Transcript of Dr. Sarah Wakeman on The Diary of A CEO Podcast

So I train doctors who want to be specialists in addiction medicine.

The Problem with How We Treat Addiction

STEVEN BARTLETT: When you think about how we treat addiction in the modern world, what are some of your gripes? Where are we going wrong?

DR. SARAH WAKEMAN: Oh, how much time do we have? Where do we begin? I mean, I think at its core, the biggest problem is that we’ve all been taught and sort of infused in this idea that addiction is an issue of behaving badly, that it’s an issue of morality, that people really need to kind of knock it off and pull themselves up by their bootstraps, and that this is like a criminal legal issue, that it’s an issue of willpower.

And so if you believe those things, then why would you think that someone should get medical care? Or why would you treat them with compassion and kindness if you think that they’re doing something wrong? And so really, reframing how we think about addiction based on all of the science we have and what effective treatment looks like, which often is very different than what people may have experienced if they were trying to access care for themselves or a loved one.

What Defines Addiction?

STEVEN BARTLETT: And what is an addiction? What falls into the bucket of addiction? You know, because I use my iPad a lot. I use my phone a lot. Is that an addiction?

DR. SARAH WAKEMAN: Yeah, it’s a great question because we use that term colloquially a lot. You know, I’m addicted to Netflix or whatever. So addiction is really defined by use despite consequences. So continuing to do something in your life despite bad things happening to you because of it.

So we talk of addiction. We talk of the four Cs as a way to remember it. So one C is loss of control, meaning like, you’ve tried to change and you haven’t been able to, so you’ve tried to cut back or you’ve tried to stop and you couldn’t. The other is compulsive use. So your use is like spiraling out of control that you’re kind of using in a way that isn’t really attached to your rational thinking. The next is consequence. So continued use despite negative consequences either in your life, your job, your relationships, your health. And then the last C is craving, which is this sort of strong psychological urge to want to use. Like, you can’t get the idea of having a drink out of your mind.

And so it’s really those four Cs that we think about. And then we make the definition based on how much criteria people meet out of this 11 list of different criteria. And based on that, people can have a mild use disorder, moderate or severe. And so moderate, severe is really what we think of as addiction. But it’s that use despite bad things happening to you.

STEVEN BARTLETT: And what things are capable of being addictive?

DR. SARAH WAKEMAN: Yeah, lots of things. I mean, I focus mostly on alcohol and drugs, so alcohol obviously probably most common. I think we’ll talk about that a lot today, which I’m excited about. And certainly when we look worldwide for 400 million people have an alcohol use disorder, meaning addiction to alcohol. It’s a lot of people.

The other are drugs. So that can be opioids like heroin or pain pills or fentanyl. It can be cocaine or stimulants like methamphetamine or prescription stimulants, sedatives that people may take for anxiety, like benzodiazepines, cannabis. And so there’s a whole sort of range of substances that can be addictive. And how addictive a substance is is really related to sort of how much dopamine is released in the brain. I know you’ve had a wonderful episode with Dr. Lembke about DOPAM. So you’ve talked about that a bit. And there are different sort of addictive indices of different substances. So cannabis is less addictive than methamphetamine, for example. But all of those substances can cause addiction in people, even beyond that.

STEVEN BARTLETT: I wonder sometimes in my life if I’m addicted to other things. Like I’m going to drink coffee every day, certainly get a craving to drink it now.

DR. SARAH WAKEMAN: Yeah, well, there’s, you know, a couple important pieces there. Is your coffee drinking causing harm in your life in any way?

STEVEN BARTLETT: No, I think it’s. I think it helps.

DR. SARAH WAKEMAN: It may be helping you. Right? Yes. It’s not addiction. So there is a difference between physiologic dependence, meaning like if you don’t drink your cup of coffee, you’re going to get a headache, and addiction, meaning that you’re spending all your day and all your money buying more and more coffee. We don’t really see this. But buying more and more coffee despite, you know, your girlfriend nagging you about it and you’re late to work because you’re purchasing coffee, we don’t really see that so much with coffee. But that would be sort of addiction.

The Scale of the Addiction Problem

STEVEN BARTLETT: And how big is the problem? So if you were to frame like, why should we care? Why should the person listening to this care? Because I imagine it’s the case that many people here don’t have an addiction that fits into the category of having severe consequence for their life. I also imagine some people are under the impression that addiction is something that happens to other people.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: So can you frame the situation for me and explain to me why we should all care about this and the, I guess the scale of the impact it’s having?

DR. SARAH WAKEMAN: Well, I guarantee that many people listening have been touched by addiction, either personally or in their lives. Because of stigma. We tend not to talk about that, but the scale is huge. So globally, 2.6 million people every year die from alcohol related causes. So that’s 7,000 people today will die from an alcohol related death. Another 600,000 people die from drug related deaths annually. So that’s like 1600 deaths today from drug related causes.

And then when we look at the criteria, sort of meeting criteria for a substance use disorder or addiction, it’s about 400 million people worldwide for alcohol and 80 million people for drug use. So it’s incredibly common. If you think about alcohol, some studies estimate that the lifetime prevalence, meaning over the course of your life, how likely are you to at some point develop alcohol addiction, somewhere between 15 and 30% in some studies. So one in three people may have a problem with alcohol at some point in their life.

So this touches all of us. We just don’t talk about it because of stigma and because of these mental images of kind of othering that, you know, it’s only those people who are injecting heroin who have addiction or that person who, you know, has the shakes every morning and is drinking as soon as they wake up, who has a problem with alcohol.

The Pandemic’s Impact on Addiction

STEVEN BARTLETT: And which direction are we going in as a society? Are we getting better or are we getting more addicted?

DR. SARAH WAKEMAN: Yeah, great question. The pandemic was not kind to addiction. So we saw rates of alcohol and drug use and deaths related to those increase significantly after the onset of the COVID pandemic. That has started to level out. So for drug use related deaths, we’re now back at the pre pandemic levels. But there was a very significant increase during the time of the pandemic. And that’s really not surprising when we think about what are the things that drive people to use alcohol or drugs in a problematic way.

STEVEN BARTLETT: I was looking at some of the, some of the life expectancy graphs and this one in particular I found quite shocking. I’ll throw it up on the screen. But it shows that obviously, you know, we would expect that there was a drop in life expectancy during the pandemic, but even when you compare it to other countries, it’s not as significant. So I’m wondering why in your view there was such a significant decline in life expectancy during the pandemic.

DR. SARAH WAKEMAN: Yeah. So obviously Covid was one driver. One of the main other drivers was substance related deaths. So actually immediately following the onset of the pandemic, so beginning March, April of 2020, we saw a 23% increase in alcohol related mortality and we saw the highest rates ever we’ve seen of drug related overdose deaths. And that actually impacted us life expectancy up until this year. This is the first year that we’ve.

STEVEN BARTLETT: Seen that change at the essence of what’s actually going on there because you know, addiction is downstream from something else. But what is actually going on?

The Root Causes of Addiction

DR. SARAH WAKEMAN: Yeah, so that’s a really great question. Like what drives people to use substances? It’s actually probably the most important question even in my work. You know, if you don’t understand what someone’s substance use is about or related to, how are you ever going to address it or help them address it?

So trauma is probably the single biggest driver. So you know, you often hear things like, cannabis is a gateway drug. I would say trauma is the gateway drug. If we look at many, many studies, there are kind of two different things that drive someone’s risk of addiction. One is genetics. It’s about 40 to 60% genetics, similar to diabetes. In terms of someone’s risk, that’s not a done deal. Obviously, there are people with strong genetic risks who never develop addiction and people without that who do.

The other half of the equation is based on kind of exposures and your experiences. And one of the number one drivers is what we call adverse childhood experiences. So there is this famous study called the ACEs study, which stands for adverse childhood experience, and it’s been replicated. There’s a recent one done actually in Europe as well, that looks at the number of adverse childhood experiences you have, and it’s a linear track increase in terms of your risk of substance use disorder.

So if you think about what’s happening in the brain with substances, you know, when we use alcohol or drugs, all sorts of feel good hormones are released, right? Dopamine, your endogenous opioid system, which is literally your natural pain reliever. And if you take someone who’s experienced trauma, there’s great relief that people can find in substance use.

And so we saw that in the pandemic, like what was going on in the pandemic, people were scared, they were bored, they were lonely, they were stuck at home. They didn’t have their usual routine. Some people were losing people that they loved. And so we saw all of this escalating substance use. And it was actually most pronounced in people who are frontline workers. So that could be a health care provider. It could also be someone working in a grocery store or a convenience store who had to work through the scariest times of the pandemic. And also people who are caregivers. So those are kind of the two groups that had the biggest increase in their substance use during the pandemic.

STEVEN BARTLETT: What is going on in the brain? You referenced it a little bit there. You referenced that dopamine makes you feel good. So, you know, very naively, I would assume a case, if you feel bad, dopamine makes you feel good, you want more dopamine. But is it more complicated? Complicated and nuanced than that?

How Alcohol Affects the Brain

DR. SARAH WAKEMAN: Yeah. Well, alcohol is a really complicated one because alcohol has lots of different effects on the brain. So any drug or substance that can cause addiction is going to release dopamine. That’s sort of a primary driver of many things that we find rewarding, whether it’s sex or food or alcohol or drugs, but alcohol also. So it binds to the part of our brain, a system called gaba, which is sort of our anti-anxiety system. So it’s the same system that anxiety medications like people may have heard of Ativan or Lorazepam or Xanax, these medications that are kind of sedatives and anxiety meds.

Alcohol acts on that part of the brain and it actually then causes a release of your endogenous opioids in your brain. So like your brain’s natural painkillers. So that’s actually why one of the medications that’s effective in helping people stop drinking actually just blocks the opioid response in the brain, which doesn’t make sense when you first hear about it until you understand these neural mechanisms that actually your sort of natural painkiller system is activated by drinking. So when you hear someone talk about alcohol, gives them pain relief, whether that’s emotional or physical, that’s a very real thing. That’s a powerful system in our brain that gets activated when you’re drinking.

STEVEN BARTLETT: So if I’m having a stressful time at work and work is making me anxious and is crippling me, then I’m more likely to want to have a big blowout on the weekend. Because that’s effectively a pain medication.

DR. SARAH WAKEMAN: Totally. It’s an anti-anxiety and a pain medication sort of all in one. And I think often this is part of the area where I think just getting more awareness and education about alcohol is so important because we see that as a way of treating ourselves right. And it’s very easy to have that get out of control. And I think, especially if in your head, you think, as long as I’m not like drinking in the morning or missing work because of drinking or having problems in my relationships, I’m fine. But actually there’s so many health problems and even life problems related to alcohol that people may make different decisions for themselves if they had that awareness.

Trauma and Addiction Risk

STEVEN BARTLETT: Earlier on, I was thinking about a friend of mine who is fairly well known, passed away from issues related to his addiction. Yeah, he had a lot of pressure on him when he was fairly young. He wasn’t necessarily a young child when he had a lot of pressure put on him, but he was young. And I was wondering, as you said, childhood experiences, what age that is?

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Is there like a certain age where those experiences, you know, if you experience a certain level of trauma at a certain age, it’s harder to recover from that and you’re more likely to be addicted?

DR. SARAH WAKEMAN: Yes, that’s a great question. Trauma at any time can put you at risk for addiction. The earlier that happens, the more sort of long lasting the impact can be. So when we think about the brain, your brain doesn’t really fully form until early to mid-20s. And so both in terms of trauma, but also in terms of early substance exposure, you’re at much greater risk when you’re younger. But that doesn’t mean that trauma in later life doesn’t put you at risk for developing substance use as well.

So I’ve seen people who their first trauma was in their 20s or 30s or 40s, and they can still develop a substance use disorder. It’s just the risk is even greater when you experience those adversities as a child. And the interesting thing is trauma is not so much about the experience. It’s about often being left alone to grapple with that experience by yourself. And so what’s traumatizing to one person may not be traumatizing to someone else.

And take the pandemic, for example. I’ve talked to people who being stuck at home and alone and bored was deeply traumatic. Other people were fine. They were in their living room, you know, doing whatever, and found ways to connect and to live their lives and did okay. It was the same experience, but it was experienced very differently by different people. So it’s less about the actual experience and more about the impact on that human, how they’re left feeling. And often it’s about feeling disconnected. We often talk about the opposite of addiction is not sobriety. It’s actually connection. It’s how do you build that connection with other people?

Isolation and Celebrity Addiction

STEVEN BARTLETT: Again, my friend that I was referencing is Liam Payne, who’s from One Direction, the boy band who passed away. And he was on my podcast a few years before he passed away. And on the show he said that much of what made his early life so difficult as a teenager was he was obviously thrust onto this big show. And then the way it worked was, you know, all this public spotlight, and then they’d like put him up on a stage and he’d be in front of 100,000 people in Dubai.

And then they, after that experience, he was then, like, driven back to a hotel room and, like, locked in the hotel room because obviously you can’t go out because you’re that famous, that if you walk out on the street, the crowds are going to emerge. So he was then locked in that hotel room. And on the show he said, I was locked in that with the mini bar, which is full of alcohol. Yeah, So I would drink, and that cycle would repeat itself, and he’d be like, stage, you know, car, hotel, locked, drink, stage, car, and that cycle repeat itself. So when you were talking about isolation and loneliness as well, I never really considered the fact that connection and social relationships could play a role in help, in creating an addiction in someone. But it’s. It tracks totally.

DR. SARAH WAKEMAN: I mean, it makes me think of a patient I saw this week who really wants to stop drinking and is able to go for a few weeks, but his life is pretty empty. Like, he’s not working right now. He doesn’t have a lot of relationships. So when he’s not drinking, he’s sitting at home, like, watching TV by himself. And it doesn’t take very long for him to think that, like, you know, the thing that’s going to give me relief is having a drink. And so then the question becomes less about the molecule of alcohol and more about, like, how do we fill up people’s lives? How do we form connection and build community and build a sense of identity and purpose and engagement outside of relief of substance use?

Personal Connection to Addiction Medicine

STEVEN BARTLETT: You’re clearly extremely smart. And when I meet people like you, I always think to myself, you could have committed your life to anything. You could have worked in pretty much any field, and you would have been a success because you have what it takes to be successful. So why do you care so much about this?

DR. SARAH WAKEMAN: Yeah, I think, like many people, I had kind of a personal thread. I had a family member who was impacted by addiction, who actually died when I was in medical school. And so that was a sort of a pivotal moment, I think. But coming at the same time that I was learning all of this science, I was realizing, like, wow, I wish I’d known this when I was younger. And dealing with family members and friends who were affected by this and that, we’ve gotten it so wrong. And most people don’t have the kind of tools and knowledge to do things differently. And so, you know, you sort of. There’s that saying, when you know better, you do better. And I think I kind of wanted to put out into the world what I wished was there for other people.

STEVEN BARTLETT: An immediate family member. And what age were you when you lost that person?

DR. SARAH WAKEMAN: Probably 24 or so.

STEVEN BARTLETT: From addiction.

DR. SARAH WAKEMAN: Yep.

The Family Experience of Addiction

STEVEN BARTLETT: When you’re dealing with a family member or someone close to you that has an addiction, so many people listening will be able to relate to that feeling.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Can you describe that? What they feel? I guess an attempt to make them feel seen. Because sometimes, especially in hindsight, if you end up losing that person. You can be filled with lots of feelings of guilt or misunderstanding and especially thinking about how society’s moved on. So how do you put into words how it feels to be a family member with someone dealing with addiction?

DR. SARAH WAKEMAN: Yeah, I think you feel powerless. You feel like you want to do something and you either don’t know what to do or feel like everything you’ve tried hasn’t worked. I think again, because people have been exposed to this idea that it’s an issue of willpower or choice, which really implies that if people wanted it bad enough, they could just stop. And so if you’re a family member, then that’s easy to feel like, oh, they don’t love me enough, you know, that they’re not choosing me over this substance.

And so I think often people feel deeply hurt and they’ve been through experiences that have created trauma for themselves. There’s a lot of trauma within families who are experiencing this. And then they’re sometimes given really bad advice, you know, that you have to, like, kick someone out or this whole concept of kind of tough love and that people need to hit bottom. And so sometimes people, you know, either do that and then wrestle with the guilt of was that the right thing or not? Or they feel bad, even, like, being kind or loving to their family member.

So I think there’s a whole mix of feelings. And of course, if you lose someone, you always wonder, what if, like, could I have done something differently? Could something else have changed? And I think people can feel angry and sad and guilty and be left with that.

STEVEN BARTLETT: What did those people in your life need that you lost that they didn’t get?

DR. SARAH WAKEMAN: I think they needed science based treatment and compassion and empathy. And I think they needed a world where addiction was not seen as something to be ashamed of or something that we judge, but rather something that is a problem. You know, the shift from like, you are the problem to like, you have a problem and we can help you with this. And I think too often we have approached it as if, like, you the person are the problem.

STEVEN BARTLETT: Do you sometimes think back and think, if, if I’d done something differently, whether it was you or someone else around you or the system around that individual, they would still be here today. Because I think that was the first thing that sprung to mind. I played back all the decisions that I made and I thought, okay, maybe that was bad advice that I was given. Maybe I should have been, you know, maybe I could have called more. Maybe I could have intervened here. Maybe, you know, maybe there’s something else I could have done.

DR. SARAH WAKEMAN: Absolutely. I mean, I think about that all the time. And, you know, I think. I think of a friend I lost to overdose. I think of a family member I lost to alcohol. And not only things that I could have done differently, but also, you know, those people, they saw their doctor, they were in the hospital, they had all these touch points, all of these, like, reachable moments where someone could have engaged with them and offered them kindness and actual effective care that’s backed by science, and they weren’t. And so there are all of these, like, missed moments and missed opportunities.

But the other thing I think about is, like, how much time I lost with them. Because I think often in this model of, like, tough love and kicking people out or thinking, like, I’m not going to see you until you stop using or stop drinking, because I think that’s going to help make them make that change. You lose out on, like, all of these moments of time with people that you love, and you can’t get those back.

And so there is this problem, I think, in that binary model of, like, you’re either, like, sober and in recovery or you’re actively using. And this is good and that is bad, is that we lose the fact that, like, people who are struggling with addiction are amazing, funny, loving people who have a problem that they’re dealing with. But if someone was dealing with cancer, you wouldn’t, like, not want to spend time with them. You know, you miss all of that time. And, you know, both cases that I’m thinking about, like, I’ll never get that back.

STEVEN BARTLETT: There’s a phrase I had many years ago which I’m now reconsidering, which is change happens when the pain of staying the same becomes greater than the pain of making a change. And that kind of dovetails into this idea that someone needs to hit their own rock bottom for them to change. I think the part of the reason why that idea prevails is because we hear so many stories. I hear them on this podcast of someone’s family rejecting them, throwing them out on the street, and then them having that eureka moment, that, fuck, I need to change my life. And people always reference that, like, rock bottom moment where they took action because, you know, they were at the very bottom of the well. And how does that phrase sit with you? Change happens when the pain of making a change becomes greater than the pain of making a change.

DR. SARAH WAKEMAN: I think that there are those times, for sure. It’s not to discount that. And I hear those stories, too, but from evidence what we know, there are probably more times where people just endure the pain again and again and again until they never change. And I think the part that we don’t see are the folks who change happens when they begin to get enough hope that things could be better for them. That someone loves them, someone cares enough that they’re reaching out a hand in the darkness, that there actually is a path forward.

I think people stay stuck when they feel hopeless, when they feel like nothing could ever change, that they’re never going to get this, they’re never going to be able to change, their life would never get better.

And so, take the example I’ll often hear from family members when their loved one is in jail that they’re like, thank heavens, you know, they’re in a safe place at least. Like there’s actually this sense of relief, there’s even a term for it called a “rescue” that people feel. I think it just goes to the desperation that families are dealing with.

But this idea that like, that’s a safe intervention. And you hear these stories, right, as someone who they get locked up and like that’s their eureka moment. And yet if imprisonment were an effective intervention for addiction, for example, we wouldn’t see that actually the time after getting released from prison, there’s 130 times increased risk of dying from a drug related cause after people leave prison. And that your risk of dying ever from addiction is much, much higher if you’ve ever been imprisoned.

And so there are those stories, but we tend to elevate those amazing narratives. And we miss the fact that so many other people are going to die in pain and alone and isolated because they have no hope. And so it’s not to discount those moments. And some people are incredibly resilient and against all odds, even with the most trauma they can make it through. And that’s incredible. But that doesn’t mean that we should create a system that makes it as hard as possible on people.

STEVEN BARTLETT: So would you say that if we are trying to help someone change, really it’s about hope, it’s about the strength of their why, and it’s about love and empathy and connection.

DR. SARAH WAKEMAN: Absolutely.

STEVEN BARTLETT: Is there anything else missing?

DR. SARAH WAKEMAN: And it’s about effective treatment and treatment.

STEVEN BARTLETT: Okay, which is subjective. Right. Which could be depending on the situation they’re in.

DR. SARAH WAKEMAN: It depends on the type of addiction and their situation. But in most cases it’s some combination of psychotherapy, medication.

The Journey of Alcohol in Society

STEVEN BARTLETT: So alcohol. Yes, there’s. I mean, alcohol’s been on a journey.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: It’s been on a journey in terms of society’s opinion about it. Can you take me on that journey and tell me where we are now? And when I’m saying that, I’m talking about society’s opinion on its health benefits and what it is, and then also what we’re getting wrong now about alcohol.

DR. SARAH WAKEMAN: Yeah, the journey of alcohol is fascinating. So first, I think we think of this as a relatively modern thing, but archeologists have discovered beer making equipment in hunter gatherers’ cave dwellings from 13,000 years ago. That’s wild. Like 13,000 years of people figuring out how to make beer. You know, you look at China 9,000 years ago, it was really about a spiritual journey or a social thing. It was never really about health.

At some point we started talking about this as something that is good for your health, like drink red wine, it’s going to improve your health. And that’s where I think we got wrong. And the reason why was actually from how we were looking at the data.

So first, if you look at only one health condition, there are some health conditions where a moderate amount of alcohol actually improves your health. But it was also how people were conducting the studies. So in most of the studies, what people do is they take a massive population, tens of thousands of people, where we have some data where they’re reporting how much alcohol they used. And then we look at health risks over time.

Scientists would lump people into sort of non-drinkers versus light drinkers, moderate drinkers, or heavy drinkers. And what they were finding is that people who are drinking even up to the moderate level were actually doing better than the people who weren’t drinking at all. And so that was where that concept that drinking is good for your health came from.

People talk about this like J-shaped curve, meaning that moderate drinkers actually have lower risks of health problems. And then it’s really only when you start drinking very high levels that you start having more risk of health problems than people who don’t drink at all.

What they realize is wrong with that is that in the people who don’t drink at all, many of those people are not drinking because they’re actually really unhealthy for another reason. Like they might have heart failure and they don’t want to drink because they don’t want it to mix with their medication, or they might have had a history of alcohol use disorder and they’re actually in recovery. So they’ve already had some damage from alcohol and they are not drinking because of that.

And so when you change the reference group, you actually make the group that you compare people to, to people who very rarely drink. So it’s not that they’re not drinkers at all, but they drink very, very light levels. Then you start to see that those health benefits of alcohol go away, especially if you look across all conditions.

STEVEN BARTLETT: Are you telling me that there’s no healthy level of alcohol consumption?

DR. SARAH WAKEMAN: Yes. I would never say drinking alcohol is good for your health. That doesn’t mean that drinking at what we call low risk levels can’t be a part of a healthy lifestyle. So it’s a slight shift that, don’t fool yourself into thinking that drinking that glass of wine is like going to exercise for 30 minutes. Like, it’s not something that’s going to promote your health.

I think of it more like having dessert, eating bacon, going out in the sun. There are risks associated with all those activities. It doesn’t mean that I would say you can never do any of that, but you need to understand what the risks are and then make sure choices for yourself.

STEVEN BARTLETT: Say I look at this glass of wine here and this pint of beer, if I drank one of these a day, not a huge amount. I think what people tend to think is they think, well, it’s only one, so my body will just flush it out and there’ll be no adverse health consequences.

DR. SARAH WAKEMAN: Yep.

STEVEN BARTLETT: Is that true?

Understanding Alcohol Units and Health Risks

DR. SARAH WAKEMAN: Well, part of the challenge is what we think of as one drink. So I think, much like if you learn to read the serving size on food, you realize that a serving of ice cream is like a half scoop, it’s not like a giant ice cream sundae. The same is true with alcohol.

So in the UK, the kind of low risk drinking limits talk about units of alcohol, which is the equivalent of 8 grams of alcohol. So how much of a drink has 8 grams of alcohol? And to be in that low risk category, you have to be below 14 units. The problem is that glass of wine, just eyeballing it has several units of alcohol. So even though we think of it as a single drink, it’s probably, I mean, I have to guess, but it’s probably like three units of alcohol.

STEVEN BARTLETT: So if I have a glass of wine every day, I’ll be over that limit.

DR. SARAH WAKEMAN: Then you’d be right at that limit. The problem is most people don’t drink just one glass. If you have two glasses one day and then one glass one day and then three glasses one day, because you’re at a social function, all of a sudden, you’re actually quite a lot over that limit.

STEVEN BARTLETT: So if you said that this is roughly three units. Roughly.

DR. SARAH WAKEMAN: And you get 14 a week.

STEVEN BARTLETT: You get 14 a week. So three times seven. 21.

DR. SARAH WAKEMAN: Yep. So yes, you’re over if you’re drinking that size. Yep.

STEVEN BARTLETT: Okay. So if I have this glass of wine every day, then I’d be over the UK limit of lower risk drinking. Lower risk drinking. So I’d be medium risk drinking.

DR. SARAH WAKEMAN: You’d be in what we call moderate risk, which is associated with pretty much every form of cancer, which I think people don’t know.

STEVEN BARTLETT: Okay. Cause I was wondering why cancer has been increasing.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: A variety of different forms of cancer increasing. Breast cancer is one of the ones we always hear about that’s increasing. So you’re saying what is the data in terms of low or moderate risk of drinking and cancer?

Alcohol and Cancer Risk

DR. SARAH WAKEMAN: Yeah, so the data is growing and really worrisome. For breast cancer, there’s a few cancers that even at low risk limits, you see the risk begin to increase. So where we would say there’s no healthy or there’s no even like low risk amount. So breast and esophageal cancer are two examples of that.

So breast cancer, if you were to drink below those low risk limits, so in the US that would be fewer than seven drinks. But a drink in the US is five ounces of wine, which is smaller than that, or in the UK is below that, 14 units. So it would be fewer than seven of that size glass of wine. We still see a slight increase in the risk of breast cancer. It’s about a 5% increase. So that means your risk of breast cancer would increase by about 5%.

Now, that’s not huge. But if you think in the US for example, the average woman has a 13% likelihood of getting breast cancer in their lifespan.

STEVEN BARTLETT: 13% likelihood?

DR. SARAH WAKEMAN: Yeah, really high. So 5% increase would increase that to like 13.6 or so.

STEVEN BARTLETT: So that means that if there’s nine women in this room, one of them is going to get breast cancer probabilistically in their life.

DR. SARAH WAKEMAN: Yep.

STEVEN BARTLETT: Damn.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Why is it? And it’s increasing.

DR. SARAH WAKEMAN: Yeah. And so the reasons for that are likely environmental because your genes don’t change over that time period. So the risk factors, if you think about breast cancer, it’s alcohol, it’s obesity, it’s age, it’s when you have children or don’t have children, because it’s a really hormonally driven cancer.

Same thing. If you think about colon cancer, that’s a really scary one where we’re seeing more and more cases in younger people. Some of the drivers of that eating meat. So processed meats increase your risk of colon cancer. So these very sort of normal behaviors.

There’s probably other environmental things, honestly, that we’re not yet measuring or able to measure. Just given the rate of acceleration. When I talk to my colleagues around colleges, you know, things like plastics or other things that we don’t yet know. There’s clearly something in the environment that is driving these increased cancer risks.

STEVEN BARTLETT: So even at, even at this sort of level, if I’m drinking, that might be one unit, right?

DR. SARAH WAKEMAN: Yes. So that would be one unit. So that would be fewer than 14 of that. So you could see if you had double that, it would be a decent pour of wine. You could not have more than 7 of those in a week to be in low risk. But even drinking that amount, your risk of breast cancer would go up a little bit. Even this amount, there’s really sort of no safe amount of alcohol when it comes to breast cancer.

STEVEN BARTLETT: Is it just breast cancer?

DR. SARAH WAKEMAN: So that low risk category. When these big cancer studies categorize people as sort of low risk or light drinkers, moderate or heavy, for pretty much every cancer, once you get to the moderate category, we start seeing increases and there’s what we call a dose response relationship. So the more you drink, the higher your risk of cancer.

There’s only a few cancers that the risk seems to increase even at that very low level. And breast cancer is one of those. And then esophageal cancer is one of those. So there are certain cancers where even a small amount of alcohol will increase your risk.

STEVEN BARTLETT: Does it have an impact on thinking about cancers that are prominent in men?

How Alcohol Affects Cancer Risk

DR. SARAH WAKEMAN: Yeah. So colon cancer, we’re seeing that in a lot of young men. Liver cancer. Prostate cancer, which is obviously a male cancer, we don’t think of as much as being sort of an alcohol sensitive cancer, but most cancers, because the way alcohol impacts your risk of cancer is not really on a specific organ outside of the liver. It’s really about how it changes our DNA. So it’s about inflammation and what are called reactive oxygen species that sort of change our cells and increase the risk over time of the mutations that lead to cancer.

STEVEN BARTLETT: So, yeah, can you drill down on that. So if I’m a heavy drinker, so say that I’m drinking. Let’s say I’m drinking two glasses of wine a day consistently, which I guess would like if I was drinking.

DR. SARAH WAKEMAN: If you’re drinking two of those glasses. Yeah. You’d be in the heavy category.

STEVEN BARTLETT: So two of those a day puts me in the heavy drink category, which.

DR. SARAH WAKEMAN: Would surprise most people. Right, like that for many people is very normal.

STEVEN BARTLETT: It is very normal, yeah. I think it’s somewhat more difficult for younger people to understand because younger people drink less. But if I think about the generation above me, having two glasses of wine a day is quite normal. After work, on the weekends, with every meal that you have. So that would make me a heavy drinker. And then what are the stats saying in terms of my cancer risk profile?

DR. SARAH WAKEMAN: Yeah, so it varies by cancer, but roughly we’re talking like a 40% increase in cancer depending on the cancer type. And the more you drink, the more that’s going to go up. So you know, these are scientific studies where it’s not precise to you as an individual. They’re based on large populations. But definitely the more you drink, the greater the risk.

STEVEN BARTLETT: And then if I have other sort of. Do they call them comorbidities?

DR. SARAH WAKEMAN: Yeah, exactly.

STEVEN BARTLETT: So other illnesses, other diseases in my body, my probability is going to go up further from obese if I’m overweight.

DR. SARAH WAKEMAN: Exactly. If you smoke. So one of the main drivers of alcohol too, and cancer is that it actually makes you more susceptible to the cancer causing effects of tobacco. So if you drink and smoke, your risk of cancer is going to be even higher.

STEVEN BARTLETT: How does that work?

DR. SARAH WAKEMAN: The thought is like if you take esophageal cancer at the cellular level, it makes you more susceptible of the carcinogens which are kind of the cancer causing compound tobacco. And so rather than just seeing like an additive risk, you actually almost get a multiplied risk in terms of the risk of cancer. So smoking and then obesity is the other big one. So a lot of cancers, your risk goes up. If you’re, if you’re, you know, have an increase in your body mass.

STEVEN BARTLETT: What’s going on in the body, then if I drink alcohol, how is that leading to cancer? You referenced it slightly there, but I’m trying to, I want to make sure I’m super clear of my brain as to like what the knock on effects are and how that ends up as cancer.

How Alcohol Affects Your Body

DR. SARAH WAKEMAN: Yeah, I mean there’s lots of different mechanisms. So I mean, maybe starting just with like what does alcohol do in your body. So you ingest alcohol. The, like, fancy name for that is ethanol. It’s a molecule, and it basically gets absorbed pretty quickly from your stomach. And so, you know, it hits your bloodstream usually within 10 minutes or so of having a drink.

How much it hits your bloodstream depends on how much water you have in your body. So alcohol doesn’t penetrate into your fat. It just kind of diffuses into the water parts of your body. So that’s actually why for many women, they will get more sort of drunk or more of an effect from alcohol at a lower level than men, because women have more body fat than men. But that’s going to depend on you as an individual. If you have more body fat, you’re going to have a different impact.

So alcohol gets in your bloodstream. Alcohol can instantly cross across what we call your blood brain barrier. So it impacts your brain instantly. And that’s where you feel the initially pleasurable effects for many people of feeling a little relaxed, feeling more social, feeling a little bit, you know, less anxiety.

If you keep drinking and that level keeps going up, then you start having impaired judgment. You might have lack of motor coordination. So we’ve all seen this in, and many people have probably experienced it. You know, you may be stumbling, not able to drive safely. You’re not going to make the same decisions you would make if you weren’t drinking. And then if you keep drinking, then you get. You actually lose consciousness, so pass out.

And people have experienced that your body is going to try to break down alcohol as quickly as it’s able to. Like anything, we want to kind of excrete any abnormality and get back to our normal functioning. And so that process happens mostly in your liver, which is why the liver is so sensitive to alcohol.

STEVEN BARTLETT: Because your body sees ethanol as poison.

DR. SARAH WAKEMAN: Yes. I mean, you know, I know you talked about this, Dr. Lemke, but your body always wants to restore what’s called homeostasis. Your body’s always going to fight to get back to what it feels its normal is. And so ethanol is not something that belongs in your bloodstream. Your body’s going to try to excrete it as fast as it can, and then it converts it into something called acetate, and then you can pee that out and breathe that out and get rid of it.

So to eliminate the alcohol in your body, you have to go through this process. And part of that process includes this toxic molecule that’s going to be floating around and causing damage to your cells. So that’s one way that alcohol can cause cancer. The other is just general sort of inflammation. People have probably heard that inflammation is just not good for the body and increases the risk of cancer. And alcohol generates a lot of that inflammation in the process of getting eliminated. And so it can actually change your cells that over time, that can lead to cancer.

Alcohol’s Impact on the Liver

STEVEN BARTLETT: So I also found this graph which shows, for anyone that can’t see what we’re describing at the moment, it shows the acceleration in liver disease, death rates and general liver disease compared to other parts of the body, other organs in the body. I believe it shows what impact does alcohol have on the liver? And we have our little mannequin here of the human body. Where is the liver?

DR. SARAH WAKEMAN: Yeah, great question. So here’s our little mannequin. So just to orient people to the body. So we’re looking at the inside of the body. So, like, the ribs are gone, the outside of the skin is gone. These two pink things are the lungs. They kind of encase the heart. You can see the hearts behind the lungs pumping your blood.

The liver is the brownish organ. It’s on the right side of your body, right under your ribs. It’s quite large and it’s an amazing organ. It is quite big. It processes much of what any kind of toxins that we take in, things that we eat. Your glucose, alcohol. 90% of it’s metabolized by the liver. So the liver is sort of the clearinghouse, getting rid of byproducts in your body. The other are the kidneys. But the liver plays a huge role, especially in alcohol. So it sits right here.

STEVEN BARTLETT: It almost looks like it’s as big as the lungs, as one lung.

DR. SARAH WAKEMAN: Yeah, yeah, it is.

STEVEN BARTLETT: Really?

DR. SARAH WAKEMAN: Yeah. It’s a giant organ and it’s an amazing organ. So you could actually cut out 80% of the liver and it would regrow itself. So kind of like, you know those lizards that you cut off their tail and they regenerate a tail. The liver is fascinating. It’s why we can do living liver transplant. So I could take half of your liver and give it to someone who needed a liver. You would still be able to live, and they would get a second chance at life from that part of your liver.

So it’s this really cool organ that can regenerate, but it can only regenerate up to a point. So once you get to a level where you have a lot of scar tissue in your liver, we call that cirrhosis. You sort of reach a point of no return where at that point, the liver can’t heal itself.

So I sort of think of it, like, to use a baking analogy, if you’re making muffins or a cake, you’re going along, you’re mixing all your ingredients, and you realize before you put things in the oven, like, oh, I forgot the eggs, you can still add the eggs in and, like, whisk it all together and it’s going to be okay. If the muffins are baking in the oven and you forgot the eggs, you can’t, like, pour the eggs on top and make the. And the liver is sort of like that, that up to a certain degree, you can actually completely repair the effects of things like alcohol or obesity, other things. But once you pass that point into scar tissue, the liver can’t regenerate anymore.

And so when you think about that graph or just the rising rates of liver disease, the main drivers of liver disease are obesity, and two is alcohol. So those are the leading causes of liver transplant. And the thing that is so sad is, I mean, I see this all the time working in the hospital. First of all, we’re seeing younger and younger people coming in in liver failure, so people in their 20s coming in and fulminant liver failure from alcohol and then dying in the hospital. And the terrible thing is that they often didn’t even know that this was causing a problem in their health. And by the time they get to the hospital, they’re so sick it’s too late.

And yet all of that could have been prevented or even repaired if it was caught sooner. And so that’s where I think this education of understanding, like, what really are the health harms of alcohol? And that we have normalized binge drinking in many occasions, especially in young people, as being total. And yet there are very serious health consequences.

STEVEN BARTLETT: So I’ve got a bunch of questions around the liver. Does that mean that my liver can take a bit of a beating before there’s any real problems? Should I, you know, someone, Someone like me, I don’t drink alcohol. I’m not engaging in anything too bad. But sometimes I do wonder if I could have, like, a blowout weekend and then my liver would just recover to normal again and I’d be fine.

DR. SARAH WAKEMAN: Yeah, I mean, so first, every person is different. One blowout weekend, you probably would be fine. Anyone would probably be fine. The challenge is because one blowout weekend then leads to, like, multiple blowout weekends, and then over time, that can actually accelerate the damage to your liver.

STEVEN BARTLETT: You said that my liver regenerates, though, so I’m thinking this thing will just pop back to normal again, as long.

DR. SARAH WAKEMAN: As you haven’t gotten to that scarring phase. So once you get too far down that path, even if you were to stop drinking, your liver won’t recover. The hard thing is that we don’t totally understand who and why that happened. So this is an active area investigation because there are people who’ve been drinking for 60 years and their livers don’t show signs of scarring. And then we’re seeing these young people at 25 who come in and die in the hospital.

And so there are individual factors that you don’t have any way of knowing that are going to impact your risk of developing liver inflammation and scar tissue. And so the safest way to prevent that is to not drink in these really high ways that we know are going to lead to harm.

The other way is to get medical care, because often we do detect these things through blood tests and we can do ultrasounds. And when we see those early phases, so what happens first is you actually get fat deposition in your liver. That’s the first step. And then we see inflammation and fatty liver. And if you don’t stop the thing that’s driving those changes over time, we see the development of what’s called fibrosis, which is like scar tissue. And then that scar tissue gets more and more advanced to the point that your liver stops functioning and you either die or you need a liver transplant.

STEVEN BARTLETT: What activities outside of alcohol cause great stress on our liver that we might not see as obvious?

DR. SARAH WAKEMAN: Yeah, so obesity.

STEVEN BARTLETT: Food does.

DR. SARAH WAKEMAN: Yeah, food. So your liver is very involved in glucose metabolism. So our diet and our body weight impact our liver health. The other medications, so acetaminophen or Tylenol, which is a very common over the counter pain reliever above a certain threshold can cause serious liver damage. So sometimes you’ll see cases where someone didn’t realize that, like their cold medicine plus the Tylenol they were taking, both have that ingredient and then they go out and drink heavily. And that kind of combination effect can cause liver damage.

STEVEN BARTLETT: How much do you think this might be? A bit of a strange, bit of an unclear question, but how much alcohol is going to cause liver damage?

Alcohol’s Impact on the Body

DR. SARAH WAKEMAN: So again, it varies person to person for liver damage. It does tend to be the moderate to higher amounts that cause damage. One thing is that having these big surges, like these massive binge episodes is probably more harmful than drinking at a moderate level for a long period of time. Those big surges cause a big buildup of that toxic byproduct that your body has to clear. And so, if you have several years of binge drinking heavily, that actually probably is going to cause more damage than a longer period of time of just drinking above the risk limits. So really trying to minimize and avoid those very heavy drinking episodes is incredibly important. And then keeping it to those low risk guidelines, which we just learned are kind of eye opening and how low risk they are is going to reduce the risk of liver damage.

STEVEN BARTLETT: And does alcohol just impact the liver?

DR. SARAH WAKEMAN: No, I mean, alcohol has effects across our body, so many parts of the body can be affected by alcohol. So kind of starting from the top, your brain. And we can look at this with pictures, like an MRI. Oh, I’ve got one actually.

STEVEN BARTLETT: Yeah, I think this is, by the way, shocking.

Brain Damage from Alcohol

DR. SARAH WAKEMAN: Yeah, to me. So when we do an MRI of someone’s brain, we basically, this is like a cross slice. So it’s almost like you’re facing me and I’m cutting your face off and looking at your brain onwards. Healthy brain tissue is the gray and white matter and you want it to be as plump and taking up as much space as possible, because that’s where all of your brain activity is. When people get really old or have dementia, one thing we see is more and more the black space is essentially water. So we see the brain start shrinking and shrinking and there’s more water and less active, healthy brain tissue.

That process is accelerated with heavy alcohol use. And so you can see here, this is a 43 year old person with severe alcohol use disorder where their brain looks the way a 90 year old with dementia would look because of that brain damage over time from alcohol use. Since we can actually a form of dementia is related to alcohol use. And so your brain can be hugely impacted with alcohol.

STEVEN BARTLETT: What is going on there? Like what’s causing the brain to deteriorate in such a way because of alcohol?

DR. SARAH WAKEMAN: Yeah, well, remember I said ethanol, which is the molecule crosses the blood brain barrier. And so especially when you’re having these high levels of blood alcohol, that ethanol is sort of bathing your brain. And if you think about what we talked about, inflammation and changes to cells and to DNA and proteins, that is happening at the brain level.

The other thing that can accelerate the brain damage we see with alcohol is actually nutritional deficiencies. So people may be drinking a lot and they’re actually not getting really crucial nutrients in their diet and that can accelerate the process of brain damage. We can even see a very sudden onset amnesia from heavy alcohol use in the setting of not getting enough nutrients in your diet.

STEVEN BARTLETT: Okay, so that’s the brain.

Effects on Other Body Systems

DR. SARAH WAKEMAN: That’s the brain. So the brain, for sure. The next is the mouth and your esophagus. So obviously you’re drinking alcohol, it’s bathing your mouth, it’s bathing your esophagus and your stomach. So we do see an increase in cancer like we talked about, and that’s accelerated by smoking. But we also see, like, benign but annoying and problematic health conditions, most notably acid reflux. So heartburn. So if you notice, like, I’m always having heartburn, I’m having to pop all these antacids and take this medicine, you might want to think, how much am I drinking? Is that contributing to my heartburn? So that’s a very common thing.

The heart is affected by alcohol. So the heart is an organ where at low risk levels, there doesn’t seem to be harm from alcohol. But once you get into the moderate and high, we see harms. And the harms can be a couple fold. One is something called atrial fibrillation, which is basically where your heart starts beating really irregularly.

So in your heart, there’s four chambers, the two chambers at the top. So this is really showing the ventricles and the atrium. So there’s two chambers that blood flows through. And in a normal heart, your electrical activity comes from the top of your heart, goes down to the bottom of your heart and tells the heart to pump. And so you get a single impulse that goes to the bottom of the heart, says pump, and that pumps blood out to your brain and your body and your organs and your liver.

In atrial fibrillation, the top of the heart is just kind of quivering with this abnormal electrical activity. And so the heart can’t pump in a normal way. We actually have a term in medicine called “holiday heart,” because we see sometimes people drink a ton over the holidays, and they’ll end up in this abnormal rhythm just from that binge drinking pattern. And then over time, if you’re drinking at high levels, your heart actually dilates, and you can end up with congestive heart failure from a cardiomyopathy, which means the heart muscle gets kind of weak and thin and floppy and can’t pump the way that it needs to.

Body Composition and Alcohol Effects

STEVEN BARTLETT: Oh, damn. Sometimes we think that if we’re good at handling our beer or our alcohol, then it’s having less harm on us. For whatever reason, I’ve always been good at drinking quite a lot when I used to drink. I don’t drink anymore, but when I used to drink and being less affected than my friend, who was a little bit bigger than me, had a little bit more body fat, which is really interesting because you pointed out an association there that I was never aware of. Just to pause on that for a second, you’re saying that if someone has more body fat, they’re more likely to get drunk.

DR. SARAH WAKEMAN: Yeah, because they have less body water and alcohol doesn’t go into your body fat. So essentially, it’s like if you took a glass of water and you dropped red dye in it, you’re going to diffuse into that water. So the more water you have, the more diffuse it’ll be and the lower your blood alcohol content. So if you have very low body fat, you probably have more body water. And so two drinks for you is going to diffuse into a larger amount of water.

STEVEN BARTLETT: Ah, that explains a lot. Because I always wondered. He was so much bigger than me at the time. He had much more body fat and he would get drunk very, very quickly. And you always think, oh, a big guy, they can handle their beer, but he’d get drunk very quickly. So I used to wonder. I used to think, well, alcohol isn’t harming me as much because I’m not as drunk as he is. But that’s not true.

DR. SARAH WAKEMAN: No. I mean, so first of all, I think the interesting story there one is not just the body fat, but also that people metabolize alcohol at different rates. You probably, I don’t know if you found this to be true. You probably had fewer hangovers than your friend, because hangover does seem to be related to how high your blood alcohol level gets. So people who don’t metabolize alcohol as quickly tend to have worse hangovers. So that may have been something you experienced, but it doesn’t protect you from the other health harms of alcohol, like liver damage, like cancer, like over time, heart problems or esophageal problems.

Understanding Hangovers

STEVEN BARTLETT: What is a hangover?

DR. SARAH WAKEMAN: Yeah, hangover is a fascinating thing that people are studying. There’s a lot of emerging evidence about it and trying to understand what happens. It seems to be most related to how high the ethanol concentration in your brain gets, because they’ve actually done a ton of studies with mice and with people. It was initially thought to be due to the byproducts of alcohol, like that acetaldehyde molecule we talked about, but it doesn’t seem to be related to that. It seems to be related to ethanol.

But essentially it’s this syndrome where after you drink, once your blood alcohol content comes down to zero, you feel sort of apathetic, you’re tired, you have a headache, you often feel nauseous. And so it’s sort of that sequelae of your brain essentially being bathed in this ethanol and then as it leaves, you just feel totally crap.

STEVEN BARTLETT: Because people think of it sometimes as just being dehydrated.

DR. SARAH WAKEMAN: Yeah, it is not just being dehydrated. There’s actual effects of ethanol on your brain that lead to the hangover. I think if you are drinking at an amount that you’re getting a hangover, it is a good sign that you’re drinking above a limit that would be considered okay for your body.

STEVEN BARTLETT: Because sometimes I remember back in the day, if I had a big glass of water before I went to bed, if I’d been drinking, I felt better in the morning.

DR. SARAH WAKEMAN: There is some element of dehydration, don’t get me wrong. And that’s partly because, if you think again, alcohol is diffused in water. So if your total body water is contracted because you’re dehydrated, your ethanol level is going to be higher. So drinking water is going to help you sort of flush it out and feel better, but it’s not only because of dehydration.

Addressing Social Drinking Concerns

STEVEN BARTLETT: There’ll be people listening to this now, I doubt they would have got this far because if they did, they probably wouldn’t think this, but there’ll be some people who would have gotten this far in the conversation and be thinking, “Yes, but alcohol helps me socialize and socializing is really important. And I can’t socialize very easily because of the design of the modern world without having a drink. Or I have great times when I drink, so I don’t want to quit my alcohol use.” And in some cases that they will be high and medium consumption alcohol drinkers. What do you say to those people?

DR. SARAH WAKEMAN: Well, first, there’s no judgment here. So a molecule of ethanol is not more moral or immoral than a molecule of glucose. You could say the same thing about diet. We have lots of awareness now about processed foods and white flour and white sugar. That doesn’t mean that everyone’s going to live this aesthetic lifestyle where they never eat dessert.

So I think it really is like you need to go in with eyes wide open and understand what are the risks, what matters to you and how do you make that calculus? If you decide it’s a choice you want to make, you want to set yourself up for success. So if you decide, “I want to cut back on how much I’m drinking, but I’m going to happy hour every night with my friends and just try to not drink while I’m there,” you’re probably not going to be very successful because you’re going to be in a situation that’s constantly reminding you of alcohol use and everyone around you is using alcohol.

So try to make some different sort of structural changes in how you set up your life and your week and your day. And you may find that actually you don’t miss it that much, that you could cut out three or four days of drinking and still get that social pleasure two days out of the week. And your overall health risk is going to go down significantly.

STEVEN BARTLETT: In terms of treating someone with alcohol abuse disorder, rehab is often the most widely known form of treatment. One of my friends who struggled with addiction really, really badly with alcohol addiction, but also drug addiction said to me multiple times, he said, “I’ve been to rehab three or four times now, and it’s just not working.”

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: And I think when the most popular or the most well known treatment doesn’t work for you, you kind of develop an even greater sense of hopelessness. Are you a fan of rehab generally?

The Truth About Rehab and Effective Addiction Treatment

DR. SARAH WAKEMAN: No. So, you know, rehab is this idea that you go away somewhere for a week, a couple weeks, and then you’re kind of cured. Right. It’s almost like people have thought of addiction as an infection where you need like two weeks of antibiotics and then you’re done. What we really understand is that for many people, addiction is more like a chronic illness or even like cancer, where you need a lot of treatment up front for the first few years, and then over time you get into stability and remission and you’re almost like a cancer survivor. You’re in long term recovery.

And so this idea that you go somewhere for a couple weeks and then you come out and you’re all better really doesn’t match what we know of it. The other problem is that much of what happens in rehab is not all that therapeutic most of the time. So the things that we know are most effective for addiction, one are medications, which there’s a lot of stigma, misunderstanding about. And then two are like evidence based psychotherapy. So things like cognitive behavioral therapy, motivational enhancement therapy, you know, working on your underlying trauma.

Often in rehabs, the model is really built around this idea of like, you remove yourself from this environment, you do some groups while you’re there sometimes. Often they’re based on more of like a peer support model. Sometimes the therapies that are offered are frankly not very evidence based. Like we actually did this study, it was a secret shopper study where we called rehab programs across the country to like ask about what they offered. And many of them offer things like, you know, horse therapy or like dolphin assisted therapy, which, like, I’m sure it’s very nice to swim with dolphins and to work with horses, but it’s not something that’s been like studied and effective.

And many places don’t offer the things that we know are actually effective, which, you know, trained clinicians during evidence based treatments or medication treatments. So it’s a combination of like this short term fix for a long term problem and not actually getting the treatment that you need. So what does work, like for alcohol use disorder? Most people don’t know. We have very effective medications that can help you even if you just want to not drink as much. So there’s this medication, I mentioned the beginning that actually blocks your opioid receptors.

STEVEN BARTLETT: Yeah.

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

And so someone named Sinclair actually in Europe did some fascinating experiments of even just using it as needed. So rather than taking it as an everyday medication, if you know that when you go to like a holiday event, you’re going to drink way more than you want to drink, you take it like 30 minutes before you go. And then what people find is they have like one drink and they’re like, oh, I’m good. I don’t have that same urge to want to drink more and more because I didn’t get the same sort of tickle of feeling better and feeling relief.

Psychedelics and New Treatments for Addiction

STEVEN BARTLETT: What do you think about psychedelics as a way to counteract addictive behaviors like the ones we’ve described?

DR. SARAH WAKEMAN: Yeah. One of the most groundbreaking trials in the last couple years for alcohol use disorder was psilocybin. So there’s a big study of psilocybin assisted psychotherapy for alcohol use disorder, which showed really remarkable effects. So people took psilocybin, actually compared it. Folks came in and they either got a big dose of Benadryl or psilocybin. And then they sat with the therapist for like eight hours for this guided psilocybin journey. And they found that people drank much less after it.

So it does seem to have some effect. And the thought is that part of the way psychedelics work is they increase neuroplasticity, meaning the ability for the brain to form new pathways and kind of retrain itself. And so it does seem to be a potential therapeutic for alcohol use disorder.

STEVEN BARTLETT: Psilocybin is the active compound in magic mushroom.

DR. SARAH WAKEMAN: Yes, exactly.

STEVEN BARTLETT: Have you heard of ibogaine?

DR. SARAH WAKEMAN: I have, yeah.

STEVEN BARTLETT: Which is often associated, which is another psychedelic often associated with addiction.

DR. SARAH WAKEMAN: Yes. People have looked at ibogaine for opioid use disorder. Those studies have been less promising than psilocybin, although it hasn’t been tested in the same kind of rigorous ways. Recently, partly for opioid use disorder, we have really effective medications that have been shown to improve recovery and reduce death. And so it’s sort of hard to be better than that.

One really interesting new whole class of medications for alcohol is medications that are being used for weight loss that people have probably heard of. So like WeGovy, Ozempic, that whole class of GLP1 medications seems to also reduce alcohol use, which is kind of interesting.

STEVEN BARTLETT: Really?

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Have they studied them?

DR. SARAH WAKEMAN: Yeah, so they… Well, first of all, there’s, I mean, there’s whole like Reddit threads and online communities about this where people were prescribed it for diabetes or for weight loss and they all of a sudden were like, I don’t really want to smoke or drink. Like that kind of urge has gone away entirely. And for some people, they really describe it as being like, miraculous. They’ve been trying to stop drinking for years and years and for the first time they don’t feel that sense of craving and urge.

And there recently have been some actual clinical trials where they’ve done placebo controlled blinded studies and have shown that it does reduce drinking. And so it’s a really interesting area where it seems like those medications kind of reset craving and appetite more globally and not just for food.

Celebrity Addiction and Public Perception

STEVEN BARTLETT: One of the ways that many of us understand addiction if we haven’t experienced it directly in our own lives, is we look up at role models on TV and in sort of celebrity pop culture and we see these role models who, you know, we see on stages start to deteriorate and deteriorate in the public eye. And ultimately it seems often like it’s inevitable that someday the TMZ headline is going to ring out and say that this person has passed away. And that happens all too often.

We think about, you know, Whitney Houston or I guess Michael Jackson’s even been associated with dying from an addiction to, I think it was painkillers or something. Prince, Elvis Presley, Mac Miller, who a lot of people will know as well, Anna Nicole Smith. And even now in the public eye, there are certain individuals where we’re starting to see this sort of erratic behavior. They’re posting on their Instagrams, they’re showing up in society in a slightly different way.

When you see that in the line of work that you operate in, what is your natural reaction? How does it make you feel when, you know, because there’s a couple of people I’m thinking about at the moment who the world are talking about that, you know, we think they have an addiction, we think they need help. What is your natural reaction to that and what is it that those people need?

DR. SARAH WAKEMAN: Yeah, when I read the headlines of someone dying, I mean to me it’s gutting and heartbreaking. One because obviously it’s a human life that with someone’s mother and sister or brother and people cared about a public figure that people looked up to and cared about, but mostly that it was a totally preventable death. Like really no one should die from a substance related death. We have tools to treat addiction. We know how to prevent the harms of drug overdose, for example.

And so the fact that someone can die, especially someone that everyone has watched for so long, is, I think, just like a tragic example of how what the mismatch is between what we do around addiction and what science says is actually happening. I think when I see someone who actively is showing signs, like, it’s just sad to see that happen so publicly without people being able to support that person. And it’s not a magic fix. It’s not going to be like, you know, you have an intervention, the person goes to treatment, gets better forever. That, I think, is often in people’s minds.

It is a process, a journey, like any change. And so really, it is around where we began. That idea of how do you begin to understand what this person… How is their substance use getting in the way of what they want for themselves? And how might their life be better for them based on whatever they believe better is if they were to make changes to their substance use.

The Hidden Pain Behind Addiction

STEVEN BARTLETT: I remember I had this one particular friend who had an addiction, and I remember always the life of the party. And I remember this one day he came up to me at an event, and he sat down in front of me and said to me, he like, whispered to me, “I’m in so much pain.” And he told me about rehab and how it failed him, et cetera. But it just… it almost sounded unbelievable that someone with such a big smile on their face would whisper to me, especially a man, because men don’t really talk much about their emotions, “I’m in so much pain.”

And then finally, I then see how the world treats that individual, him having whispered that to me one day. And the world… how the world responds to his behavior and attacks him and criticizes him. But I was privy to the whisper.

DR. SARAH WAKEMAN: Yeah. Yeah.

STEVEN BARTLETT: And that one whisper helped me to kind of reframe how to treat that person. But also really, what was at the heart of what was going on and probably give you…

DR. SARAH WAKEMAN: So much empathy, you know, a huge amount of empathy.

STEVEN BARTLETT: Because I would have been like the rest of the world. I would have just thought, what an idiot. What a dickhead. Like, what’s he doing that strange behavior.

DR. SARAH WAKEMAN: Yeah. And you said something really important. That was a slight shift in words. You didn’t say he failed treatment. You said the treatment failed him. And that matters so much because I think too often we’ve made it seem as if people are failing. Like, if they go to rehab and they don’t get well, it’s their problem, you know, and actually the treatment wasn’t right for them.

If someone had cancer and their cancer came back or didn’t get treated by chemotherapy, we wouldn’t say, like, oh, they failed. You know, we would say, well, what’s the next treatment? How do we get them to the right doctor? And so there is this, like, personal blaming, and that gets its stigma, which is one of the main reasons that people don’t share that they’re struggling with substances, that they don’t seek treatment.

And so we have tremendous stigma towards drug and alcohol addiction. It’s one of the most stigmatized kind of social conditions globally. And so, of course, then if you’re a person who starts to think like, oh, maybe I do have a problem, like, maybe my alcohol use is getting in the way of things, it’s really hard to then say anything because you worry that you’re going to be judged, you’re going to be labeled, you’re going to be misunderstood. In some cases, terrible things could happen to you. You might get your children taken away by child welfare. You could lose your housing or lose your job.

And so that stigma has played into this terrible cycle where people, you know, have to whisper it to someone. Shows how much he trusted you to even be able to say honestly what he was going through because there’s so much stigma about the condition itself.

STEVEN BARTLETT: You must have had many cases that broke your heart.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Can you tell me about one that changed you?

Losing Patients to Addiction

DR. SARAH WAKEMAN: Oh, goodness. So many. You know, one gentleman in particular struggled with heroin addiction for a long time. It had been, like we talked about, a chronic illness for him. He’d had periods where he’d done really well and periods where he had struggled, but had always stayed safe through all of that.

His one really meaningful relationship that kept him together was with his mom. He lived with her in public housing. They were dealing with economic insecurity, like many people. Someone found out that he was staying with her, which would have put her at risk for her housing. He didn’t want her to lose her housing, so he left.

But he was newly homeless, and all of a sudden, because of social barriers, was dealing with the stress of homelessness and being alone, even with all of the connection he’d had with his mom and with treatment. He was found dead between two parked cars, overdosed alone in the street.

And I always think—and you knew him—the cascading effects… it didn’t have to be that way. There are so many deaths like that where I just think, it doesn’t have to be like this. Really, no one should die like this. And there are so many things that in the moment feel so out of our control.

I think that’s part of what generates my passion for this work. I can’t always save the person in front of me or change issues around homelessness or housing policy, but I can try to work on a broader scale to make things different for the next person. That, for me, counteracts some of the distress of losing people that I care about.

STEVEN BARTLETT: If you were president of the United States, for example, let’s just use this country as an example. And you had to make upstream changes to the way society was designed in order to mitigate the downstream symptom of addiction and addictive behaviors, what are those things that you would change about the way that our society is designed? You could change anything.

Upstream Solutions to Addiction

DR. SARAH WAKEMAN: Starting upstream, the biggest thing would be building resilience and building connection early on. I think these things that feel so not related to addiction per se are actually deeply related when we think about adverse childhood experiences.

When we think about prevention for children, often people have looked at education, like telling kids that drugs are bad. That doesn’t work. What does work is actually building resilience among young people. So building resilience, building connection.

What does that look like? That looks like affordable housing. That looks like parks where people can get outside and play sports and exercise and build relationships. That looks like supporting families so that families can stay together, and so those early relationships and attachment can be well formed. That’s the true prevention work—trying to break the cycles of intergenerational trauma, poverty, substance use, and actually supporting families and communities.

STEVEN BARTLETT: At the very start, it reminds me of Rat Park.

DR. SARAH WAKEMAN: Yes. Rat Park is a great example of that.

STEVEN BARTLETT: What is Rat Park for those that don’t know?

DR. SARAH WAKEMAN: Rat Park was a series of experiments where they were trying to understand drivers of addiction using rat models. They took rats and had one model where rats were isolated in their own cage with nothing to do and no connection. They had access to a substance like morphine or cocaine where they could push a lever and get more of it. Those animals, when they were deprived of connection and had nothing to do, used more of it. It gave them relief, it gave them pleasure.

They took those same animals and put them in this amazing cage with areas to play, wheels to climb on, and lots of friends and other rats. All of a sudden, they saw the same animals were no longer pushing the lever and trying to get more of the drug.

It’s a somewhat simplified model that’s probably oversimplified, but it demonstrates that so much of addiction really is around this idea of connection and restoring the world around us, the community, the interrelatedness that we all have, the opportunities and purpose and meaning and hope.

That’s the real prevention. And then there’s how we actually address folks who are having a problem. What I would do there is first make addiction treatment widely available immediately when people need it. The minute you walk into your general practitioner’s office or an emergency room, you get treated with compassion, with science, with people asking you what they can do to help and offering you effective care the same way they would if you had a new cancer diagnosis or a heart problem.

We need to reframe treatment entirely to look like the way it looks for any other health condition. And we need to stop punishing people who use substances. A lot of times people are still sent to jail for substance use, which is a confusing, mixed message if we’re saying this is a health problem on the one hand, but we’re going to put you in prison or jail at the same time. Those two things don’t necessarily align.

Modern Isolation and Addiction

STEVEN BARTLETT: Many of us are living in the first model of Rat Park. We’re living alone. We’re living in these big cities. We’re more sedentary than ever before. Maybe we’ve moved to a big city, which means we don’t have our family around. We might be doing a job that’s incredibly challenging.

So it’s no wonder when we think about addiction and alcohol and other addictive behaviors, whether it’s social media or what we eat or pornography, or in the inverse—the good habits, the healthy food, working out, exercise, the productive behaviors—why we’re struggling so much. I’ve often wondered if we should all just go to communes and live in groups.

DR. SARAH WAKEMAN: I don’t think human beings were meant to live this way. It’s a relatively new thing. We often lived in a village or a community. We lived in multi-generational households.

I have little kids, and having kids was such an eye-opener—it makes sense why people live with their parents and their grandparents and have these big families to create community and a sort of extended family around you. We have lost that in a lot of ways.

The ways we used to get at that, like religion, maybe still resonates for some people. For others it may not. So finding other ways of engagement and meaning and purpose can be through lots of different things. People are finding creative ways of doing that—through volunteer activities, finding social groups, through sports. They find connection and engagement with people over a shared love around an activity or a team, but really seeing that as a priority, the same way you’d prioritize other things in your life and health.

STEVEN BARTLETT: And are you a fan of therapy as an approach to aim at the early childhood trauma?

The Importance of Empathy in Treatment

DR. SARAH WAKEMAN: Absolutely. I think one of the problems is that too often therapy has been forced on people. I’m much more of the approach that we need to make treatment available and welcoming and high quality so that people get value out of it. Therapy is a huge part of that.

It’s about connection, it’s about figuring out those reasons why people are using in the first place, addressing and healing those traumas. It also matters that we have good, well-trained empathetic therapists.

There have been interesting studies looking at how empathetic your therapist is, which is probably the strongest predictor of whether you make changes to your alcohol or drug use. Which is so interesting because we often think, “I don’t really like my therapist,” and sometimes the reaction to that is, “Oh, you’re not that into therapy.”

But they’ve actually done a lot of studies showing that a therapist who is less empathetic, their client is more likely to use more substances at the end of that course of treatment. So actually having a really well-trained, compassionate, evidence-based workforce is hugely important too.

STEVEN BARTLETT: And I guess the same applies for family and friends.

DR. SARAH WAKEMAN: Yeah, I think empathy is really powerful. Those kind of things that we think of as soft skills actually matter tremendously.

STEVEN BARTLETT: Is it possible to prop somebody up? I was talking to Dr. Anna about this, about the idea that you can play a role in someone’s addiction. I want to help my friend who’s addicted, so I’m there for them, I’m comforting them, but I’m actually in some way reinforcing that addictive behavior because I’m positively reinforcing it. I’m supporting them so much and loving them so much and showing them so much empathetic attention that actually I’m playing a role in continuing that addiction.

Support vs. Enabling

DR. SARAH WAKEMAN: This is the concept of “enabling,” which I think is nuanced. I would say at its core, it’s really deeply problematic—for the most part, love and support are never going to be harmful.

When I talk to patients, often the thing that caused them to ultimately engage in treatment was not some terrible consequence. It was the idea that someone cared enough about them in a moment where they didn’t love themselves very much and felt hopeless, that someone was willing to lift them up and believe in them.

It’s these small moments of kindness. I’ll tell you a story of a patient we took care of in the hospital who was there for a really life-threatening infection related to their drug use. A year to the date after he was hospitalized, he wrote a letter to our team and said, “I’ll never forget the moments you guys came in and just sat with me and talked to me.” He now sends an email every single year on the anniversary of when he got out of the hospital.

It’s those moments of humanity, of connection again—that connection idea that often are the catalyst for change. The hope and belief that your life could be better somehow, as opposed to this idea of increasing someone’s pain and suffering.

In families, one of the most effective tools we teach people is something called CRAFT, which stands for Community Reinforcement and Family Training. It’s very different than what people may have seen on shows where you’re supposed to stage an intervention and tell someone “all or nothing.”

CRAFT teaches people first how to understand the signs of addiction. Second, how to get support for yourself, because it’s really tough to deal with addiction in the family. And then how to start to learn about consequences in a different way—if you’re a parent and your kid is missing school because they’re using, you don’t want to cover for them and reinforce their pattern, but you also don’t need to kick them out of your house. There are gradations of consequence that can actually help people change.

One of the biggest motivators for change is actually positive reinforcement of the behaviors you want to see. That’s been called contingency management in the treatment world. Health insurance companies and lots of companies have figured this out—if you get money back because you join a gym or get reimbursements for doing something that people want to see, people do more of it. It’s true in human behavior, it’s very true with addiction. But we often do the opposite. We try to punish people into getting well instead of reinforcing the healthy behavior, what we want to see more of.

STEVEN BARTLETT: I guess I’m trying to represent the audience member that’s listening to this right now that knows someone in their life that was addicted and they tried to be empathetic, they tried to offer support, they tried to give the person help and still nothing changed.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: In that situation, maybe the person that was struggling with the addiction didn’t accept the support.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Didn’t go to the meetings, didn’t speak to the therapist.

DR. SARAH WAKEMAN: Yeah.

Supporting Someone with Addiction

STEVEN BARTLETT: In such a situation where you’re offering help to someone and they’re not taking it, they’re not willing to investigate different medical treatments, they’re living at your house, they’re in your business, whatever. Is there a point where you say enough is enough?

DR. SARAH WAKEMAN: Yeah. Well, first, like it is just so hard to be there as a family member or friend. So for anyone listening, I’ve been there, it’s incredibly impossible. So have grace with yourself.

I think that’s a different decision you’re talking about is at some point you have to make a decision to protect yourself. So let’s say you have someone in your home who’s dealing with addiction, who, you know, gets aggressive or stealing money or is causing trauma to the people living in the house. At some point you may need to decide that for my well being, for the rest of the family’s well being, I can’t have this in my life right now.

That’s very different than saying kicking them out is going to make them better. So the distinction there is that it’s okay to protect ourselves. Sometimes we have to do that. And sometimes there’s only so much you can do, but to not sort of fool yourself into thinking that the action is to help the other person, and that’s okay.

I think the other piece is, you know, at the end of the day, first of all, it’s easier to be a treater. So I’ve been a family member, I’ve been a clinician. As a clinician, I can truly be unconditional. So I’m going to be someone’s doctor whether they continue to use heroin or continue to drink or don’t. And there’s something really beautiful in that. Like my engagement with someone is not premised on whether they make changes or not. As a family member, that’s harder. Especially if you’re a kid dependent on someone or you’re in a marriage or a relationship. So you may have to make different choices.

But I think at the end of the day, people don’t change because of why we think they should change. They change because they think their life is going to get better in some way. So the key then becomes figuring out, like, why might this person’s life get better if they were to make changes to their alcohol or drug use? So it’s a shift where you become sort of on their team. Instead of trying to drag them towards water, you know, drag the horse towards water.

And there’s this fascinating kind of human instinct that none of us like being told what to do. So there’s something called the writing reflex, which is it’s really hard for caregivers, it’s hard for parents because we love to tell people, like, our great advice and why what they’re doing is wrong and they should take our, like, brilliant doctor advice. And this can be like telling someone, like, don’t you see what you’re doing is causing harm? You should make changes. It can also be subtler. It can be like lecturing someone or trying to educate them. But when someone shoves something down your throat, your instinct is to resist. It’s just like natural human behavior.

Even if it’s a great idea, if someone’s like shoving an ice cream cone in your face and like eating, even if you like ice cream, you might be like, wait, wait, I don’t know if I want this ice cream. And so the key then is not to sort of tell someone what to do. It’s to understand why might they want to make changes. And so once you do that, then you all of a sudden realize, like, it just feels better. You’re not trying to drag someone towards something. You don’t have like, personal skin in the game about what choice they make, but you’re really a partner with them and figuring out how is this thing causing problems to you and why might your life get better if you were to make changes to your alcohol use or your drinking or your substance use.

Motivational Interviewing

STEVEN BARTLETT: What’s the difference in delivery there in terms of delivering that message? Because they’re both ultimately getting to the same outcome. But it sounds like the language might be slightly different.

DR. SARAH WAKEMAN: Yeah, very different. So in kind of like medical speak and therapy speak, we talk about something called motivational interviewing, which is. It becomes almost like a mind trick, but it is basically a way of trying to identify from the person their reasons for change and reflecting it back to them. And so it’s not you telling them you think they should change, but you are trying to elicit their motivation and amplify it. And then at the end of the day, you’re turning over the power back to them. So that might look like someone says, you know, I’ll be your…

STEVEN BARTLETT: Your patient.

DR. SARAH WAKEMAN: Okay.

STEVEN BARTLETT: So, yeah, I do drink a lot. I drink a couple of times a day, especially in the mornings. But it’s fine. You know, I’m still managing to get to work every day. Obviously I have a couple of misconduct issues at work, but other than that, you know, and my partner’s left me, but other than that, everything else is fine and I can manage this.

DR. SARAH WAKEMAN: It sounds like your alcohol use is causing some problems at work and in your relationships.

STEVEN BARTLETT: It is, yeah. Yeah. I lost. My partner’s left me, and I keep getting these misconduct notifications at work in disciplinaries because I sometimes get there late and when I’m there, sometimes I fall asleep, etc, and I’ve. I work with big machinery, so there’s a little bit of a risk there. But otherwise it’s.

DR. SARAH WAKEMAN: It sounds like you’re worried about your safety at work and also how your drinking is starting to affect your job and your relationships.

STEVEN BARTLETT: That’s true. Yeah, I am. You know, I’ve been on the crane in particular, being intoxicated on the crane in particular has caused a few incidences and, you know, sometimes. Do you worry that one day it’ll go a little bit too far?

DR. SARAH WAKEMAN: Yeah. It sounds like that’s really scary that you’re really worried your alcohol use could cause even like a serious or life threatening accident at work.

STEVEN BARTLETT: Yeah. And then what am I going to do for work? You know, because if you get something like that on your file, then I’m never going to be able to be a machine operator ever again. So.

DR. SARAH WAKEMAN: Yeah. And your job sounds really important to you and alcohol is starting to get in the way of that.

STEVEN BARTLETT: Yeah, 100%.

DR. SARAH WAKEMAN: Yeah. And so what are your goals, looking forward around your job or your relationship?

STEVEN BARTLETT: Well, I mean, I really should. I really should fix this alcohol issue that I have. And I would love to find a partner that’s really important to me because I want to have a family. So obviously prerequisite of having a family is finding a partner. Really? So.

DR. SARAH WAKEMAN: Yeah, yeah. It sounds like you’re really committed to thinking about making a change to your drinking and that you’re looking forward to finding a partner and family and you’re worried that alcohol might get in the way of that.

STEVEN BARTLETT: So what you’re doing there is. You’re not leading me, you’re kind of pushing me, if that makes sense.

DR. SARAH WAKEMAN: There’s like a little bit of like a Jedi mind trick thing where you’re essentially. It’s actually really. It’s a little tricky when you’re first learning how to do it. Because what I’m trying to do is I’m listening for what’s called change talk. So any little nugget you’re giving me about making a change, so you’re saying like, oh, I’m starting to get this misconduct. I’m worried about this thing with safety at work. I want a partner. Those are like, it’s a goldmine of little kernels of change.

And I’m ignoring all of your sustained talk. So anything where you’re arguing for the status quo, it’s not a big deal. Drinking’s not that big a deal. I can’t make a change. I don’t even acknowledge it or address it. And that’s actually hard because I think most of us pay attention to the narrative. So if you think about like a performance review at work or someone telling you any kind of feedback, we tend to amplify and remember like the one bad thing that someone said to us and forget the millions of good things.

So you have to change. You have to like train yourself to do the opposite, to hear those little kernels of change talk. And then I’m basically being a mirror, but I’m amplifying it. So I’m taking these little kernels of change talk. I’m reflecting back to your own words. So I’m not telling you that you should stop drinking because it’s unsafe at work. I’m reflecting to you like you’re starting to get worried that you might have an accident at work, and that’s really something serious. And that’s kind of guiding the conversation forward.

The other key is that if you meet a point of resistance, you want to pivot. Because once you start arguing, whether it’s not politics or anything, people dig in. So if you start arguing with someone, you got to find another way. You just got to pivot and roll to a different tactic. Because the more you argue, the more people dig in on their point of view. And it’s more about like winning the argument than it is about moving forward.

Finding Your “Why” for Change

STEVEN BARTLETT: What if you want to change your yourself? Is there a process, a system, a methodology to help you discover what your ideal behaviors are, what your why is, and to implement change?

DR. SARAH WAKEMAN: That’s why I say all the time, what’s your why? I think that’s so exciting. Like, we all want to live our best lives, whatever that means to us. And so having a purpose, having a goal is probably the most important thing.

Motivation is important. We talk a lot about motivation, but motivation is fleeting. It can slip and slide over the course of one day. So, you know, you may take kind of a mundane example. You want to get in shape and you’re feeling super motivated one day, and then the next morning your alarm clock goes off at like 5 in the morning and you’re tired and it’s cozy in your bed and maybe you stayed up a little too late, your motivation is going to be flagging, right?

So if you don’t have a goal or a reason or a why or a purpose, it’s going to be really hard to actually get up the energy to get up. And so figuring out what that purpose is and then trying to find ways to enjoy the process. Because if you’re always working towards a future goal, some people are very goal oriented and that works for them. But finding joy in the process will help you.

So I’ll take alcohol, for example. Like, not an addiction issue, just like making changes to your drinking in your life. So if you’re just like, I should stop drinking because drinking is bad for me, that’s like a relatively vague goal, right? It’s not really about anything that matters specifically to you. And it’s going to be hard to stick to that.

If instead you think, okay, I, you know, I’ve started to realize that when I drink every single night, I don’t get the work done that I want to get done because I’m too tired and I fall asleep. I don’t feel refreshed in the morning because I’m not sleeping very well. I’m not getting up early to exercise. And that’s something that really matters to me. I’m not, like, as present with my family as I wanted to be then. It’s these, all these little micro goals that make it much easier to make a change.

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

So you want to make these, like, really focused, personalized goals and really anchoring it on what is your why. And your why may be very different than my why or someone else’s why. So it may be, you know, sleep really matters to you, or, you know, you may have a different relationship with alcohol.

So the other kind of example I’d give is people are different, right? We respond differently to things. Some people can open a bag of, like, potato chips and eat two in one walk away. Some people, like, they open the bag, they’re going to eat all of the chips. And so it’s just easier not to open the bag. And alcohol is like that, too. Some people might find if they open a bottle of wine or they have alcohol in the house, they’re going to drink all of it. And the idea of, like, trying to keep to these small amounts of alcohol is actually really hard. And it’s simpler and easier to just avoid it completely or to only drink at a restaurant or something.

So you do have to understand, like, how your goals, your why, your purpose interacts with your response to whatever it is that you’re working on. And that’s going to be different for everyone.

Habits to Overcome Addiction

STEVEN BARTLETT: Are there any other things, any other habits that we should be thinking about when we’re trying to overcome an addiction? So if we think about alcohol as being at, like, the bottom of the stream.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Is there anything else upstream that I should be thinking about? So we talked about social connections and relationships. So I need to be making sure that I’m surrounded by people I’m socializing, because that’s going to be an insulator to, like, stress and loneliness, which is going to cause me discomfort, which is going to lead me to alcohol. But are there any other things that I should be thinking about when I’m setting off to make a change in my life?

DR. SARAH WAKEMAN: Yeah, there’s a bunch. I think first, any behavior change, whether it’s alcohol or other, if you’re feeling depleted and tired and not your best self, it’s going to be harder to make a change. So if you think about any big decision you made to change your job, to start an exercise routine, to leave your partner, you probably didn’t choose the day that you were exhausted and feeling anxious and stressed and not your best self to make that change. Like, change is hard. So you want to try to boost up other things in your life, eat well, get enough rest, try to exercise things that are going to help you feel healthy and your best self when you’re trying to make a change.

STEVEN BARTLETT: Is that linked to dopamine?

DR. SARAH WAKEMAN: Yeah, because our natural reward system, the thing that triggers it is exercise, food, sex connection. So trying to have healthy, other ways of positive dopamine release. And so I think for many people, alcohol or substances can feel like a way of doing something nice for ourselves. Like, I’m going to. This is going to help me reduce my stress after a bad day at work. So the goal then is not that you just white knuckle it all night and feel really stressed after work. It’s that you figure out what are some other things that help me reduce stress after work? Maybe it’s going to a yoga class with a friend. Maybe it is spending time with my family. Maybe it’s getting massage or meditating or watching a show I like. It’s not just you’re removing the thing that you’re trying to change. You want to fill up the empty space with other things.

Replacing One Addiction With Another

STEVEN BARTLETT: So what if I fill it up with, like, Haagen Dazs ice cream and burgers, because that will cause a dopamine hit. So presumably if I just eat loads of sweets and candy, then that’s going to stop me from engaging in addictive behavior.

DR. SARAH WAKEMAN: But we see that all the time. So that’s like replacing things. And you know, I was reading an article, people have probably heard of dry January, this idea of like not drinking for the month of January to rethink your relationship with alcohol. I was reading an article that dry January has become high January because people are just smoking a ton of weed instead of drinking. And so it’s very. I think you want to be cautious that you’re not just replacing the thing that you’re trying to change with something that’s also going to cause health problems.

Now if having dessert once in a while for this, you know you’re not getting calories from alcohol. And having a nice ice cream cone once a week is a way of sort of treating yourself that’s healthier and maybe more aligned with your goals. That’s fine. I think thinking about these things, actually thinking about alcohol, the way we think about dessert, sunbathing, eating processed meats, all of these things have risk and benefit in our lives. I think where we’ve gone so wrong with alcohol was this idea that it’s like a health promoting behavior, that you shouldn’t be drinking for your health. It’s not going to make you healthier. And also, much like many things we do that are not health promoting activities, there are ways of reducing the health harms of that activity so that it’s okay in small amounts in your life.

Brain Plasticity and Recovery

STEVEN BARTLETT: Just thinking about something we said earlier about how early childhood trauma causes the brain to change and then results in addictive behaviors. If I went through an early childhood trauma and my brain has changed because of that, and then I get into, I become addicted to alcohol as a young man, and then I managed to find my way off the alcohol. My brain is still addicted, right? My brain still has that addictive sort of predisposition. So isn’t it the case that I’ll just end up being addicted to something else that gives me a dopamine hit?

DR. SARAH WAKEMAN: So it turns out the brain is amazing plastic, meaning it can change. We see that over time. So the first thing is even adverse childhood experiences are not a done deal. So we talk a lot about aces. We don’t talk a lot about pieces or PCE positive childhood experiences. But actually you can reduce the risk that someone develops addiction by increasing the number of positive childhood experiences. So take someone who’s experienced some terrible adversity. Their parent has died, or they have a parent who’s in prison, or they have addiction in their family. If that kid has one single adult figure that they believe cares about them, that reduces their risk of addiction.

So there are a lot of positive ways that we can actually change the trajectory even in the midst of terrible trauma. When you think about someone who’s had a substance use disorder, we actually have good data on this, that after five years of recovery and often that is fits and starts. So most people think of like this is one fell swoop that you like decide to stop drinking and then success is that you never drink again. For most people, what we find is that’s actually like a series. So I always like to think of progress, not perfection, and not have this kind of all or nothing mindset that for many people, they may early on have a month where they go without alcohol and then maybe next time it’s three months and then maybe it’s a year and these recurrences happen.

But ultimately they get to this place where they go into long term recovery. After five years of recovery, a person’s risk of subsequently developing addiction is no higher than the general public. So your brain actually does change. And we see that on functional imaging. We see this in longitudinal studies that follow people over time. So you actually can overwhelm those things and get to a place where you don’t have a higher risk than other people.

The “Addictive Personality”

STEVEN BARTLETT: Because some people say I’ve got an addictive personality. They sort of self label and self identify as having an addictive personality. Sometimes they even reference their brain as being easily addictive. Is there truth in that? Is it possible to have an addictive personality?

DR. SARAH WAKEMAN: It’s not so much about personality, but we do respond differently to substances. So take alcohol or opioids, anything. People feel differently the first time they ever use it. So often if you talk to someone who then develops addiction, they tell you that first time they used the substance, it was like this amazing feeling. It felt like I’ve had people describe it as falling in love or a warm hug or like a relaxing bath. These incredible comforting experiences.

Other people, they get prescribed like an opioid for a tooth extraction. They feel nauseous and kind of like not like themselves and they don’t like the feeling. So how we respond to substances is definitely based on our neurobiology and is different for different people. So some people are both from a genetic reason and their own brain are just more wired to be at risk of addiction. And that’s important to know about yourself because then you can make different choices. You may decide never to keep alcohol in the house or not to drink because the risk is too great.

Other Types of Addiction

STEVEN BARTLETT: How much do you think about other things that are taking hold of society? Some of the other things that are non substance related. So social media addiction and pornography addictions. And what else are some of the big ones?

DR. SARAH WAKEMAN: Food addictions, food, sex, gambling. I think there are a lot of similarities. It’s not my particular area of focus, but I think there are a lot of overlaps. I mean, I think many of the things you just listed you could talk about one, dopamine obviously, but two, this idea of needing to fill yourself with something else. Either thinking about trauma, thinking about untreated mental illness, thinking about just kind of the deficit of connection and of meaning and reward and reaching to these external sorts.

Trauma and Addiction

STEVEN BARTLETT: Can you tell me about a time where you’ve worked with a patient who through the process of working with them and understanding their trauma, you discovered something unexpected about the root cause of their addictive behavior?

DR. SARAH WAKEMAN: Yeah, I can think of many patients, but one in particular who, I knew that he’d experienced hard things in his life. He’d been in prison, for example, which is a traumatizing experience. He’d lost his parents. Another thing I never truly understood the depth of his trauma and had. He had struggled his whole life with substance use disorder and using lots of things, mostly opioids, but also alcohol and cocaine. And just had had a really, really hard time.

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

STEVEN BARTLETT: Did he recover?

DR. SARAH WAKEMAN: He actually passed away.

STEVEN BARTLETT: From substance abuse.

DR. SARAH WAKEMAN: From substance use, yeah.

Finding Hope in Addiction Medicine

STEVEN BARTLETT: You must carry a lot of this stuff with you, because your line of work sounds like you’re doing dealing with bad news quite often more so than the average person. And the news you’re dealing with is a different type of news. You’re dealing with somebody sort of reaching the end of their life through something that you also have said many times you believe is preventable in many cases. How do you manage that?

DR. SARAH WAKEMAN: Yeah, I mean, I think a couple things. One, there are so many stories of hope that I think counterbalance that for me. So I think the other stories in my mind are I carry with me and still care for and are in touch with people who are living these amazing, vibrant lives in recovery. And in the US alone, there’s 24 million people living in recovery. So there are these stories of people who have overcome just trauma, tragedy, hardship, and are doing awesome. They’re parenting, they’re working. You probably don’t even know they’re around you.

They don’t tell people necessarily that they’re in recovery and getting to be sort of a part of that process with someone and watching, you know, there’s nothing in medicine where I can actually see as dramatic of a change as with addiction, where someone can be in a moment where they’re dealing with all of these health consequences and relationship challenges, and then they get better. And it’s just like the most beautiful thing to be a part of.

And so I think the hope from that, the sort of positivity of it, is what keeps me going every day, obviously, finding ways to care for myself through that and family and connection, exercise. I run, I write. You know, you have to keep yourself whole through it all too. But I think I get tremendous purpose and mostly like a lot of hope from working with people and seeing them recover.

STEVEN BARTLETT: What is the most important thing we didn’t talk about that we should have talked about?

The Power of Language in Addressing Addiction

DR. SARAH WAKEMAN: I think one thing is language. It’s like this subtle thing. I sort of mentioned an example where you did it really well, where instead of saying someone failed treatment, you said the treatment failed them. But a lot of the language that we use with addiction actually subtly and not so subtly worsens stigma. And sometimes it sounds like I’m being politically correct or it’s like an issue of semantics, but there’s actually really good data on this.

So if you think about words we use for addiction, one is substance abuse, right? So the term abuse, what does abuse refer to? It actually comes from an old English word that means like a willful act of misconduct. And it’s a word that we use for child abuse, for sexual abuse, for domestic abuse. Like it’s only for these terribly violent acts of commission that are very stigmatized because they’re terrible things. And yet we use it for this thing that we’re seeing as a health condition that you’re like a substance abuser or you have substance abuse.

And so there have actually been these elegant studies that took like PhD level psychologists, really highly trained clinicians, and they described a person as either a substance abuser or as a person with a substance use disorder. And the clinician was actually more likely to recommend a punitive intervention for the person described as a substance abuser.

STEVEN BARTLETT: What does that mean?

DR. SARAH WAKEMAN: So in this case they were given like an option, you read this paragraph about like a fictional patient and they don’t really know what the researchers are testing. And they’re given a bunch of different options for intervention. And one is this like, send them to drug court or send them to jail. One is like, offer them, you know, outpatient, effective treatment. There’s a bunch of different choices. When they hear someone described as a substance abuser, they’re actually more likely to recommend the jail based intervention.

So words actually influence how we think, even how we make clinical decisions. They’ve also done this to the public. So if you describe someone as a drug addict, the public has a more negative view of them than if you describe them as a person with addiction. So there are these subtle ways there’s been a shift in addiction to really using what we call person first language, which has been true across medicine.

So like, we used to use terrible words. Like, we refer to someone as, like, the schizophrenic, you know, or really labeling them as their health condition. And thankfully, there’s been a change from that to realize that people are people first who have an illness. They’re not defined by it. So I would never say, like, I’m going to go see the lung cancer in room 204. I’d say, I’m going to see, you know, Mr. Smith, who has lung cancer.

And so with addiction, too. Like, people are more than that. So to say, say, you know, person with addiction, person with alcohol use disorder, rather than saying they’re an addict or an alcoholic. And then even terms like clean and dirty, which are commonly used when we talk about addiction. So, you know, take the word clean. It sounds really positive. Like you’re saying, oh, you’re clean, but, like, what are you really saying? So you’re saying, like, if you’re clean now, when you were actively struggling, what were you? You were dirty.

And so I always remember an example. A friend of mine who’s in recovery was interviewing for jobs in the recovery space. And so people on the interview trail would say that him, like, how long have you been clean for? And he would say, well, I’ve been bathing since I was a newborn. I’ve been clean my whole life, and I’ve been in recovery for five years or whatever.

So I think these little things actually matter, that we should use terminology that we’d use for another health condition. If we’re labeling, you know, people with active addiction as dirty or, you know, people with addiction as the same as child abusers. With that sort of language, we’re really sort of subtly increasing stigma. So that’s a small thing that we can all do is just try to use language that’s a bit more humanizing.

Changing Our Language Habits

STEVEN BARTLETT: It’s so interesting because I was aware of this, but I still found myself accidentally using the word abuse.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: And I’d stumble into it. Oh, fuck an osteoart. I tried to avoid the use of the word addict.

DR. SARAH WAKEMAN: Yeah, it’s hard to change. But, you know, like, everything, you just want to be humble, curious, and keep trying. I mean, there’s lots of language that we’ve changed. Like, think about so many terms we use for, you know, for people who are born with different abilities or for people of different races or other identities that we’re really stigmatizing and we’ve learned to use different language, even if it feels a little awkward when you’re first learning it.

STEVEN BARTLETT: I think understanding the science and the data behind the impact it has to use certain language, I think is really useful.

DR. SARAH WAKEMAN: Yeah.

STEVEN BARTLETT: Because that’s helped me to understand. Just because now I understand the first principles of it. I need to make sure I describe people as a person first. So a person with addiction is much better than calling someone an addict.

DR. SARAH WAKEMAN: Yeah, exactly. And one thing people ask me will say, well, what if someone refers to themselves that way? Because people may do that. And that’s fine. People can use whatever language they want for themselves. But I think as a healthcare professional for sure, or someone who’s trying to help combat stigma, like, we can choose to use different language. And I’ve actually had patients sort of ask me like, well, why do you use that terminology when they use a different language? And it actually can be sort of empowering to be like, oh, yeah, I’m actually a person in recovery, or I’m a person with addiction. I’m not going to label myself that way anymore.

STEVEN BARTLETT: Something I’ve been really curious about just in my life, generally, because in conversation, I’ll often. I said something yesterday when we were at dinner with the team here. I said, I can’t remember the exact phrase, but it was words to the effect of I’m not good at that, or I’m not that type of person, or I’m not organized. And I stopped myself, and the team will remember. And I go, actually, I shouldn’t say that. I should say, right now.

DR. SARAH WAKEMAN: You’re like, defining yourself as incapable of doing something instead of being like, I’m working on organization right now.

STEVEN BARTLETT: I think it’s so important, and we don’t think about it how casually we create an identity for ourself that is, like, fundamentally limiting or puts us in a box or frames us as having a deficit or captures our whole identity in some kind of deficiency we have often in the case of the habits I’m referring to. Does this a similar thing take effect when we’re talking about calling someone an addict?

DR. SARAH WAKEMAN: Yeah, you’re sort of labeling them as that is the only thing that they are and that they will be that forever. And, you know, a friend of mine who’s a journalist who is in recovery and writes a lot about addiction, Maya Solovitz wrote this great New York Times piece that addiction doesn’t always last a lifetime. Because I think there’s this idea in our head that, like, you know, people with addiction will always have addiction, and it’s this, like, incurable thing.

And that actually people have lots of different journeys. And for some people, you know, that becomes something they deal with and then they move on in their lives. For other people, it’s something that they actively manage. But this idea that, that you sort of boil things down to like, the only thing I am in this world as a person with addiction, you really limit everything else about yourself.

Closing Thoughts

STEVEN BARTLETT: We have a closing tradition on this podcast where the last guest leaves a question for the next, not knowing who they’re going to be leaving it for. And the question that’s been left for you is if you could redo or revise one thing that you have successfully accomplished, what would that be and why?

DR. SARAH WAKEMAN: I guess I would say, and I could think of lots of successful accomplishments I’d apply this to. But I’ll take the example of medical training, which is a successful accomplishment. I think I would be more present that we are always like, rushing to the accomplishment, to the finish line, to sort of getting to the next goal. And I think back and wish I had realized what an amazing journey it was in that moment.

And, I mean, even things with medical training that I was never going to be a heart surgeon, but to stand in an operating room and look inside someone’s chest and watch a beating heart is an experience that I’ll never get again. And I think in this journey to always achieve and move forward and get to the next exam and the next thing, we sometimes miss, like the miracle that’s right in front of us. And so I think I would have been even more present.

STEVEN BARTLETT: That applies to all of us. I felt like I was being called out.

DR. SARAH WAKEMAN: True for parenting, true for everything.

STEVEN BARTLETT: Thank you so much. I’m so grateful for the work that you’re doing because there’s so much conflicting information, especially as it relates to alcohol. There’s been so much information over the last five, ten years about the impact alcohol has on us. And I’ve sat here and had conversations with people who are pretty convinced that even, you know, moderate levels of alcohol are good for us. And having read your work, I’m now clear on what the truth is there is.

Thank you for doing what you do. It’s incredibly important and I actually think it’s going to become increasingly important, unfortunately, because the way that the world is heading, the loneliness epidemic that we’re experiencing and the access we now have to digital devices and to low cost consumption of addictive substances is terrifying for me. I know you’ve got a book on the way, which I’m extremely excited about, which is due in autumn, next Autumn, spring of 27.

DR. SARAH WAKEMAN: So we have.

STEVEN BARTLETT: Okay. And what’s that book about? Can you give me a clue. I mean, I could guess, but it.

DR. SARAH WAKEMAN: It is going to be about changing the narrative around addiction and about really reframing how people think about it to see it as a treatable, good prognosis, illness and using some of the stories of people I’ve had the privilege of knowing to hopefully help people see things in a different way.

STEVEN BARTLETT: Where do people find you if they want to reach out or learn more?

DR. SARAH WAKEMAN: Yes, they can find me on LinkedIn, on Instagram. They can email me. Yeah, happy to connect. And would love to come back after the book is out, too.

STEVEN BARTLETT: I look forward to that. I’d love to. So your Instagram, your LinkedIn. I’ll put those details below. I’m sure you’ll probably get a lot of messages because these issues in particular are incredibly, incredibly potent issues in people’s lives and very emotional issues as well. So thank you for, on behalf of all my audience, thank you for your generosity today, but also thank you for your wisdom. Really, really appreciate it. And I would love to speak to you again soon. The book is out.

DR. SARAH WAKEMAN: Thank you. Thank you for having me.

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