it's a really interesting area where [58:46] it seems like those medications kind of [58:48] reset craving and appetite more globally [58:50] and not just for [58:54] food. What the hell is this? I'm going [58:57] to tell you. All of you will probably [58:58] know that I spend a huge amount of year [59:00] about 50 weeks a year traveling around [59:02] the world. And one of the great tips [59:03] that I've always offered for traveling [59:04] is to pack as light as you possibly can. [59:07] Because if you do, I found that I can [59:08] save hours by not having to check in my [59:10] bags and then having to wait for them on [59:12] the other side. So, I always travel with [59:14] a small, tiny bag that can be stowed [59:17] above me in the plane everywhere I go, [59:19] even for trips that take weeks and [59:21] weeks. It is a massive travel hack. And [59:24] that's why I have to tell you about [59:25] today's show sponsor, Extra. This bag [59:27] uses some clever technology to suck all [59:29] the air out of your luggage so that you [59:31] can fit up to three times more things in [59:34] a tiny tiny little space. You can learn [59:36] more at extra.com. And if you want to [59:37] buy one of these, you can use code DOAC [59:40] for 10% off plus free shipping and a 100 [59:43] day trial. That's extra.com with code [59:46] DOAC. [59:48] One of the ways that many of us [59:49] understand addiction if we haven't [59:50] experienced it directly in our own lives [59:51] is we look up at role models on TV and [59:55] in sort of celebrity pop culture and we [59:57] see these role models who you know we [59:58] see on stages start to deteriorate and [60:01] deteriorate in the public eye and [60:03] ultimately it seems often like it's [60:05] inevitable that someday the TMZ [60:06] headlines going to ring out and say that [60:08] this person has passed away and that [60:10] happens all too often. We think about [60:11] you know Whitney Houston or um I guess [60:14] Michael Jackson's even been associated [60:16] with dying from an addiction to I think [60:18] it was painkillers or something. Prince [60:20] Elvis Presley Mac Miller who a lot of [60:23] people will know as well and a Nicole [60:25] Smith and even now in the public eye [60:27] there are certain individuals where [60:29] we're starting to see this sort of [60:30] erratic behavior. They're posting on [60:32] their Instagrams. They're they're [60:34] showing up in society in a slightly [60:36] different way. When you see that in the [60:38] line of work that you operate [60:40] in, what is your natural reaction? How [60:43] does it make you feel when you know [60:45] because there's a couple of people I'm [60:46] thinking about at the moment who the [60:47] world are talking about that you know we [60:49] think they have an addiction, we think [60:50] they need help. What is your natural [60:52] reaction to to that and what what is it [60:55] that those people need? Yeah. Well, when [60:57] I when I read the headlines of someone [60:59] dying, I mean, to me, it's gutting and [61:02] heartbreaking. One, because obviously [61:04] it's a human life that was someone's [61:06] mother and sister or brother and people [61:08] cared about, a public figure that people [61:09] looked up to and cared about, but mostly [61:11] that it was a totally preventable death. [61:13] Like really, no one should die from a [61:15] substance related death. We have tools [61:16] to treat addiction. We know how to [61:18] prevent the harms of, you know, drug [61:20] overdose, for example. And so the fact [61:22] that someone can die, especially someone [61:24] that everyone has watched for so long, [61:26] is I think just like a tragic example of [61:28] how what the mismatch is between what we [61:31] do around addiction and what science [61:32] does is actually helpful. Um I think you [61:35] know when I see someone who actively is [61:38] showing signs, like it's just sad to see [61:40] that happen so publicly without people [61:42] being able to support that person. And [61:45] it's not a magic fix. not going to be [61:47] like a you know you have an intervention [61:49] the person goes to treatment gets better [61:50] forever that I think is often in [61:52] people's minds it is a process a journey [61:54] like any change and so really it is [61:58] around where we began that idea of how [62:00] do you begin to understand with this [62:01] person how is their substance use [62:03] getting in the way of what they want for [62:05] themselves and how might their life be [62:07] better for them based on whatever they [62:09] believe better is if they were to make [62:10] changes to their substance use I am I [62:13] remember I had this one particular [62:14] friend who had an addiction and um I [62:16] remember always the life of the party. [62:18] And I remember this one day he came up [62:20] to me at at an event and he'd sat down [62:24] in front of me and said to me [62:26] um he said he like whispered to me, "I'm [62:30] in so much pain." Mhm. And he told me [62:32] about rehab and how it had failed him, [62:35] etc. But it it just it almost sounded [62:39] unbelievable that someone with such a [62:40] big smile on their face would whisper to [62:43] me, especially a man because men don't [62:44] really talk much about their emotions. [62:46] I'm in so much pain. Mhm. And then [62:48] funnily, I I then see how the world [62:50] treats that individual, him having [62:51] whispered that to me one day and the [62:54] world how the world responds to his [62:56] behavior and attacks him and criticizes [62:58] him. But I was privy to the whisper. [63:00] Yeah. Yeah. And that that one whisper [63:03] helped me to kind of reframe how to how [63:05] to treat that person, but also really [63:06] what was at the heart of what was going [63:08] on and probably gave you so much [63:10] empathy, you know, a huge amount of [63:11] empathy cuz I would have been like the [63:12] rest of the world. I would have just [63:13] thought what an idiot, what a [ __ ] [63:14] Like what's he doing that? That's [63:15] strange behavior. Y, you know, and you [63:17] said something really important that was [63:19] a slight shift in words. You didn't say [63:21] he failed treatment. You said the [63:22] treatment failed him. And that matters [63:24] so much because I think too often we've [63:26] made it seem as if people are failing. [63:28] like if they go to rehab and they don't [63:30] get well h it's their problem you know [63:32] and actually the treatment wasn't right [63:34] for them. If someone had cancer and [63:36] their cancer came back or didn't get [63:37] treated by chemotherapy we wouldn't say [63:39] like they failed you know we would say [63:40] well what's the next treatment how do we [63:42] get them to the right doctor and so [63:43] there is this like personal blaming and [63:46] that gets it stigma which is one of the [63:47] main reasons that people don't share [63:49] that they're struggling with substances [63:50] that they don't seek treatment and so we [63:52] have tremendous stigma towards drug and [63:54] alcohol addiction. It's one of the most [63:55] stigmatized kind of social conditions [63:57] globally. And so, of course, then if [63:59] you're a person who starts to think [64:00] like, "Oh, maybe I do have a problem." [64:02] Like, maybe my alcohol use is getting in [64:03] the way of things. It's really hard to [64:05] then say anything because you worry that [64:06] you're going to be judged. You're going [64:07] to be labeled. You're going to be [64:09] misunderstood. In some cases, terrible [64:11] things could happen to you. You might [64:12] get your children taken away by, you [64:14] know, child welfare. You could lose your [64:15] housing or lose your job. And so, that [64:17] stigma has like played into this [64:19] terrible cycle where people, you know, [64:20] have to whisper it to someone. shows how [64:22] much he trusted you to even be able to [64:24] say honestly what he was going through [64:26] because there's so much stigma about the [64:28] condition itself. You must have had many [64:29] cases that broke your heart. Yeah. Can [64:32] you tell me about one that changed you? [64:37] Oh goodness. So many um you know so one [64:42] gentleman in particular he was um [64:44] struggled with heroin addiction for a [64:46] long time and had been like we talked [64:49] about it had been kind of a chronic [64:50] illness for him. He'd had periods where [64:51] he'd done really well. He'd had periods [64:53] where he had struggled and had always [64:56] stayed safe through all of that. And he [64:57] actually his like one really meaningful [64:59] relationship in his life that kind of [65:01] kept him together was a relationship [65:03] with his mom and he lived with her. And [65:06] um and they lived in public housing. [65:08] They were, you know, dealing with [65:09] economic insecurity like many people. [65:11] And someone found out that he was [65:13] staying with her and it would have put [65:14] her at risk for her housing. And so he [65:16] didn't want her to lose her housing. So [65:18] he left. But he was newly homeless. and [65:20] all of a sudden because of just social [65:22] barriers was dealing with the stress of [65:24] homelessness and being alone and um even [65:27] with kind of all of the connection he'd [65:30] had with his mom and with treatment he [65:32] was found um dead between two parked [65:34] cars had overdosed alone in the street [65:36] and I always think like if and you knew [65:39] him. Oh yeah, the cascading effects that [65:42] you know that it didn't have to be that [65:43] way. And I think there are so many [65:44] deaths like that where I just think it [65:46] doesn't have to be like this. You know, [65:48] really no one should die like this. And [65:51] um and there are so many things that, [65:53] you know, in the moment feel so out of [65:55] our control. And I think that's part of [65:56] what generates my passion for this work [65:59] is I can't always save the person in [66:02] front of me or change issues around [66:04] homelessness or housing policy, but I [66:06] can try to work on a broader scale to [66:08] make things different for the next [66:09] person. And I think that kind of that [66:12] for me counteracts some of the distress [66:14] of of of losing people that I care [66:16] about. If you were president of the [66:18] United States, for example, let's just [66:20] use this country as an example, and you [66:22] had to make upstream changes to the way [66:25] society was designed in order to [66:27] mitigate the downstream symptom of [66:30] addiction and addictive behaviors, etc. [66:33] What are those things that you would [66:34] change about the way that our society is [66:36] designed? You could change anything. [66:38] Yeah, I mean, starting upstream, the [66:41] biggest thing would be building [66:42] resilience and building connection early [66:44] on. So you know I think these things [66:46] that feel so not related to addiction [66:48] per se are actually deeply related when [66:50] we think about adverse childhood [66:51] experiences. So we think about [66:53] prevention for children you know often [66:55] people have looked at like education [66:56] like you know telling people telling [66:58] kids that drugs are bad that doesn't [67:00] work. What does work is actually [67:01] building resilience in young people. So [67:03] building resilience building connection. [67:05] So what does that look like? That looks [67:06] like affordable housing. That looks like [67:08] parks where people can get outside and [67:09] play sports and exercise and build [67:12] relationships. That looks like, you [67:14] know, supporting families so that [67:15] families can stay together and so those [67:16] early relationships and attachment can [67:19] be wellformed. That's like the true [67:21] prevention work is trying to break the [67:22] cycles of intergenerational trauma, [67:25] poverty, substance use, and actually [67:27] supporting families, communities at the [67:29] very start. It reminds me of Rat Park. [67:32] Yes. Yeah. Rat Park is a great example [67:34] of that. What is Rat Park for those that [67:36] don't know? Yeah. So rat park was a [67:38] series of experiments that were done um [67:41] where essentially they took they're [67:43] trying to understand kind of drivers of [67:44] addiction using rat models. And so they [67:46] took rats and they had one model where [67:48] rats were isolated in their own cage [67:50] with nothing to do and no human [67:52] connection. And they had access to a [67:54] substance like morphine or cocaine where [67:57] they could push a lever and get more of [67:58] it. And those animals when they were [68:01] deprived of connection and isolation, [68:02] anything to do more of the drug. It gave [68:05] them relief. who gave them pleasure. [68:07] They took those same animals and they [68:08] put them in this amazing cage with, you [68:11] know, areas to play and like wheels to [68:13] climb on and lots of friends and other [68:15] rats. And all of a sudden, they saw the [68:17] same animals were no longer kind of [68:18] pushing the lever and trying to get more [68:20] of the drug. And so, you know, it's it's [68:23] a somewhat simplified model that there's [68:25] lots of it's probably oversimplified, [68:26] but I it demonstrates that so much of [68:29] addiction really is around this idea of [68:31] connection restoring sort of the world [68:34] around us, the community, the [68:36] interrelatedness that we all have, the [68:38] opportunities and purpose and and [68:40] meaning and hope. So, I think that's the [68:42] real prevention. And then there's how do [68:43] we actually address folks who are having [68:45] a problem? And I think you know what I [68:47] would do there is first make addiction [68:48] treatment widely available immediately [68:51] when people need it. So the minute you [68:52] walk into your general practitioner's [68:54] office or an emergency room, you get [68:57] treated with compassion, with science, [68:59] with people asking you what can they do [69:00] to help and offering you effective care [69:02] the same way they would if you had a new [69:03] cancer diagnosis or a new diagnosis of a [69:06] heart problem. And that we really [69:08] reframe treatment entirely to look like [69:09] the way it looks for any other health [69:11] condition. and that we stop punishing [69:13] people who use substances where, you [69:16] know, a lot of times people are still [69:17] sent to jail for substance use, which, [69:20] you know, is a confusing mixed message [69:21] of we're saying this is a health problem [69:23] on the one hand, but we're going to put [69:24] you in prison or jail at the same time. [69:27] Those two things don't necessarily [69:28] align. Many of us are living in the [69:31] first model of Rat Park. Yeah, we're [69:33] living alone. We're living in these big [69:34] cities. We're more sedentary than ever [69:36] before. [69:38] um maybe you know we've moved to a big [69:41] city because we don't h which means we [69:42] don't have our family around um we might [69:45] be doing a job that's incredibly [69:47] challenging. So, it's no wonder when we [69:48] think about addiction and alcohol and [69:50] some of these other behaviors, but more [69:52] broadly beyond alcohol um as a [69:55] substance, other addictive behaviors, [69:58] whether it's social media or it's uh [70:01] what we eat or pornography or in the [70:04] sort of inverse the good habits, the [70:06] healthy food, the working out, the [70:08] exercise, the productive behaviors, why [70:11] we're struggling so much. And um I've [70:14] often wondered if we should all just [70:15] like go to like communes and live, do [70:20] you know what I mean? In like in in [70:22] groups. I mean, I don't think human [70:24] beings were meant to live this way. And [70:25] it's a relatively new thing, right? We [70:27] often lived in a village or a community. [70:29] We lived in these multigenerational [70:31] households. I mean I have little kids [70:33] and I think having kids was such an eye [70:34] openener of that of like well that makes [70:36] sense why people live with their parents [70:38] and their grandparents and have these [70:39] big families to create you know [70:41] community and and a sort of extended [70:43] family around you and we have lost that [70:45] in a lot of ways and I think the ways [70:47] that we used to get that like religion [70:49] maybe not maybe that still resonates for [70:51] some people but for others it may not [70:53] and so finding other ways of engagement [70:55] of meaning of purpose that can be [70:58] through lots of different things you [70:59] know I think people are finding creative [71:00] ways of doing that it can be through [71:02] like, you know, finding a volunteer [71:04] activity, finding some other type of [71:06] social group. Some people do it through [71:07] sports. You know, they they find [71:09] connection and engagement with people [71:10] they don't really know over the shared [71:12] love around around an activity or a [71:14] team. But really sort of seeing that as [71:16] a priority the same way you'd prioritize [71:17] other things in your life, in your [71:18] health. And are you a fan of of therapy [71:20] as an approach to aim at the early [71:23] childhood trauma? Absolutely. Yeah. I [71:25] mean, I think one of the problems is [71:27] that too often therapy has been like [71:29] forced on people. I think that um I'm [71:32] much more of the approach of like we [71:34] need to make treatment available and [71:35] welcoming and high quality so that [71:37] people get value out of it and therapy [71:39] is a huge part of that. You know, it's [71:41] about a lot of things. It's about [71:42] connection. It's about figuring out [71:43] those reasons why people are using in [71:45] the first place addressing and healing [71:47] those traumas. It also matters that we [71:49] have um good well-trained empathetic [71:51] therapists. So there's been a lot of [71:52] interesting studies looking at actually [71:54] how empathetic your therapist is is [71:56] probably the strongest predictor of [71:58] whether you stop make changes to your [71:59] alcohol or drug use really which is so [72:01] interesting because we often think like [72:03] you you've probably heard someone say [72:04] like I don't really like my therapist [72:05] and I think sometimes reaction to that [72:06] is like oh like you're you're not that [72:08] into therapy but they've actually done a [72:10] lot of studies showing that a therapist [72:12] who is less empathetic their client is [72:14] more likely to use more substances at [72:16] the end of that course of treatment. So [72:18] actually having a really well-trained, [72:20] compassionate, evidence-based workforce [72:22] is hugely important, too. And I guess [72:24] the same applies for family and friends. [72:26] Yeah. Yeah. I think empathy is really [72:28] powerful. Those kind of things that we [72:29] think of as soft skills actually matter [72:31] tremendously. Is it possible to prop [72:34] somebody [72:36] up. You know, because I was talking to I [72:38] think it was talking to Dr. Anna L about [72:40] this about the idea that you can play a [72:43] role in someone's addiction. Yeah. I.e. [72:45] I want to help my friend who's addicted [72:49] and so I I'm there for them. I'm [72:51] comforting them, but I'm actually in [72:53] some way reinforcing that addictive [72:54] behavior [72:55] because I'm I'm positively reinforcing [72:58] it because I'm supporting them so much [73:00] and I'm loving them so much and I'm [73:01] showing them so much empathetic [73:03] attention that actually I'm playing a [73:05] role in continuing that addiction. Is [73:07] that possible? Yeah. And this is this [73:08] concept of like enabling which I think [73:10] is nuanced. I would say at its core it's [73:13] really deeply problematic that for the [73:15] most part love and support are never [73:17] going to be harmful. And when I talk to [73:18] patients often the thing that caused [73:20] them to ultimately engage in treatment [73:22] was not some terrible consequence. It [73:24] was the idea that someone cared enough [73:26] about them in a moment where they didn't [73:28] love themselves very much and felt [73:30] hopeless that someone was willing to [73:32] sort of lift them up and believe in [73:33] them. And it's these small moments of [73:35] kindness, like I'll tell you a story of [73:36] a patient that we took care of in the [73:38] hospital who was there for a really [73:40] life-threatening infection related to [73:41] their drug use. And a year to the date [73:44] after um he was hospitalized, he wrote a [73:46] letter to our team. And he said, you [73:48] know, I'll never forget the moments you [73:49] guys came in and just sat with me and [73:51] talked to me. And he now sends an email [73:53] every single year on the anniversary of [73:54] when he got out of the hospital. And [73:56] it's those those moments of humanity of [73:58] connection again that connection idea [74:00] that often are the catalyst for change [74:02] the kind of hope and belief that your [74:04] life could be better somehow as opposed [74:06] to this idea of like increasing [74:08] someone's pain and suffering. And that [74:10] plays out in different ways. So in [74:11] families one of the most effective tools [74:13] we teach people is something called [74:14] craft which is um stands for community [74:16] reinforcement and family training. And [74:18] it's very different than the like people [74:20] may have seen like shows where you're [74:22] supposed to like stage an intervention [74:23] and you know tell someone all or nothing [74:25] but craft is very different. It teaches [74:27] people first how do you understand the [74:28] science of addiction family members. [74:30] Second, how do you get support for [74:31] yourself? Because it's really tough to [74:33] deal with addiction in a family. And [74:35] then how do you start to learn about [74:36] consequences in a different way that you [74:38] know if you're a parent and your kid is [74:40] missing school because they're using, [74:42] you don't want to cover for them and and [74:44] sort of reinforce their pattern, but you [74:46] also don't need to kick them out of your [74:48] house. That there's sort of gradations [74:49] of consequence that can actually help [74:51] people change. And one of the biggest [74:53] sort of motivators for change is [74:55] actually positive reinforcement of the [74:56] behaviors you want to see. So that's [74:58] been called contingency management in [75:00] the kind of treatment world. And you [75:02] know, health insurance companies, lots [75:04] of companies have figured this out, [75:05] right? So if you get money back because [75:06] you join a gym or you get those, you [75:08] know, you get reimbursements for doing [75:09] something that people want to see, [75:11] people do more of it. It's true in human [75:13] behavior. It's very true with addiction. [75:15] But we often do the opposite. We try to [75:16] punish people into getting well instead [75:18] of reinforcing kind of the healthy [75:20] behavior, the what we want to see more [75:22] of, if that makes sense. Yeah. I I I'm I [75:25] guess I'm trying to represent the [75:27] audience member that's listening to this [75:28] right now that knows someone in their [75:30] life that was addictive and they tried [75:31] to be empathetic. They they tried to [75:34] offer support. They tried to give the [75:37] person help and still nothing changed. [75:40] Yeah. In that situation, maybe the [75:43] person that was struggling with the [75:45] addiction didn't accept the support. [75:48] Yeah. Didn't go to the meetings, didn't [75:49] speak to the therapist. Yeah. in such a [75:52] situation where you're offering help to [75:53] someone and they're not taking it, [75:54] they're not willing to investigate [75:56] different medical um [75:58] treatments, they're living at your [76:00] house, they're in your business, [76:02] whatever. [76:03] Is there a point where you say enough is [76:06] enough? Yeah. Well, first like it is [76:08] just so hard to be there as a family [76:10] member or friend. So for anyone [76:12] listening, I've been there. It's [76:14] incredibly impossible. So have grace [76:16] with yourself. I think that's a [76:18] different decision you're talking about [76:20] is at some point do you have to make a [76:22] decision to protect yourself. So let's [76:23] say you have someone in your home who's [76:26] dealing with addiction who you know gets [76:28] aggressive or is stealing money or is [76:30] you know causing trauma to the people [76:32] living in the house. At some point you [76:33] may need to decide that for my wellbeing [76:35] for the rest of the family's wellbeing I [76:36] can't have this in my life right now. [76:38] That's very different than saying [76:40] kicking them out is going to make them [76:41] better. So the distinction there is that [76:43] it's okay to protect ourselves. [76:45] Sometimes we have to do that and [76:47] sometimes there's only so much you can [76:48] do. But to not sort of fool yourself [76:50] into thinking that the action is to help [76:52] the other person and that's okay. I [76:54] think the other piece is, you know, at [76:56] the end of the day, first of all, it's [76:58] easier to be a treater. So I've been a [76:59] family member, I've been a clinician. As [77:01] a clinician, I can truly be [77:02] unconditional. So I can I'm going to be [77:04] someone's doctor whether they continue [77:05] to use heroin or continue to drink or [77:07] don't. And there's something really [77:08] beautiful in that. Like my engagement [77:10] with someone is is not premised on [77:12] whether they make changes or not. as a [77:14] family member, that's harder, especially [77:16] if you're a kid dependent on someone or [77:18] you're in a marriage or relationship. [77:20] So, you may have to make different [77:22] choices. But I think at the end of the [77:24] day, people don't change because of why [77:26] we think they should change. They change [77:27] because they think their life is going [77:29] to get better in some way. So, the key [77:31] then becomes figuring out like why might [77:32] this person's life get better if they [77:34] were to make changes to their alcohol or [77:35] drug use. So, it's a shift where you [77:38] become sort of on their team instead of [77:40] trying to drag them towards water, you [77:41] know, drag the horse towards water. And [77:44] there's this um fascinating kind of [77:45] human instinct that none of us like [77:47] being told what to do. So there's [77:48] something called the writing reflex, [77:50] which is it's really hard for [77:51] caregivers, it's hard for parents [77:52] because we love to tell people like our [77:54] great advice and why what they're doing [77:56] is wrong and they should take our like [77:57] brilliant doctor advice. And this can be [77:59] like telling someone like, "Don't you [78:01] see what you're doing is causing harm? [78:02] You should make changes." It can also be [78:04] subtler. It can be like lecturing [78:06] someone or trying to educate them. But [78:08] when someone shoves something down your [78:09] throat, your instinct is to to resist. [78:11] It's just like natural human behavior. [78:13] even if it's a great idea, if someone's [78:14] like shoving an ice cream cone in your [78:15] face and like eat it. Even if you like [78:17] ice cream, you might be like, "Wait, [78:18] wait, I don't know if I want this ice [78:20] cream." And so the key then is not to [78:22] sort of tell someone what to do. It's to [78:23] understand why might they want to make [78:24] changes. And so once you do that, then [78:26] you all of a sudden realize like it just [78:29] feels better. You're not trying to drag [78:30] someone towards something. It doesn't [78:33] you don't have like personal skin in the [78:35] game about what choice they make, but [78:36] you're really a partner with them and [78:38] figuring out how is this thing causing [78:40] problems to you and why might your life [78:42] get better if you were to make changes [78:43] to your alcohol use or your drinking or [78:45] your substance use. What's the [78:47] difference in delivery there in terms of [78:48] delivering that message? Because they're [78:50] both ultimately getting to the same [78:52] outcome, but it sounds like the language [78:55] might be slightly different. Yeah, very [78:57] different. So um in kind of like medical [79:00] speak and therapy speak we talk about [79:01] something called motivational [79:02] interviewing which is it becomes almost [79:04] like a mind trick but it's um it is [79:06] basically a way of trying to identify [79:08] from the person their reasons for change [79:10] and reflecting it back to them. And so [79:12] it's not you telling them you think they [79:14] should change but you are trying to [79:16] elicit their motivation and amplify it. [79:19] And then at the end of the day you're [79:20] turning over the power back to them. So [79:21] that might look like something someone [79:22] says you know I'll I'll be your your uh [79:25] patient. Okay. So yeah, I I I do drink a [79:28] lot. I drink a couple of times a day, [79:30] especially in the mornings, but it's [79:31] fine, you know. Uh I'm still managing to [79:34] get to work every day. Obviously, I have [79:35] a couple of uh misconduct issues at [79:37] work, but other than that, you know, and [79:39] my partner's left me, but other than [79:41] that, everything everything else is fine [79:42] and I can manage this. It sounds like [79:45] your alcohol use is causing some [79:46] problems at work and in your [79:47] relationships. It is. Yeah. Yeah. I lost [79:50] my my partner's left me and um I keep [79:52] getting these misconduct notifications [79:55] at work in disciplinaries because I [79:57] sometimes get there late and when I'm [79:58] there sometimes I fall asleep etc. and [80:00] I've obly I work with big machinery so [80:02] there's a little bit of a risk there but [80:04] otherwise it's okay. It sounds like [80:06] you're worried about your safety at work [80:08] and also how your drinking is starting [80:09] to affect your job and your [80:10] relationships. That's true. Yeah, I am. [80:13] You know, I've been on the on the crane [80:14] in particular, being um being [80:17] intoxicated on the crane in particular [80:18] has caused a few incidences. And you [80:20] know, I sometimes do worry that one day [80:22] it'll it'll go a little bit too far. [80:24] Yeah. Yeah. It sounds like that's really [80:26] scary that you're really worried your [80:28] alcohol use could cause even like a [80:30] serious or lifethreatening accident at [80:32] work. Yeah. And then what am I going to [80:34] do for work? You know, because if you [80:35] get a something like that on your file, [80:37] then you I'm never going to be able to [80:38] be a machine operator ever again. So, [80:40] yeah. Man, your job sounds really [80:41] important to you and so important. [80:42] Alcohol's starting to get in the way of [80:44] that. Yeah, 100%. Yeah. And so what are [80:46] your goals looking forward around your [80:48] job or your relationship? Well, I I [80:50] really should [80:52] um I really should fix this alcohol [80:55] issue that I have and uh I would love to [80:58] find a partner. I'd really that's really [81:00] important to me cuz I want to have a [81:02] family. So obviously prerequisite of [81:05] having a family is finding a partner [81:06] really. So yeah. Yeah. Yeah, it sounds [81:08] like you're really committed to thinking [81:10] about making a change to your drinking [81:11] and that you're looking forward to [81:13] finding a partner and family and you're [81:14] worried that alcohol might get in the [81:16] way of that. So, you're what you're [81:17] doing there is you're you're you're not [81:19] leading me, you're kind of pushing me, [81:21] if that makes sense. There's like a [81:23] little bit of like a Jedi mind trick [81:24] thing where you're so essentially it's [81:27] actually really it's a little tricky [81:28] when you're first learning how to do it [81:29] because what I'm trying to do is I'm [81:31] listening for what's called change talk. [81:32] So, any little nugget you're giving me [81:34] about making a change. So, you're saying [81:37] like, "Oh, I'm starting to get this [81:38] misconduct. I'm worried about this thing [81:40] with safety at work. I want a partner." [81:42] Those are like it's a gold mine of [81:43] little kernels of change and I'm [81:46] ignoring all of your sustained talk. So, [81:48] anything where you're arguing for the [81:49] status quo, it's not a big deal, [81:51] drinking's not that big a deal, I can't [81:52] make a change, I don't even acknowledge [81:54] it or address it. And that's actually [81:55] hard because I think most of us pay [81:57] attention to the negative stuff. So if [81:58] you think about like a performance [81:59] review at work or someone telling you [82:02] any kind of feedback, we tend to amplify [82:03] and remember like the one bad thing that [82:05] someone said to us and forget the [82:06] millions of good things. So you have to [82:08] change you have to like train yourself [82:09] to do the opposite to hear those little [82:11] kernels of change talk and then I'm [82:13] basically being a mirror but I'm [82:14] amplifying it. So I'm taking these [82:16] little kernels of change talk. I'm [82:18] reflecting back to your own words. So [82:19] I'm not telling you that you should stop [82:20] drinking because it's unsafe at work. [82:22] I'm reflecting to you like you're [82:24] starting to get worried that you might [82:25] have an accident at work and that's [82:26] really serious. And that's kind of [82:28] guiding the conversation forward. The [82:31] other key is that if you meet a point of [82:33] resistance, you want to pivot because [82:34] once you start arguing, whether it's [82:36] about politics or anything, people dig [82:38] in. So if you start arguing with [82:40] someone, you got to find another way. [82:42] You just got to pivot and roll to a [82:43] different tactic because the more you [82:45] argue, the more people dig in on their [82:47] point of view. And it's more about like [82:49] winning the argument than it is about [82:50] moving forward. What if you want to [82:52] change yourself? Are is there a process, [82:55] a system, a methodology to help you [82:57] discover what your ideal behaviors are, [83:00] what your why is, and to implement [83:02] change? That's why I say all the time, [83:03] what's your why? I think that's so [83:05] exciting. Like, we all want to live our [83:07] best lives, whatever that means to us. [83:09] And so, um, having a purpose, having a [83:11] goal is probably the most important [83:13] thing. Motivation is important. We talk [83:15] a lot about motivation, but motivation [83:17] is fleeting. It can slip and slide over [83:19] the course of one day. So you may, you [83:21] know, take kind of a mundane example. [83:23] You want to get in shape and you're [83:25] feeling super motivated one day and then [83:26] the next morning your clock, your alarm [83:28] clock goes off at like 5 in the morning [83:29] and you're tired and it's cozy in your [83:31] bed and maybe you stayed up a little too [83:33] late. Your motivation is going to be [83:35] flagging, right? So if you don't have a [83:36] goal or a reason or a why or a purpose, [83:39] it's going to be really hard to actually [83:40] get up the energy to get up. And so [83:42] figuring out what that purpose is and [83:45] then trying to find ways to enjoy the [83:46] process because if you're always working [83:48] towards a future goal, some people are [83:49] very goal-oriented and that works for [83:51] them. But finding joy in the process [83:53] will help you. So I'll take alcohol for [83:54] example, like not an addiction issue, [83:56] just like making changes to your [83:57] drinking in your life. So if you're just [83:59] like, I should stop drinking because [84:01] drinking is bad for me. That's like a [84:03] relatively vague goal, right? It's not [84:05] really about anything that matters [84:06] specifically to you and it's going to be [84:09] hard to stick to that. If instead you [84:11] think, okay, I, you know, started to [84:13] realize that when I drink every single [84:15] night, I don't get the work done that I [84:17] want to get done because I'm too tired [84:18] and I fall asleep. I don't feel [84:19] refreshed in the morning, so I'm not [84:20] sleeping very well. I'm not getting up [84:22] early to exercise, and that's something [84:23] that really matters to me. I'm not like [84:25] as present with my family as I wanted to [84:27] be. Then it's these all these little [84:29] micro goals that make it much easier to [84:31] make a change. So, you may decide, you [84:32] know, I'm not going to drink. I'm only [84:34] going to drink two days out of the week, [84:35] and when I do drink, I'm going to keep [84:37] it to this amount. But the reason why is [84:38] not some vague recommendation from some [84:40] doctor. It's because like you're working [84:42] really hard at work and it feels good to [84:44] be productive after dinner and you're [84:46] training for a race and you want to get [84:47] up in the morning and run. And so you [84:49] actually notice those little steps like, [84:50] "Wow, it feels great. I woke up this [84:52] morning and I feel so refreshed." Like [84:54] you're reinforcing your goal right [84:55] there. You're not working towards some [84:57] abstract thing that doesn't really [84:58] matter to you. So you want to make these [85:00] like really focused, personalized goals [85:02] and really anchoring it on what is your [85:05] why. And your why may be very different [85:06] than my why or someone else's why. Um so [85:09] it may be you know sleep really matters [85:11] to you or you know you may have a [85:14] different relationship with alcohol. So [85:15] the other kind of example I'd give is [85:17] people are different right? We respond [85:19] differently to things. So some people [85:20] can open a bag of like potato chips and [85:22] eat two and walk away. Some people like [85:24] they open the bag they're going to eat [85:25] all of the chips. And so it's just [85:27] easier not to open the bag. And alcohol [85:29] is like that too. Some people may find [85:30] if they open a bottle of wine or they [85:32] have alcohol in the house they're going [85:33] to drink all of it. And the idea of like [85:36] trying to keep to these small amounts of [85:37] alcohol is actually really hard. And [85:39] it's simpler and easier to just avoid it [85:41] completely or to only drink at a [85:43] restaurant or something. So, you do have [85:44] to understand like how your goals, your [85:46] why, your purpose interacts with your [85:49] response to whatever it is that you're [85:50] working on. And that's going to be [85:51] different for everyone. Are there any [85:53] other things, any other habits that we [85:55] should be thinking about when we're [85:56] trying to overcome an addiction? So if [85:59] we think about alcohol as being at like [86:01] the bottom of the stream, are there is [86:03] there anything else upstream that I [86:04] should be thinking about? So we talked [86:05] about social connections and [86:06] relationships. So I need to be making [86:08] sure that I'm surrounded by people. I'm [86:09] socializing because that's going to be [86:11] an insulator to like stress and [86:13] loneliness which is going to cause me [86:15] discomfort which is going to lead me to [86:16] alcohol. But are there any other things [86:19] that I should be thinking about when I'm [86:21] setting off to make a change in my life? [86:23] Yeah. Yeah. There's a bunch. I think [86:25] first any behavior change whether it's [86:27] alcohol or other. If you're feeling like [86:29] depleted and tired and not your best [86:31] self, it's going to be harder to make a [86:33] change. So, if you think about like any [86:34] big decision you made to change your [86:36] job, to start an exercise routine, to [86:38] leave your partner, you probably didn't [86:39] choose like the day that you were [86:40] exhausted and feeling anxious and [86:42] stressed and not your best self to make [86:44] that change. Like, change is hard. So, [86:45] you want to try to boost up other things [86:47] in your life. Eat well, you know, get [86:49] enough rest, try to exercise, things are [86:51] that are going to help you feel healthy [86:53] and your best best self when you're [86:54] trying to make a change. Is that linked [86:56] to dopamine? Yeah, because I mean so our [86:58] natural reward system, the thing that [87:00] triggers it is exercise, food, sex, [87:02] connection. So, you know, trying to have [87:04] healthy other ways of um of positive [87:08] dopamine release. And so, I think for [87:10] many people, alcohol or substances can [87:12] feel like a way of doing something nice [87:14] for ourselves, like I'm going to this is [87:16] going to help me reduce my stress after [87:18] a bad day at work. So, the goal then is [87:20] not that you just like white knuckle it [87:22] all night and feel really stressed after [87:23] work. It's that you figure out like what [87:24] are some other things that help me [87:25] reduce stress after work? Maybe it's [87:27] going to a yoga class with a friend. [87:29] Maybe it is, you know, spending time [87:31] with my family. Maybe it's getting [87:34] massage or meditating or watching a show [87:35] I like. So, you want to, it's not just [87:37] you're removing the thing that you're [87:38] trying to change. You want to fill up [87:40] the empty space with other things. So, [87:42] what if I fill it up with like Hargan's [87:45] ice cream and burgers because that will [87:49] cause a dopamine hit. Mhm. So presumably [87:52] if I just eat loads of sweets and candy [87:55] then that's going to stop me from [87:57] engaging in addictive behavior. But we [87:59] see that all the time. So that's like [88:00] replacing things. And um you know I was [88:03] reading an article people have probably [88:04] heard of dry January. This idea of like [88:06] not drinking for the month of January to [88:08] rethink your relationship with alcohol. [88:09] I was reading an article that dry [88:10] January has become high January because [88:12] people are just smoking a ton of weed [88:13] instead of drinking. And so it's very I [88:15] think you want to be cautious that [88:17] you're not just replacing the thing that [88:19] you're trying to change with something [88:20] that's also going to cause health [88:21] problems. Now, if having dessert once in [88:23] a while for this, you know, you're not [88:24] getting calories from alcohol and having [88:26] a nice ice cream cone once a week is a [88:29] way of sort of treating yourself that's [88:30] healthier and maybe more aligned with [88:32] your goals. That's fine. I think [88:34] thinking about these things, actually [88:35] thinking about alcohol, the way we think [88:37] about dessert, sunbathing, eating [88:39] processed meats, all of these things [88:41] have risk and benefit in our lives. I [88:43] think where we've gone so wrong with [88:45] alcohol is this idea that it's like a [88:46] healthpromoting [88:47] behavior that you shouldn't be drinking [88:50] for your health. It's not going to make [88:51] you healthier. Um, and also much like [88:54] many things we do that are not [88:55] healthpromoting activities, there are [88:56] ways of reducing the health harms of [88:58] that activity so that it's okay in small [89:00] amounts in your life. I think B2B [89:04] marketeteers keep making this mistake. [89:05] They're chasing volume instead of [89:08] quality. And when you try to be seen by [89:10] more people instead of the right people, [89:12] all you're doing is making noise. But [89:13] that noise rarely shifts the needle and [89:16] it's often quite expensive. And I know [89:18] as there was the time in my career where [89:20] I kept making this mistake that many of [89:21] you will be making it too. Eventually I [89:24] started posting ads on our show sponsors [89:26] platform LinkedIn. And that's when [89:27] things started to change. I put that [89:29] change down to a few critical things. [89:31] One of them being that LinkedIn was then [89:33] and still is today the platform where [89:35] decision makers go to not only to think [89:37] and learn but also to buy. And when you [89:39] market your business there, you're [89:41] putting it right in front of people who [89:42] actually have the power to say yes. And [89:45] you can target them by job title, [89:47] industry, and company size. It's simply [89:49] a sharper way to spend your marketing [89:50] budget. And if you haven't tried it, how [89:53] about this? Give LinkedIn ads a try. and [89:55] I'm going to give you a $100 ad credit [89:57] to get you started. If you visit [90:00] linkedin.com/diary, you can claim that [90:02] right now. That's [90:06] linkedin.com/diary. Just thinking about [90:07] something we said earlier about how [90:09] early childhood trauma causes the brain [90:11] to change and then results in addictive [90:14] behaviors. If I went through an early [90:16] childhood trauma and my brain has [90:18] changed because of that and then I get [90:20] into uh I become addicted to alcohol as [90:23] a as a young man and then I manage to [90:25] find my way off the alcohol. My brain is [90:28] still addicted, right? My brain still [90:30] has that addictive sort of [90:32] predisposition. So isn't it the case [90:34] that I'll just end up being addicted to [90:35] something else that gives me a dopamine [90:37] hit? So it turns out the brain is [90:39] amazingly um plastic meaning it can [90:41] change. We see that over time. So the [90:43] first thing is even adverse childhood [90:45] experiences are not a done deal. So we [90:47] talk a lot about ACEs. We don't talk a [90:49] lot about pieces or PCE positive [90:51] childhood experiences but actually you [90:54] can reduce the risk that someone [90:55] develops addiction by increasing the [90:57] number of positive childhood [90:58] experiences. So take someone who's [90:59] experienced some terrible adversity. [91:01] Their parent has died or they have a [91:03] parent who's in prison or they have [91:05] addiction in their family. If that kid [91:07] has one single adult figure that they [91:09] believe cares about them, that reduces [91:11] their risk of addiction. So there are a [91:13] lot of positive ways that we can [91:14] actually change the trajectory even in [91:16] the midst of terrible trauma. When you [91:18] think about someone who's had a [91:19] substance use disorder, we actually have [91:21] good data on this that after 5 years of [91:23] recovery and often that is fits and [91:26] starts. So most people think of like [91:27] this is one fail swoop that you like [91:29] decide to stop drinking and then success [91:31] is that you never drink again. For most [91:33] people what we find is that's actually [91:34] like a series of steps. So I always like [91:37] to think of progress not perfection and [91:39] not have this kind of all or nothing [91:40] mindset that for many people they may [91:42] early on have a month where they go [91:44] without alcohol and then maybe next time [91:45] it's three months and then maybe it's a [91:47] year and these recurrences happen but [91:49] ultimately they get to this place where [91:51] they go into long-term recovery. After 5 [91:53] years of recovery, a person's risk of [91:55] subsequently developing addiction is no [91:57] higher than the general public. So your [91:59] brain actually does change and we see [92:00] this on functional imaging. We see this [92:02] in longitudinal studies that follow [92:04] people over time. So you actually can [92:06] overwhelm those things and get to a [92:09] place where you don't have a higher risk [92:10] than other people. Because some people [92:12] say, "I've got an addictive personality [92:14] that's they sort of self-label and [92:15] selfidentify as having an addictive [92:17] personality." Sometimes they even [92:18] reference their brain as being easily [92:20] addictive. Is there is there truth in [92:22] that? Is it possible to have an [92:24] addictive personality? It's not so much [92:25] about personality, but we do respond [92:27] differently to substances. So um you [92:30] know, take alcohol or opioids, anything. [92:33] People feel differently the first time [92:34] they ever use it. So often if you talk [92:36] to someone who then develops addiction, [92:38] they tell you that first time they use [92:39] the substance, it was like this amazing [92:41] feeling. It felt like I've had people [92:43] describe it as falling in love or, you [92:45] know, a warm hug or or like a relaxing [92:47] bath. These like incredible comforting [92:49] experiences. Other people, they get [92:51] prescribed like an opioid for a tooth [92:53] extraction. They feel nauseous and kind [92:55] of like not like themselves and they [92:56] don't like the feeling. So how we [92:58] respond to substances is definitely [92:59] based on our neurobiology and is [93:02] different for different people. Um so [93:04] some people are both from a genetic [93:06] reason and and their own brain are just [93:08] more wired to be at risk of addiction. [93:10] And that's important to know about [93:11] yourself because then you can make [93:12] different choices. You may decide, you [93:14] know, never to keep alcohol in the house [93:16] or not to drink because the risk is too [93:18] great. But how much do you think about [93:20] other things that are taking hold of [93:21] society? some of the other things that [93:23] are non substance related. So, social [93:26] media addictions and pornography [93:28] addictions and what else? What else are [93:30] some of the big ones? Food addictions, [93:31] food, sex, gambling. Um, I think there [93:34] are a lot of similarities. It's not my [93:36] particular area of focus, but I think [93:37] there are a lot of overlaps. I mean, I [93:39] think many of the things you just [93:40] listed, you could talk about. One, [93:42] dopamine obviously, but two, this idea [93:44] of needing to fill yourself with [93:47] something else. either, you know, [93:48] thinking about trauma, thinking about [93:50] untreated mental illness, thinking about [93:51] just kind of the deficit of connection [93:54] and of meaning and reward um and [93:56] reaching to these external solutions. [93:58] Can you tell me about a time where [94:00] you've worked with a patient [94:01] who through the process of working with [94:04] them and understanding their trauma, you [94:06] discovered something unexpected about [94:08] the root cause of their addictive [94:11] behavior? Yeah. Yeah. I can think of [94:14] many patients, but one in particular [94:16] who, you know, I I had this I knew that [94:19] he'd experienced hard things in his [94:20] life. He'd been in prison, for example, [94:21] which is a traumatizing experience. He'd [94:24] lost his parents and other thing. I [94:25] never truly understood the depth of his [94:27] trauma and had he had struggled his [94:29] whole life um with substance use [94:31] disorder and and using lots of things, [94:33] mostly opioids, but also alcohol and [94:35] cocaine and um and just had had a really [94:38] really hard time. And after I mean years [94:41] of knowing him, one day he broke down my [94:43] office and shared that he'd actually [94:44] been molested as a young kid. And so [94:46] sometimes there is that like that thing [94:48] that people have never felt like they [94:50] could share with anyone that really is [94:52] at the root of so much of what they've [94:53] been dealing with. And like the person [94:55] who whispered to you, I think the pain [94:57] of keeping that inside. Not only the [94:59] trauma of experiencing that as a child, [95:01] but then holding that secret and feeling [95:03] like you somehow are damaged or you know [95:05] that this this thing inside you is there [95:07] and not being able to heal it, talk [95:10] about it, share it with people. I think [95:12] um is just this like this well of pain [95:14] that lives inside people. Did he [95:16] recover? He actually passed away [95:20] from substance abuse. From substance [95:22] use. Yeah. [95:24] You must carry a lot of this stuff with [95:26] you because your line of work sounds [95:29] like you're dealing with bad news quite [95:31] often, more so than the average person. [95:34] And the news you're dealing with is is a [95:36] different type of news. You're dealing [95:37] with somebody sort of reaching the end [95:39] of their life um through something that [95:41] you also have said many times you [95:44] believe is preventable in many cases. [95:46] How do [95:48] you how do you manage that? Yeah, I mean [95:51] I think a couple things. one um there [95:54] are so many stories of hope that I think [95:56] um counterbalance that for me. So I [95:58] think you know the other stories in my [96:00] mind are you know I carry with me and [96:02] still care for and are in touch with [96:03] people who are living these amazing [96:05] vibrant lives in recovery and in the US [96:07] alone there's 24 million people living [96:09] in recovery. So there are these stories [96:10] of people who have overcome just trauma, [96:13] tragedy, hardship and are doing awesome. [96:15] They're parenting, they're working. You [96:17] probably don't even know they're around [96:18] you. you know, they don't tell people [96:20] necessarily that they're in recovery. [96:21] And getting to be sort of a part of that [96:23] process with someone and watching, you [96:26] know, there's nothing in medicine where [96:27] I can actually see as dramatic of a [96:29] change as with addiction, where someone [96:31] can be, you know, at a moment where [96:33] they're dealing with all of these health [96:34] consequences and relationship challenges [96:36] and then they get better and it's just [96:38] like the most beautiful thing to be a [96:40] part of. And so, I think the hope from [96:41] that, the sort of positivity of it is [96:44] what keeps me going every day. Obviously [96:46] finding ways to care for myself through [96:47] that and family and connection, [96:49] exercise. I run, I write, you know, you [96:51] gota you have to keep yourself whole [96:53] through it all, too. But I think I get I [96:55] get tremendous purpose and mostly like a [96:57] lot of hope from working with people and [96:59] seeing them recover. What is the most [97:00] important thing we didn't talk about [97:01] that we should have talked about? [97:04] I think one thing is language. It's like [97:06] this subtle thing. I sort of mentioned [97:08] an example where you did it really well [97:09] where instead of saying someone failed [97:10] treatment, you said the treatment failed [97:12] them. But a lot of the language that we [97:14] use with addiction actually subtly and [97:16] not so subtly worsen stigma. And [97:18] sometimes this sounds like I'm being [97:20] politically correct or it's like an [97:21] issue of semantics, but there's actually [97:23] really good data on this. So if you [97:24] think about words we use for addiction, [97:26] one is substance abuse, right? So the [97:28] term abuse, what does abuse refer to? So [97:30] it actually comes from an old English [97:31] word that means like a willful act of [97:33] misconduct. And it's a word that we use [97:35] for child abuse, for sexual abuse, for [97:37] domestic abuse. like it's only for these [97:39] like terribly violent acts of commission [97:42] that are very stigmatized because [97:43] they're like terrible things. And yet we [97:45] use it for this thing that we're saying [97:46] as a health condition that you're like a [97:47] substance abuser or you have substance [97:49] abuse. And so there have actually been [97:51] these elegant studies that took like PhD [97:53] level psychologists, really highly [97:54] trained clinicians, and they described a [97:56] person as either a substance abuser or [97:58] as a person with a substance use [97:59] disorder. And the clinician was actually [98:01] more likely to recommend a punitive [98:03] intervention for the person described as [98:04] a substance abuser. What does that mean? [98:06] So in this case, they were given like an [98:08] option. You read this paragraph about a [98:10] p about like a fictional patient and [98:12] they don't really know what the [98:13] researchers are testing and they're [98:14] given a bunch of different options for [98:16] intervention and one is this like send [98:18] them to drug court or send them to jail. [98:20] One is like offer them, you know, [98:22] outpatient effective treatment. There's [98:24] a bunch of different choices. When they [98:25] hear someone described as a substance [98:27] abuser, they're actually more likely to [98:28] recommend the like jailbased [98:29] intervention. [98:31] So words actually like very in they [98:33] influence how we think even how we make [98:35] clinical decisions. They've also done [98:36] this to the public. So if you describe [98:38] someone as a drug addict the public has [98:40] a more negative view of them than if you [98:41] describe them as a person with [98:43] addiction. So there are these subtle [98:44] ways there's been this shift in [98:46] addiction to really using what we call [98:48] person first language which has been [98:50] true across medicine. So like we used to [98:52] use terrible words like we'd refer to [98:53] someone as like the schizophrenic you [98:55] know or really labeling them as their [98:57] health condition. And thankfully there's [98:58] been a change from that to realize that [99:00] people are people first who have an [99:01] illness or not defined by it. So I would [99:03] never say like I'm going to go see the [99:05] lung cancer in room 204. I'd say I'm [99:07] going to see you know Mr. Smith who has [99:09] lung cancer. And so with addiction too [99:10] like people are more than that. So to [99:12] say you know person with addiction [99:14] person alcohol use disorder rather than [99:15] saying they're an addict or an [99:16] alcoholic. And then even terms like [99:18] clean and dirty which are commonly used [99:20] when we talk about addiction. So you [99:22] know take the word clean. It sounds [99:24] really positive. Like you're saying, [99:25] "Oh, you're clean." But like what are [99:26] you really saying? So you're saying [99:28] like, "If you're clean now, when you [99:29] were actively struggling, what were you? [99:31] You were dirty." And so I always [99:34] remember an example, a friend of mine [99:35] who's in recovery was interviewing for [99:37] jobs in the recovery space. And so [99:39] people on the on the interview trail [99:40] would say to him like, "How long have [99:42] you been clean for?" And he would say, [99:43] "Well, I've been bathing since I was a [99:44] newborn. So I've been clean my whole [99:46] life and I've been in recovery for five [99:48] years or whatever." So, I think these [99:50] little things actually matter that we [99:52] should use terminology that we'd use for [99:54] another health condition. If we're [99:55] labeling, you know, people with active [99:57] addiction as dirty or, you know, people [99:59] with addiction is the same as child [100:01] abusers with that sort of language, um, [100:03] we're really sort of subtly increasing [100:04] stigma. So, that's a small thing that we [100:06] can all do is just try to use language [100:08] that's a bit bit more humanizing. It's [100:10] so interesting because I was aware of [100:11] this, but I still found myself [100:13] accidentally using the word abuse. Yeah. [100:15] And I' I'd stumble into it. Go [ __ ] [100:18] um I try to avoid the use of the word [100:20] addict. Yeah, it's hard to change, but [100:23] you know, like everything you just want [100:24] to be humble, curious, and keep trying. [100:26] I mean, there's lots of language that [100:28] we've changed. Like, think about so many [100:29] terms we use for, you know, for you [100:32] know, people who are born with different [100:33] abilities or for people of different [100:35] races or other identities that were [100:37] really stigmatizing and we've like [100:39] learned to use different language even [100:40] if it feels a little awkward when you're [100:42] first learning it. I think understanding [100:43] the science and the data behind the [100:45] impact it has to use certain language I [100:47] think is really useful. Yeah. Because [100:49] that's helped me to understand just [100:50] because now I understand the first [100:51] principles of it. I need to make sure I [100:52] describe people as a person first. So a [100:55] person with addiction addiction is much [100:57] better than calling someone an addict. [100:59] Yep. Exactly. And one thing people ask [101:01] me will say well what if someone refers [101:02] to themselves that way because people [101:04] may do that and that's I'm that's fine. [101:06] People can use whatever language they [101:08] want for themselves. But I think as a [101:10] health care professional for sure or [101:11] someone who's trying to help combat [101:13] stigma, like we can choose to use [101:15] different language. And I've actually [101:16] had patients sort of ask me like, well, [101:18] why do you use that terminology when [101:19] they use a different language? And it [101:21] actually can be sort of empowering to be [101:23] like, oh yeah, I'm actually a person in [101:24] recovery or I'm a person with addiction. [101:26] I'm not going to label myself that way [101:28] anymore. [101:30] Something I've been really um curious [101:31] about just in my life generally because [101:32] in conversation, I'll often I said [101:34] something yesterday when we were at [101:35] dinner with with the team here. I said, [101:38] I can't remember the exact phrase, but [101:39] it was words to the effect [101:43] of I'm not good at that or I'm not that [101:46] type of person or I'm [101:48] not organized. And I stopped myself and [101:52] the team will remember and I go actually [101:53] I shouldn't say that. I should say right [101:56] now uh was you're like defining yourself [101:59] as incapable of doing something instead [102:01] of being like I'm working on [102:02] organization right now. I think it's so [102:04] important and we don't think about it [102:05] how casually we create an identity for [102:08] oursel that is like fundamentally [102:09] limiting or puts us in a box or frames [102:12] us having a deficit or captures our [102:14] whole identity and some kind of [102:15] deficiency we have often in the case of [102:18] the habits I'm referring to does this a [102:20] similar thing take effect when we're [102:22] talking about calling someone an addict [102:24] yeah you're sort of labeling them as [102:25] that is the only thing that they are and [102:27] that they will be that forever and you [102:29] know um a friend of mine who's a [102:30] journalist who is in recovery and writes [102:32] a lot about addiction. My Solivitz wrote [102:34] this great New York Times piece that [102:36] addiction doesn't always last a lifetime [102:37] because I think there's this idea in our [102:39] head that like you know people with [102:40] addiction will always have addiction and [102:42] it's this like incurable thing and that [102:45] actually people have lots of different [102:46] journeys and for some people you know [102:48] that becomes something they deal with [102:50] and then they move on their lives. For [102:51] other people it's something that they [102:52] actively manage. But this idea that you [102:55] sort of boil things down to like the [102:57] only thing I am in this world as a [102:58] person with addiction, um, you really [103:01] limit everything else about [103:02] yourself. We have a closing tradition on [103:05] this podcast where the last guest leaves [103:06] a question for the next, not knowing who [103:08] they're going to be leaving it for. And [103:09] the question that's been left for you [103:12] is, if you could redo or revise one [103:17] thing that you have successfully [103:21] accomplished, what would that be and [103:23] why? [103:25] I guess I would say, and I could think [103:28] of lots of successful accomplishments [103:31] I'd apply this to, but I'll take the [103:32] example of medical training, which is a [103:34] successful accomplishment. I think I [103:36] would be more present that we are always [103:38] like rushing to the accomplishment to [103:40] the finish line to sort of getting to [103:42] the next goal and I think back and wish [103:46] I had realized what an amazing journey [103:48] it was in that moment and I mean even [103:50] things with medical training that I was [103:52] I was never going to be a heart surgeon [103:53] but to stand in an operating room and [103:55] look inside someone's chest and watch a [103:58] beating heart is an experience that I'll [104:00] never get again and I think in this [104:01] journey to always achieve and move [104:03] forward and get to the next exam and the [104:04] next thing we sometimes miss like the [104:06] miracle that's right in front of us. And [104:08] so I think I would have um been even [104:10] more present. [104:12] That applies to all of us. I felt like I [104:15] was being called out. [104:19] True for parenting, true for everything. [104:22] Thank you so much. I'm so grateful for [104:24] the work that you're doing because [104:25] there's so much there's so much um [104:27] conflicting information, especially as [104:29] it relates to alcohol. There's been so [104:31] much information over the last 5 10 [104:33] years about um the impact alcohol has on [104:35] us. And I've sat here and and had [104:37] conversations with people who are pretty [104:39] convinced that even, you know, moderate [104:42] levels of alcohol are good for us. And [104:44] having read your work, I'm now clear on [104:46] what the truth there is. Um thank you [104:48] for doing what you do. It's incredibly [104:49] important. And I actually think it's [104:51] going to become increasingly important [104:52] unfortunately because the way that the [104:54] world is heading, the loneliness [104:56] epidemic that we're experiencing and um [104:59] the the access we now have to digital [105:01] devices and to um lowcost consumption of [105:04] addictive substances is is terrifying [105:06] for me. I know you've got a book on the [105:08] way which I'm extremely excited about [105:09] which is due in autumn, next autumn. [105:11] Spring of 27. So we have Okay. And [105:14] what's that book about? Can you give me [105:15] a give me a clue? I mean, I could gasp. [105:18] It is going to be about changing the [105:19] narrative around addiction and um about [105:22] really reframing how people think about [105:24] it to see it as a treatable good [105:26] prognosis illness and using some of the [105:28] stories of people I've had the privilege [105:29] of knowing to hopefully help people see [105:31] things in a different way. Where do [105:33] people find you if they want to reach [105:35] out or learn more? Yes. Um they can find [105:37] me on LinkedIn, on Instagram, they can [105:40] email me. Um yeah, happy to connect and [105:43] would love to come back after the book [105:44] is out too. I look forward to that. I'd [105:46] love to. So, your Instagram, your [105:48] LinkedIn, I'll put those details below. [105:50] I'm sure you'll probably get a lot of [105:51] messages. Great. Um because these issues [105:53] in particular are incredibly um [105:56] incredibly potent issues in people's [105:58] lives and um very emotional issues as [106:00] well. So, thank you for on behalf of all [106:02] my audience, thank you for your [106:03] generosity today, but also thank you for [106:04] your wisdom. Really, really appreciated [106:06] and I would love to speak to you again [106:07] soon when the book is out. Thank you. [106:09] Thank you for having me. [106:13] This has always blown my mind a little [106:14] bit. 53% of you that listen to the show [106:17] regularly haven't yet subscribed to the [106:19] show. So, could I ask you for a favor? [106:21] If you like the show and you like what [106:22] we do here and you want to support us, [106:24] the free simple way that you can do just [106:25] that is by hitting the subscribe button. [106:27] And my commitment to you is if you do [106:29] that, then I'll do everything in my [106:30] power, me and my team, to make sure that [106:32] this show is better for you every single [106:34] week. We'll listen to your feedback. [106:36] We'll find the guests that you want me [106:37] to speak to and we'll continue to do [106:39] what we do. Thank you so much. Heat. [106:40] Heat. N. [106:43] [Music] [107:00] [Music]