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Why moderate drinking ages the brain and feeds cancer

How alcohol damages organs at any dose and shrinks the brain like dementia; addiction tracks genetics and trauma far more than moral weakness.

Dr. Sarah WakemanguestSteven Bartletthost
May 22, 20251h 47mWatch on YouTube ↗

EVERY SPOKEN WORD

  1. 0:00 – 2:13

    Intro

    1. SW

      (instrumental music plays) The amount of alcohol it takes to begin to cause health-related problems is much lower than you think.

    2. SB

      Okay, so if I have this glass of wine every day?

    3. SW

      You'd be in what we call moderate risk, which is associated with pretty much every form of cancer.

    4. SB

      So say that I'm drinking two of those there?

    5. SW

      If you're drinking two of those glasses, we're talking, like, a 40% increase. But even drinking that amount, your risk of breast cancer would increase by about 5%.

    6. SB

      This amount?

    7. SW

      Mm-hmm. Which, for many people, is very normal. So there's a lot of misinformation out there about how much should you drink, which I think people don't know, but I can take you through everything. So.

    8. SB

      Dr. Sarah Wakeman is a Harvard professor and addiction expert.

    9. SW

      Leading the charge against one of the biggest public health crises of our time, addiction, bringing facts, empathy, and hard-earned truth. One in three people may have a problem with alcohol at some point in their lives, and globally, 2.6 million people every year die from alcohol-related causes because pretty much every organ in the body is impacted by it. You can see here, this is a 43-year-old person where their brain looks the way a 90-year-old with dementia would look because of that brain damage over time from alcohol use. But what drives people to use substances is probably the most important question. And if we look at studies, one is about 40 to 60% genetics and then other half of the equation is trauma. And so when we hear someone talk about alcohol gives them pain relief, whether that's emotional or physical, that's a very real thing. That's because your sort of natural painkiller system is activated by drinking. It's an anti-anxiety and a pain medication sort of all in one.

    10. SB

      So when you think about how we treat addiction, where are we going wrong?

    11. SW

      The biggest problem is that people haven't been given the evidence and tools to understand addiction. But also, many rehabs don't offer the things that we know are actually effective.

    12. SB

      And what is it that people need?

    13. SW

      Great question. One of the most effective tools we teach people is something called (glass shatters) And they found that people drank much less after it. Yeah.

    14. SB

      Wow. This has always blown my mind a little bit. 53% of you that listen to this show regularly haven't yet subscribed to the show. So could I ask you for a favor before we start? If you like the show, and you like what we do here, and you wanna support us, the free simple way that you can do just that is by hitting the subscribe button. And my commitment to you is, if you do that, then I'll do everything in my power, me and my team, to make sure that this show is better for you every single week. We'll listen to your feedback, we'll find the guests that you want me to speak to, and we'll continue to do what we do. Thank you so much. (instrumental music plays) Dr.

  2. 2:13 – 2:42

    Sarah's Mission

    1. SB

      Sarah Wakeman, with all the work that you do, what is the mission that you are on?

    2. SW

      My mission is really to change the way people think about and understand alcohol and drug problems, and also to give people the evidence and the facts, both to understand addiction, which are sort of problems related to alcohol and drug use, but also to just understand the science around, for example, how much should you drink? Is drinking healthy? Is it not healthy? There's a lot of misinformation out there, and I wanna give people the tools to make the right decision for them in their lives.

  3. 2:42 – 3:29

    Sarah's Education and Experience

    1. SW

    2. SB

      And who, who are you, and wh- what is your sort of body of experience-

    3. SW

      Yeah.

    4. SB

      ... and education?

    5. SW

      So I'm a medicine doctor by training, so I still do some general medicine, like in the hospital I take care of pneumonia and heart failure, and in the outpatient setting take care of people's diabetes and, um, depression. But I trained specially in addiction medicine, so I'm board certified in addiction medicine, and that's been kind of my life's work. I work in a big academic medical center in Boston, Massachusetts where I would say my kind of focus professionally has been thinking about how do we bring addiction care back into the medical system so that it's not this separate and unequal and often very poorly done sort of siloed system, but actually just a part of the healthcare that people get. And then I train people. So I'm, um, program director of our fellowship program, so I train doctors who wanna be specialists in addiction

  4. 3:29 – 4:20

    Issues With Addiction Treatment in the Modern World

    1. SW

      medicine.

    2. SB

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

    3. SW

      Oh, how much time do we have? (laughs)

    4. SB

      (laughs) I think we have enough. Yeah.

    5. SW

      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 kinda knock it off and pull themselves up by their bootstraps, and that this is like a criminal legal issue, that, um, it's an issue of willpower. And so if you believe those things, then why would you think that someone should get medical care, or why would you treat them with compassion and kindness if you think that they're doing something wrong?

    6. SB

      Mm-hmm.

    7. SW

      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

  5. 4:20 – 5:37

    What Is Addiction?

    1. SW

      one.

    2. SB

      And what is an addiction?

    3. SW

      Yeah.

    4. SB

      Wh- wh- what, what falls into the, the bucket of addiction? You know, 'cause I'm, I use my iPad a lot, I use my phone a lot, um, is that, is that an addiction?

    5. SW

      Yeah, it's a great question 'cause we use that term colloquially a lot, you know, "I'm addicted to Netflix," or whatever. Um, so addiction is really defined by use despite consequences. So continuing to do something in your life despite bad things happening to you because of it. So we talk of addiction, we talk of the four 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 wanna 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 many criteria people meet out of this 11 list of different criteria. And then based on that, people can have a mild use disorder, moderate, or severe. And so moderate/severe is really what we think of as addiction, but it's that use despite bad things happening

  6. 5:37 – 6:36

    What Things Are Capable of Being Addictive?

    1. SW

      to you.

    2. SB

      And what things are capable of being addictive in this world?

    3. SW

      Yeah, lots of things. I mean, um, I focus mostly on alcohol and drugs. So alcohol obviously probably most common. I think we'll talk about that a lot today, which I'm excited about. And certainly when we look worldwide, 400 million people have an alcohol use disorder, meaning addiction to alcohol. That's a lot of people.The other are drugs. So that can be, you know, 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. Um, so there's a whole sort of range of substances that can be addictive. And how addictive a substance is, um, is really related to sort of how much dopamine is released in the brain. I know you've had a wonderful episode with Dr. Lembke about dopamine, so you've talked about that a bit. Um, and there are different sort of addictive indices of different substances. So cannabis is less addictive than methamphetamine, for example. But all of those substances can cause addiction in people.

  7. 6:36 – 7:15

    Physiological Dependence vs. Addiction

    1. SW

    2. SB

      Even beyond that, I wonder sometimes in my life if I'm addicted to other things, like, I mean, I drink coffee every day.

    3. SW

      (sips)

    4. SB

      Certainly get a craving to drink it now.

    5. SW

      Yeah. Well, there's, you know, a couple important pieces there. Is your coffee drinking causing harm in your life in any way?

    6. SB

      No. I think it's h- I think it helps.

    7. SW

      It may be helping you, right?

    8. SB

      Okay, so it's not.

    9. SW

      Yeah, so it's not addiction. So there's a difference between physiologic dependence, meaning, like, if you don't drink your cup of coffee, you're gonna get a headache, and addiction, meaning that you're spending all your day and all your money buying more and more coffee.

    10. SB

      Mm-hmm.

    11. SW

      We don't really see this, but, um, buying more and more coffee despite, you know, your girlfriend nagging you about it, and you, you're late to work 'cause you're purchasing coffee. We don't really see that so much with coffee. But that would be sort of addiction.

  8. 7:15 – 8:49

    Scale of the Problem: Why Should People Care?

    1. SW

    2. SB

      How big is the problem? So if you had to frame-

    3. SW

      Yeah.

    4. SB

      ... like, why should we care?

    5. SW

      Yeah.

    6. SB

      Why should the person listening to this care? 'Cause 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.

    7. SW

      Yeah.

    8. SB

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

    9. SW

      Well, I guarantee you 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 1,600 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 in, over the course of your life, how likely are you to, at some point, develop alcohol addiction? Somewhere between 15 and 30% in some studies. So one in three people may have a problem with alcohol at some point in their life. So this touches all of us. We just don't talk about it because of stigma, and because of these mental images of kind of othering that, you know, it's only those people who are injecting heroin who have addiction, or that person who, you know, has the shakes every morning and is drinking as soon as they wake up who has a problem with alcohol.

  9. 8:49 – 9:22

    Is Society Getting Better or More Addicted?

    1. SW

    2. SB

      In which direction are we going in as a society? Are we getting better, or are we getting more addicted?

    3. SW

      Yeah, great question. Um, the pandemic was not kind to addiction. So we saw rates of alcohol and drug use and deaths related to those increase significantly after the onset of the COVID pandemic. Um, that has started to level out. So for drug use-related deaths, we're now back at the 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.

  10. 9:22 – 10:11

    Substance-Related Deaths During the Pandemic

    1. SW

    2. SB

      I was looking at some of the, some of the life expectancy graphs, and, um-

    3. SW

      Yeah.

    4. SB

      ... 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.

    5. SW

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

  11. 10:11 – 12:13

    What Drives People to Use Substances?

    1. SW

    2. SB

      At the essence of what's actually going on there-

    3. SW

      Yeah.

    4. SB

      ... because, you know, a- addiction is downstream from something else.

    5. SW

      Mm-hmm. Yeah.

    6. SB

      But what is actually going on?

    7. SW

      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 gonna address it or help them address it? Um, so trauma is probably the single biggest driver. So, you know, you often hear things like cannabis is a gateway drug. I would say trauma is the gateway drug. If we look at many, many studies, there are kind of two different things that drive someone's risk of addiction. One is genetics. It's about 40 to 60% genetic, similar to diabetes in terms of someone's risk. That's not a done deal, obviously. There are people with strong genetic risks who never develop addiction and people without that who do. The other half of the equation is based on kind of your exposures and your experiences. And one of the number one drivers is what we call adverse childhood experiences. So there this famous study called the ACEs study which i- 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 healthcare provider, it could also be someone working in a grocery store or convenience store who had to work through the scariest times of the pandemic, and also people who are caregivers. So those were kind of the two groups that had the biggest increase in their substance use during the pandemic.

  12. 12:13 – 14:19

    Substances' Effects on the Brain

    1. SB

      What is going on in the brain? You- you referenced it-

    2. SW

      Yeah.

    3. SB

      ... a little bit there. You referenced that dopamine makes you feel good.

    4. SW

      Yeah. Yeah.

    5. SB

      Um, so, you know, very naively, I would assume, okay, so if you feel bad, dopamine makes you feel good, you want more dopamine. But is it, is it more complicant- complicated and nuanced than that?

    6. SW

      Yeah. Well, alcohol's a really complicated one 'cause alcohol has lots of different effects on the brain. Um, so any drug that can, or substance, that can cause addiction is gonna release dopamine. That's sort of a primary driver of many things that we find rewarding, whether it's sex or food or alcohol or drugs. But alcohol also, so it binds to the part of our brain, um, a system called GABA, which is sort of our anti-anxiety system, so it's the same system that anxiety medications like, people may have heard of 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 drink actually just blocks the opioid response in the brain, which doesn't make sense when you first hear about it until you understand these neural mechanisms that actually your sort of natural painkiller system is activated by drinking. So when you hear someone talk about alcohol gives them pain relief, whether that's emotional or physical, that's a very real thing. That's a powerful system in our brain, um, that gets activated when you're drinking.

    7. SB

      Ah, okay. So if I'm having a stressful time at work and work is making me anxious and-

    8. SW

      Mm-hmm.

    9. SB

      ... um, it's crippling me, then I'm more likely to want to have a big blowout on the weekend because that's ef- effectively a, uh, a pain medication?

    10. SW

      Totally. It's an anti-anxiety and a pain medication sort of all in one. You know, and I think often this is part of the area where I think just getting more awareness and, and education about alcohol is so important because we see that as a way of, like, treating ourselves, right? And, and it's very easy to have that get out of control. And I think especially if in your head you think, "As long as I'm not, like, drinking in the morning or missing work 'cause of drinking or, you know, having problems with my relationships, I'm fine."

    11. SB

      Mm-hmm.

    12. SW

      But actually, there's so many health problems and even life problems related to alcohol that people may make different decisions for themselves if they had that awareness earlier on.

  13. 14:19 – 16:26

    Does Trauma at a Young Age Increase Addiction Risk?

    1. SW

    2. SB

      You know, I was, I was thinking about a friend of mine who is fairly well known. Um, passed away from-

    3. SW

      Mm-hmm.

    4. SB

      ... issues related to his addiction.

    5. SW

      Yeah.

    6. SB

      Had a lot of pressure on him when he was fairly young. He wasn't necessarily a ch- a young child when he had a lot of pressure put on him-

    7. SW

      Mm-hmm.

    8. SB

      ... but he was young. And I was wondering, as you said childhood experiences, what age that is.

    9. SW

      Yeah.

    10. SB

      Is there, like, a certain age where those experiences bec- uh, you know, if you experience a certain level of trauma at a certain age, it's harder, um, to rec- recover from that and you're more likely to be addicted?

    11. SW

      Yeah, so it's a great question. Trauma at any time can put you at risk for addiction. The earlier that happens, the more sort of long-lasting the impact can be. Um, so when we think about the brain, you know, your brain doesn't really fully form until early to 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, um, put you at risk for developing substance use as well. So I've seen people who, you know, their first trauma was in their 20s or 30s or 40s, and they can still develop a substance use disorder. It's just the risk is even greater when you experience those adversities as a child. And the interesting thing is, you know, trauma is not so much about the experience. It's about often being left alone to grapple with that experience by yourself. And so what's traumatizing to one person may not be traumatizing to someone else. And, you know, f- take the pandemic for example. I've talked to people who were like, "Being stuck at home and alone and bored was deeply traumatic." Other people were fine. They, like, were in their living room, you know, doing whatever and found ways to connect and to live their lives and did okay. It was the same experience, but it was experienced very differently by different people. So it's less about the actual experience and more about the impact on that human, how they're left feeling, and often it's about feeling disconnected. Um, we often talk about the opposite of addiction is not sobriety, it's actually connection. It's how do you build that connection with other people again?

    12. SB

      My friend, um, that I was referencing is, is

  14. 16:26 – 18:01

    The Opposite of Addiction Is Connection

    1. SB

      Liam Payne who's from One Direction, the, the boy band who passed away.

    2. SW

      Mm-hmm. Yeah.

    3. SB

      And he was on my podcast in, uh, a few years before he passed away, and on the show he said that much of what made his early life so difficult as a teenager was he was obviously thrust onto this big show and then the way it worked was, you know, you've got all this public spotlight and then they'd, like, put him up on a stage and he'd be in front of 100,000 people in Dubai and then they, after that experience, he was then, like, driven back to a hotel room and, like, locked in a hotel room because obviously you can't go out 'cause you're s- you're that famous that if you walk out on the street, crowds are gonna em- emerge.

    4. SW

      Yeah.

    5. SB

      So he was then locked in that hotel room and on the show he said, "I was locked in there with the minibar which is full of alcohol-"

    6. SW

      Yeah.

    7. SB

      "... so I would drink." And then that cycle would repeat itself and he'd be, like, stage, you know, car, hotel, locked, drink, stage, car.

    8. SW

      Yeah.

    9. SB

      And that cycle repeated itself. So when you were talking about isolation and loneliness as well-

    10. SW

      Yeah.

    11. SB

      ... I never really considered the fact that connection and social, um, relationships could play a role in help- in creating an addiction in someone, but it, it tracks.

    12. SW

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

    13. SB

      You're- you're clearly extremely smart.

  15. 18:01 – 18:51

    Why Addiction Matters to Sarah

    1. SB

    2. SW

      (laughs)

    3. SB

      And when I meet people like you, I always think to myself, "You could have committed your life to anything." You could have, you could have worked in pretty much any field and you would have been a success 'cause you have what it takes to be successful. So wha- why do you care so much about this?

    4. SW

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

    5. SB

      An immediate family member?

    6. SW

      Mm-hmm.

    7. SB

      And what age were you

  16. 18:51 – 20:33

    Living With a Family Member Struggling With Addiction

    1. SB

      when you lost that person?

    2. SW

      Probably 24 or so.

    3. SB

      From addiction?

    4. SW

      Yep.

    5. SB

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

    6. SW

      Yeah.

    7. SB

      Can you, can you describe that th- what they feel? To, in a, I guess, an attempt to make them feel-

    8. SW

      Yeah.

    9. SB

      ... seen, because sometimes-

    10. SW

      Yeah.

    11. SB

      ... especially in hindsight, if you end up losing that person, you can be filled with lots of feelings of guilt or misunderstanding-

    12. SW

      Yeah.

    13. SB

      ... and especially, uh, thinking about how society's moved on. S- so, how do you put into words how it feels to be a family member with someone dealing with addiction?

    14. SW

      Yeah. I think you feel powerless. You feel like you wanna do something and you either don't know what to do or feel like everything you've tried hasn't worked. Um, I think again because people have been exposed to this idea that it's an issue of willpower or choice, which really implies that if people wanted it bad enough, they could just stop. And so if you're a family member, then that's easy to feel like, "Oh, they don't love me enough," you know, that, "They're not choosing me over this substance." And so I think often people feel deeply hurt, and they've, you know, been through experiences that have created trauma for themselves. There's a lot of trauma within families who are experiencing this. And then they're sometimes given really bad advice, you know, that you have to, like, kick someone out or this whole concept of kind of tough love and that people need to hit bottom. And so sometimes people, you know, either do that and then wrestle with the guilt of, "Was that the right thing or not?" Or they feel bad even like being kind or loving to their family member. So I think there's a whole mix of feelings. And of course, if you lose someone, you always wonder what if, like, could I have done something differently? Could something else have h- changed? And I think people can feel angry and sad and guilty and be left with that.

    15. SB

      What did those people in your life need

  17. 20:33 – 22:47

    Who Is Sarah Trying to Save?

    1. SB

      that you lost, that they didn't get?

    2. SW

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

    3. SB

      Do you sometimes think back and think, "Do you know, if, 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?" 'Cause I think that was the first thing that's sprung to mind. I played back all the decisions that I made, and I thought, "Okay, maybe that was bad advice-"

    4. SW

      Mm-hmm.

    5. SB

      "... that I was given. Maybe I should have been-"

    6. SW

      Mm-hmm.

    7. SB

      "You know, maybe I could have called more. Maybe I could have intervened here. Maybe m- you know, maybe there's something else I could have done."

    8. SW

      Absolutely. I mean, I think about that all the time. And, um, you know, I think, I mean, I think of a friend I lost to overdose, I think of the family member I lost to alcohol, and not only things that I could have done differently, but also, you know, those people, they, they saw their doctor, they were in the hospital, they had all these touch points, all of these like reachable moments where someone could have engaged with them and offered them kindness and actual effective care that's backed by science, and, and they weren't. And so there are all of these like missed moments and missed opportunities. But the other thing I think about is like how much time I lost with them because I think often in this model of like tough love and kicking people out or thinking like, "I'm not gonna see you until you stop using or stop drinking," because I think that's gonna help make them make that change, you lose out on like all of these moments of time with people that you love, and you, you can't get those back. And so there is this problem, I think, in that binary model of like you're either like sober 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 wanna spend time with them, you know? You miss all of that time. And you know, the both cases that I'm thinking about, like I'll never get that back, you know?

    9. SB

      There's

  18. 22:47 – 25:42

    Change Happens When the Pain of Staying the Same Is Greater Than the Pain of Change

    1. SB

      a phrase I had many years ago, which I'm now reconsidering, which is, um, "Change happens when the pain of staying the same becomes greater than the pain of making a change."

    2. SW

      Mm-hmm.

    3. SB

      And that kind of dovetails into this idea that someone needs to hit their own rock bottom for them-

    4. SW

      Mm-hmm.

    5. SB

      ... to change. I think the part, the reason why that idea prevails is because we hear so many stories, I hear them on this podcast, of someone's family rejecting them, throwing them out on the street, and then them having that eureka moment, that, "Fuck-"

    6. SW

      Mm-hmm. Mm-hmm.

    7. SB

      "... I need to change my life."

    8. SW

      Mm-hmm.

    9. SB

      And people always reference that like rock-bottom moment where-

    10. SW

      Mm-hmm.

    11. SB

      ... they took action because, you know, they were at the very bottom of the well. And, um, how does that phrase sit with you, "Change happens when the pain of making a change becomes greater than the pain of making a change"?

    12. SW

      I think that there are those times for sure. It's not to discount that, and I hear those stories too, but I think there are, um, from evidence, what we know, there are probably more times where people just endure the pain again and again and again until they never change. And I think the part that we don't see, or are the folks who change happens when they begin to get enough hope that things could be better for them, that, you know, someone loves them, someone cares enough that they're reaching out a hand in the darkness, that there actually is a path forward. I think people stay stuck when they feel hopeless, when they feel like nothing could ever, that they're never gonna get this, they're never gonna be able to change, their life would never get better. And so, you know, take the example, I'll often hear from family members when their loved one is in jail that they're like, "Thank heavens," you know, they're, they're in a safe place at least. Like there's actually this sense of relief. There's even a term for it called a rescued that people feel. I think it just goes to the desperation that families are dealing with, but this idea that like that's a safe intervention. And you hear these stories, right? Of someone who they get locked up and like that's their eureka moment.And yet, if imprisonment were an effective intervention for addiction, for example, we wouldn't see that actually the time after getting released from prison, there's 130 times increased risk of dying from a 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 I think there are those stories, but we tend to elevate those, like, amazing narratives, and we miss the fact that so many other people are gonna die in pain and alone and isolated because they have no hope. And so it's not to discount those moments, and some people are incredibly resilient and against all odds, even with the most trauma, they can, you know, make it through, and that's incredible. But that doesn't mean that we should, like, create a system that makes it as hard as possible on people.

    13. SB

      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?

    14. SW

      Absolutely.

    15. SB

      Is there anything else missing?

    16. SW

      And it's about effective treatment.

    17. SB

      And treatment, okay. Which is subjective, right? Which could be depending on the situation they're in.

    18. SW

      It depends on the type of addiction and their situation, but in most cases, it's some combination of psychotherapy, medication.

  19. 25:42 – 28:05

    Misconceptions About Alcohol

    1. SW

    2. SB

      So alcohol.

    3. SW

      Yes.

    4. SB

      There's, I mean, alcohol's been on a journey.

    5. SW

      Yes.

    6. SB

      It's been on a journey in terms of s- society's opinion about it.

    7. SW

      Mm-hmm.

    8. SB

      Can you take me on that journey and tell me where we are now? And-

    9. SW

      Yeah.

    10. SB

      And in term, when, when I'm saying that I'm talking about society's opinion on its health benefits and what it is.

    11. SW

      Mm-hmm.

    12. SB

      And, and then, and then also what we're getting wrong now about alcohol.

    13. SW

      Yeah. Yeah. Um, so I mean, the journey of alcohol is fascinating. So first, I think we think of this as a relatively modern thing, but, you know, archeologists have discovered, like, beer-making equipment in hunter-gatherers' cave dwellings from 13,000 years ago. That's wild.

    14. SB

      Wow.

    15. SW

      Like, 13,000 years of people figuring out how to make beer. You know, you look at China 9,000 years ago, it was really about, like, a spiritual journey or a social thing. It was never really about health. At some point, we started talking about this as something that is good for your health. Like, drink red wine, it's gonna improve your health.

    16. SB

      Mm-hmm.

    17. SW

      And that's where I think we got wrong. And the reason why was actually from how we were looking at the data. So first, if you look at only one health condition, there are some health conditions where a moderate amount of alcohol actually improves your health. But it was also how people were conducting the studies. So in most of those studies, what people do is they take, like, a massive population, tens of thousands of people, where we have some data where they're reporting how much alcohol they used. And then we look at health risks over time. And scientists would lump people into sort of non-drinkers versus light drinkers, moderate drinkers, or heavy drinkers. And what they were finding is that people who are drinking in the, even up to the moderate level, were actually doing better than the people who weren't drinking at all. And so that was where that, um, concept that drinking is good for your health came from. And so people talk about this, like, J-shaped curve, meaning that moderate drinkers actually have lower risks of health problems. And then it's really only when you start drinking very high levels that you start having more risk of health problems than people who don't drink at all. What they realize is wrong with that is that in the people who don't drink at all, many of those people are not drinking 'cause they're actually really unhealthy for another reason. Like, they might have heart failure and they, like, don't wanna drink 'cause they don't want it to mix with their medication. Or they might have had a history of alcohol use disorder and they're actually in recovery. So they've already had some damage from alcohol and they're not drinking because of that. And so when you change the reference group, you actually make the, the sort of group that you compare people to, to people who very rarely drink, so it's not that they're not drinkers at all, but they drink, you know, very, very light levels. Then you start to see that those, like, health benefits of alcohol go away, especially if you look across all conditions.

  20. 28:05 – 28:40

    Is There a Healthy Level of Alcohol Consumption?

    1. SW

    2. SB

      Are, are you telling me that there's no healthy level of alcohol consumption?

    3. SW

      Yes. I would never say, "Drinking alcohol is good for your health." That doesn't mean that drinking at what we call low-risk levels can't be a part of a healthy lifestyle. So it's a slight, slight shift that, like, don't fool yourself into thinking that drinking that glass of wine is like going to exercise for 30 minutes. Like, it's not something that's gonna promote your health. I think of it more like having dessert, eating bacon, going out in the sun. There are risks associated with all those activities. It doesn't mean that I would say you can never do any of that, but you need to understand what the risks are and then make choices for yourself.

  21. 28:40 – 30:28

    Is One Drink a Day Safe for Health?

    1. SW

    2. SB

      Say I look at this glass of wine here.

    3. SW

      Yeah.

    4. SB

      And this pint of beer.

    5. SW

      Yep.

    6. SB

      If I drank one of these a day, not a huge amount, um, I think what people tend to think is they think, "Well, it's only one."

    7. SW

      Yeah.

    8. SB

      "So my body will just flush it out and there'll be no adverse health consequences."

    9. SW

      Yeah.

    10. SB

      I- Is that true?

    11. SW

      Well, so part of the challenge is what we think of as one drink. So I think, um, much like, you know, if you learn to re- read the serving size on a food, you realize that like, oh, a serving of ice cream is like a half a scoop. It's not like a giant ice cream sundae. The same is true with alcohol. So, um, in the UK, the kind of low-risk drinking limits talk about units of alcohol, which is the equivalent of eight grams of alcohol. So how much of a drink has eight grams of alcohol? And to be in that low-risk category, you have to be below 14 units. The problem is that glass of wine, just eyeballing it, has several units of alcohol. So it is not a s- even though we think of it as a single drink, it's probably, I mean, I'd have to guess, but it's probably, like, three units of alcohol.

    12. SB

      So if I have a glass of wine every day, I'll be over that limit then?

    13. SW

      You'd be right at that limit. The problem is most people don't drink just one glass. If you, um, you know, if you have two glasses one day, and then one glass one day, and then three glasses one day 'cause you're at a social function, all of a sudden you're actually quite a lot over that limit.

    14. SB

      So if you said that th- this, this is roughly three units, roughly.

    15. SW

      Yeah. And you get 14 a week.

    16. SB

      And you get 14 a week.

    17. SW

      Mm-hmm.

    18. SB

      So three times seven?

    19. SW

      Mm-hmm.

    20. SB

      21?

    21. SW

      Yeah. So yes, you're over if you're drinking that size, yeah.

    22. SB

      Okay, so if I have this glass of wine every day, then I'd be over the UK limit of?

    23. SW

      Lower-risk drinking.

    24. SB

      Lower-risk drinking. So I'd be medium-risk drinking.

    25. SW

      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.

  22. 30:28 – 33:13

    Link Between Moderate Drinking and Cancer

    1. SB

      Okay. 'Cause I was wondering why c- cancer has been increasing.

    2. SW

      Yes.

    3. SB

      Um, v- a variety of different forms of cancer-

    4. SW

      Yeah.

    5. SB

      ... are increasing. You know, breast cancer's one of the ones we always hear about that's-

    6. SW

      Yep.

    7. SB

      ... increasing. S- so you're saying, w- what is the data in terms of m- low or moderate risk of drinking and cancer?

    8. SW

      Yeah. So the data is, um, growing and really worrisome. So for breast cancer, so there's really, there's a few cancers that even at low-risk limits, you see the risk begin to increase, so where we would say there's kind of no healthy, or there's no even, like, low-risk amount. So breast and esophageal cancer are two examples of that. So with breast cancer, if you were to drink, um, below those low-risk li- 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, it's below that 14 units, so it would be, you know, fewer than seven of that, that size glass of wine, we still see a slight increase in the risk of breast cancer. It's about a 5% increase. So that means your risk of breast cancer would increase by about 5%. And that's not huge, so I think, you know, percent increase is kind of hard to do the math on, but if you think, in the US for example, the average woman has a 13% likelihood of getting breast cancer in their lifespan.

    9. SB

      13% likelihood?

    10. SW

      It's really ... yeah.

    11. SB

      Wow.

    12. SW

      Really high. So a 5% increase would increase that to, like, 13.6 or so.

    13. SB

      S- s- so that means that if there's nine women in this room-

    14. SW

      Yeah.

    15. SB

      ... one of them has, is gonna get breast cancer probabilistically?

    16. SW

      In their life, yep.

    17. SB

      Damn.

    18. SW

      Yeah.

    19. SB

      Why is it in- and it's increasing?

    20. SW

      Yeah, and so the reasons for that are likely environmental, 'cause your genes don't change over that time period. So the risk factors, you know, if we think about breast cancer, it's alcohol, it's obesity, um, it's, you know, age at w- when you have children or don't have children 'cause it's really a hormonally driven cancer. Same thing if you think about colon cancer. That's a really scary one where we're seeing more and more cases in younger people. Some of the drivers of that, eating meat, so processed meats increase your risk of colon cancer. So, you know, these very sort of normal behaviors. There's probably other environmental things, honestly, that we're not yet measuring or able to measure, just given the rate of acceleration. When I talk to my colleagues who are oncologists, you know, things like plastics or other things that we don't yet know, there's, um, it's clearly something in the environment that is driving these increased cancer risks.

    21. SB

      So even at, even at this sort of level, if I'm drinking ... that might be one unit, right?

    22. SW

      Yes. So-

    23. SB

      That would be seven units a week.

    24. SW

      ... that would be one unit, so you'd ... that would be fewer than 14 of that. So you could see like in, you know, if you had double that, it would be a decent pour of wine. You could not have more than seven of those in a week c- to be in low risk, but even drinking that amount, your risk of breast cancer would go up a little bit.

    25. SB

      Even this amount?

    26. SW

      Mm-hmm. There's really sort of no safe amount of alcohol when, when it comes to breast cancer.

  23. 33:13 – 34:41

    Types of Cancer Linked to Alcohol Consumption

    1. SW

    2. SB

      Is it just breast cancer?

    3. SW

      So that low-risk category, so when we ... these big cancer studies categorize people as sort of low-risk or light drinkers, moderate, or heavy, and for pretty much every cancer, once you get to the moderate category, we start seeing increases, and there's what we call a dose response 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.

    4. SB

      Does it have an impact on thinking about cancers that are pr- prominent in men?

    5. SW

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

    6. SB

      So yeah, can you drill down on that? So if I, if I'm a heavy drinker-

    7. SW

      Mm-hmm.

    8. SB

      So say that I'm drinking, uh, let's say I'm drinking two glasses of wine a day consistently-

    9. SW

      Mm-hmm.

    10. SB

      ... which I guess would cons- like, if I was drinking two of those a day-

    11. SW

      If you were drinking two of those glasses, yeah, you'd be in the heavy category.

    12. SB

      So two of those a day puts me in the heavy drinker category?

    13. SW

      Yeah, which would surprise most people, right? Like, that, for many people, is very normal.

  24. 34:41 – 35:21

    Cancer Risk Among Heavy Drinkers

    1. SW

    2. SB

      It is very normal.

    3. SW

      Yeah.

    4. SB

      Yeah. I think it's som- uh, somewhat more difficult for younger people to understand-

    5. SW

      Yes.

    6. SB

      ... because younger people drink less, but if I think about the generation above me-

    7. SW

      Mm-hmm.

    8. SB

      ... having two glasses of wine a day-

    9. SW

      Mm-hmm.

    10. SB

      ... is quite normal.

    11. SW

      Mm-hmm.

    12. SB

      After work, on the weekends, with, with every meal that you have. So that would make me a heavy drinker.

    13. SW

      Mm-hmm.

    14. SB

      And then what are my s- what are the stats saying in terms of my cancer, uh, risk profile?

    15. SW

      Yeah, so it varies by cancer, but roughly, we're talking, like, a 40% increase in c- cancer depending on the cancer type. And the more you drink, the more that's gonna 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.

  25. 35:21 – 36:10

    Heavy Drinking and Comorbidities as Cancer Risk Factors

    1. SW

    2. SB

      And then if I have other sort of ... do they call them comorbidities?

    3. SW

      Yeah, exactly.

    4. SB

      So other illnesses, other diseases-

    5. SW

      Yeah.

    6. SB

      ... in my body, my probability is gonna go up further if I'm obese and if, if I'm overweight.

    7. SW

      Exactly.

    8. SB

      Um ...

    9. SW

      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 gonna be even higher.

    10. SB

      H- how does that work?

    11. SW

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

    12. SB

      What's going on in the

  26. 36:10 – 37:49

    How Alcohol Drives Cancer Mechanisms

    1. SB

      body then? If I drink alcohol, how is that leading to cancer? You referenced it slightly there, but I- I'm trying to ... I want to make sure I'm super clear in my brain-

    2. SW

      Yeah.

    3. SB

      ... as to, like, what the, the, the knock-on effects are and-

    4. SW

      Yeah.

    5. SB

      ... how that ends up as cancer.

    6. SW

      Yeah. I mean, there's lots of different mechanisms. So j- 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, hits your bloodstream usually within 10 minutes or so of having a drink. Um, how much it hits your bloodstream depends on how much water you have in your body. So alcohol doesn't penetrate into your fat. It just kind of diffuses into the water parts of your body. So that's actually why for many women, they will get more sort of drunk or more of an effect from alcohol at a lower level than men 'cause women have more body fat than men.

    7. SB

      Mm-hmm.

    8. SW

      But that's gonna depend on you as an individual. If you have more body fat, you're gonna 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 motor, lack of motor coordinations. We've all seen this and many people have probably experienced it. You know, you may be stumbling, not able to drive safely. You're not gonna make the same decisions you would make if you weren't drinking. And then if you keep drinking, then you get, uh, you can actually lose consciousness, so pass out, and people have experienced that. Your body is gonna try to break down alcohol as quickly as it's able to. Like anything, we wanna 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

  27. 37:49 – 38:43

    Alcohol and Weight Gain

    1. SW

      to alcohol.

    2. SB

      Because your body sees ethanol as poison.

    3. SW

      Yes. I mean, you know, I th- I know you talked about this, Dr. Lembke, but your body always wants to restore what's called homeostasis. You're always, your body's always gonna 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 gonna 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 gonna be floating around and causing damage to your cells. So that's one way that alcohol can cause cancer. The other is, um, just general sort of inflammation. People have probably heard that inflammation is just not good for the body and increases the risk of cancer. And ox-, um, uh, 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.

    4. SB

      So I also found

  28. 38:43 – 41:57

    The Role of the Liver

    1. SB

      this graph, which shows, for anyone that can't see what we're describing at the moment-

    2. SW

      Yeah.

    3. SB

      ... it shows the acceleration in liver disease, uh, death rates, and general livi- liver disease compared to other parts of the body-

    4. SW

      Yeah.

    5. SB

      ... other organs in the body, I believe it shows.

    6. SW

      Yeah.

    7. SB

      What impact does alcohol ha- have on the liver? And we have our little mannequin here-

    8. SW

      Yeah.

    9. SB

      ... of the human body. Where is the liver?

    10. SW

      Yeah. Great question. So here's, um, our little mannequin. So just to orient people to the body, so we're looking at the inside of the body, so like, the ribs are gone. The outside of the skin is gone. These two pink things are the lungs. They kind of encase the heart. You can see the heart's behind the lungs pumping your blood. The liver is this brownish organ. It's on the right side of your body, right under your ribs. It's quite large, and it's-

    11. SB

      It's big.

    12. SW

      ... an amazing organ. It is quite big. It processes much of what any kind of toxins that we take in, things that we eat, your glucose, alcohol. 90% of it's metabolized by the liver. So the liver is sort of the clearing house, getting rid of byproducts in your body. The other are the kidneys, but the liver plays a huge role, especially in alcohol. So it sits right here.

    13. SB

      It almost looks like it's as big as the lung, as one lung.

    14. SW

      Yeah. Yeah. It is. Yeah.

    15. SB

      Really?

    16. SW

      Yeah. It's, it's a giant organ, and it's an amazing organ. So you can actually cut out 80% of the liver, and it would regrow itself. So kind of like-

    17. SB

      What?

    18. SW

      ... you know, those lizards that you cut off their tail and they regenerate a tail. Uh, the liver is fascinating. It's why we can do living liver, um, transplant. So I could take half of your liver and give it to someone who needed a liver. You would still be able to live, and they would get a second chance at life from that part of your liver. So it's this really cool organ that can regenerate.

    19. SB

      What?

    20. SW

      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. Um, you sort of reach a point of no return, where at that point, the liver can't heal itself. So I sort of think of it like, to use a baking analogy, if you're making muffins or a cake, you're going along, you're mixing all your ingredients, and you realize before you put things in the oven, like, "Oh, I forgot the eggs." You can still add the eggs in and, like, whisk it all together and it's gonna 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, the batter the same. And the liver's sort of like that, that up to a certain, uh, degree, you can actually completely repair the effects of things like alcohol or obesity, other things. But once you pass that point into scar tissue, the liver can't regenerate anymore. And so when you think about that graph or just the rising rates of liver disease, um, the, the main drivers of liver disease are obesity and two is alcohol. And so those are the leading causes of a- of liver transplant. And the thing that is, you know, so sad is, I mean, I see this all the time working in the hospital, is first of all, we're seeing younger and younger people coming in in liver failure. So people in their 20s coming in in fulminant liver failure from alcohol and then dying in the hospital. And the terrible thing is that they often didn't even know that this was causing a problem in their health, and by the time they get to the hospital, they're so sick it's too late. And yet all of that could have been prevented or even repaired if it was caught sooner. And so that's where I think this education of understanding, like, what really are the health harms of alcohol and that we have normalized binge drinking in many occasions, especially in young people as being totally normal, and yet there are very serious health consequences.

  29. 41:57 – 43:42

    Liver's Ability to Regenerate

    1. SB

      So I've got a, a bunch of questions around-

    2. SW

      Yeah.

    3. SB

      ... around the liver. Um, does that mean that my liver can take a bit of a beating before there's any real problems? Should I, you know, someo- 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.

    4. SW

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

    5. SB

      You said that my, my liver regenerates though, so I'm thinking-

    6. SW

      Yeah.

    7. SB

      ... this thing will just pop back to normal again.

    8. SW

      As long as you haven't gotten to that scarring phase. So once you get too far down that path, even if you were to stop drinking, your liver won't recover. The hard thing is at that we don't totally understand who and why that happens so young too, so this is an active area of investigation 'cause 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 gonna 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 gonna lead to harm. The other way is to get medical care 'cause 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.

  30. 43:42 – 44:21

    What Else Damages the Liver Besides Alcohol?

    1. SW

    2. SB

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

    3. SW

      Yeah. Um, so obesity. Um, so-

    4. SB

      Food does?

    5. SW

      Yeah, food. So your liver is very involved in glucose metabolism.

    6. SB

      Ah.

    7. SW

      Um, so, so our diet and our body weight impact our liver health. Um, the other medications, so, um, acetaminophen or Tylenol, which is a very common over-the-counter pain reliever, um, above a certain threshold can cause serious liver damage. So sometimes we'll see cases where someone didn't realize that, like, their cold medicine plus the Tylenol they were taking both had that ingredient, and then they go out and drink heavily, and that kind of combination effect can cause liver

  31. 44:21 – 45:17

    How Much Alcohol Causes Liver Damage?

    1. SW

      damage.

    2. SB

      How much do you think ... uh, this might be a bit of a strange, uh, bit of an, an unclear question, but how much alcohol is gonna cause liver damage?

    3. SW

      So again, it varies person to person. For liver damage, it does tend to be the moderate to higher amounts that cause damage. Um, one thing is that, you know, that having these big surges, like these massive binge episodes, is probably more harmful than drinking, like, at a moderate level for a long period of time. Those, like, big surges cause a big buildup of that toxic byproduct that your body has to clear, and so, you know, if you have several years of binge drinking heavily, that actually probably is gonna cause more damage than a longer period of time of just drinking above the risk limit. 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 in, in how low-risk they are, is gonna reduce the risk of liver damage.

  32. 45:17 – 46:27

    Alcohol's Impact on the Brain

    1. SW

    2. SB

      And does alcohol just impact the liver?

    3. SW

      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.

    4. SB

      Oh, I've got one actually.

    5. SW

      Yeah, I think-

    6. SB

      This is, by the way, sh- shocking-

    7. SW

      Yes.

    8. SB

      ... to me.

    9. SW

      So when we do an MRI of someone's brain, um, we basically ... This is like a cross slice, so it's almost like you're, you're facing me and I'm cutting your face off and looking at your brain onwards. Um, healthy brain tissue is the gray and white matter, and you want it to be as plump and, like, taking up as much space as possible 'cause 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 of the black space is essentially water. So we see the brain start shrinking and shrinking, and there's more water and less active, healthy brain tissue. That process is accelerated with heavy alcohol use. And so you can see here, this is a 43-year-old person with severe alcohol use disorder, where their brain looks the way, you know, a 90-year-old with dementia would look because of that, um, brain damage over time from alcohol use. And so we can actually, a form of dementia is related to alcohol use, and so your brain can be hugely impacted with alcohol.

  33. 46:27 – 47:13

    How Alcohol Causes Brain Deterioration

    1. SW

    2. SB

      What is going on there? Like, w- what's causing the brain to deteriorate in such a way because of alcohol?

    3. SW

      Yeah, well, um, remember I said, um, ethanol, which is the molecule, crosses the blood-brain barrier? And so especially when you're having these high levels of blood alcohol, that ethanol is sort of bathing your brain, and if you think about what we talked about, inflammation and changes to cells and to DNA and proteins, that is happening at the brain level. The other thing that can cause, accelerate the brain damage we see with alcohol is actually nutritional deficiencies. So people may be drinking a lot and they're actually not getting really crucial nutrients in their diet, and that can accelerate the process of brain damage. We can even see a very, like, sudden onset amnesia from heavy alcohol use in the, in the setting of not getting enough nutrients in your diet.

    4. SB

      Okay,

  34. 47:13 – 47:50

    Other Organs Affected by Alcohol

    1. SB

      so that's the brain.

    2. SW

      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 he- health conditions, most notably acid reflux, so heartburn. So if you notice like, "Ugh, I'm, like, always having heartburn. I'm having to pop all these, like, antacids and take this medicine," you might wanna think, like, "How much am I drinking? Is that contributing to my heartburn?" So that's a very common thing. Um, the heart is affected by alcohol. So, you know, the heart is an organ where at low risk

  35. 47:50 – 48:57

    Alcohol's Impact on the Heart

    1. SW

      levels, there doesn't seem to be harm from alcohol, but once you get into the moderate and high, we see harms, and the harms can be a couple fold. One is, um, something called atrial fibrillation, which is basically where your heart starts beating really irregularly.

    2. SB

      Yeah.

    3. SW

      So, um, in your heart, there's four chambers. The two chambers at the top ... So this is really showing the ventricles and the atrium. So there's two chambers that blood flows through, and in a normal heart, your electrical activity comes from the top of your heart, goes down to the bottom of your heart, and tells the heart to pump.

    4. SB

      Mm-hmm.

    5. SW

      And so you get a single impulse that goes to the bottom of the heart that says pump, and that pumps blood out to your brain and your body and your organs and your liver. In atrial fibrillation, the top of the heart is just kind of quivering with this abnormal electrical activity, and so the heart can't pump in a normal way. We actually ... There's a, a term in medicine called holiday heart 'cause we see sometimes people drink a ton over the holidays and will 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.

    6. SB

      Oh, damn.

  36. 48:57 – 49:55

    Body Fat Percentage and Alcohol Tolerance

    1. SB

      Sometimes we think that if we're good at handling our beer or our alcohol, then it's having less harm on us. So I'm ... For whatever reason, I've always been good at drinking-... quite a lot when I used to drink.

    2. SW

      Mm-hmm.

    3. SB

      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 'cause you-

    4. SW

      Yeah.

    5. SB

      ... pointed out an association there that I was never aware of.

    6. SW

      Mm-hmm.

    7. SB

      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?

    8. SW

      Yeah, 'cause they have less body water, and alcohol doesn't go into your body fat. So you're, essentially it's like if you took, you know, a glass of water and you dropped red dye in it, you're gonna diffuse into that water. So the more water you have, the more diffuse it'll be, and the lower your blood alcohol content. So if you have very low body fat, you probably have more body water, and so, you know, two drinks for you is gonna diffuse into a larger amount of water.

    9. SB

      Ah, that explains a lot. 'Cause I always wondered. He was, he was so much bigger than me. At the time, he was, um, he had, uh, much more body fat. And he would get drunk very, very quickly.

    10. SW

      Mm-hmm.

    11. SB

      And you always think, "Oh, a big guy. They can

  37. 49:55 – 50:36

    Does High Alcohol Tolerance Prevent Organ Damage?

    1. SB

      handle their beer or whatever."

    2. SW

      Yeah.

    3. SB

      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 having, I'm not as drunk as he is."

    4. SW

      Mm-hmm.

    5. SB

      But you, but that's not true?

    6. SW

      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 'cause it, hangover does seem to be related to the amount, how high that your blood alcohol level gets. So people who don't metabolize alcohol as quickly tend to have worse hangovers. So that may have been something you experienced. But it doesn't protect you from the other health harms of alcohol, like liver damage, like cancer, like over time, you know, heart problems or esophageal problems.

    7. SB

      What

  38. 50:36 – 52:03

    What Is a Hangover?

    1. SB

      is a hangover?

    2. SW

      Yeah, hangover's a fascinating thing that people are, uh, you know, there's a lot of emerging evidence about it in trying to understand what happens. It seems to be most related to how high the ethanol concentration in your brain gets because they've actually done a ton of studies with mice and with people. It was initially thought to be due to the byproducts of alcohol, like that acetal-aldehyde molecule we talked about, but it doesn't seem to be related to that. It seems to be related to the 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 crappy.

    3. SB

      'Cause people think of it sometimes as just being dehydrated.

    4. SW

      Yeah, it, it is not just being dehydrated. There's actual sort of effects of ethanol on your brain that lead to the hangover.

    5. SB

      Okay.

    6. SW

      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 le-limit that would be considered okay for your body.

    7. SB

      'Cause s-sometimes y- 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.

    8. SW

      There is some element of dehydration. Don't get me wrong. And that's partly 'cause, right, if you think again, alcohol is diffused in water, so if your total body water is contracted because you're dehydrated, your ethanol level's gonna be higher. So drinking is gonna help you sort of flush it out and feel better, um, drinking water. But it's not only because of dehydration.

  39. 52:03 – 53:36

    Balancing the Risks and Benefits of Alcohol

    1. SW

    2. SB

      There'll be people listening to this now. I doubt they would've got this far, but, um, because if they, if they did, they probably wouldn't think this. But there'll be some people who would've gotten this far in the conversation and be thinking, "Yes, but..."

    3. SW

      Mm-hmm.

    4. SB

      ... alcohol helps me socialize, and socializing's 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 wanna quit my alcohol use." And, you know, in some cases that they will be high and medium consumption alcohol drinkers. What do you say to those people?

    5. SW

      Well first, like, 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 gonna live this, like, ascetic lifestyle where they never eat dessert. So I think it really is like an, you need to go in with eyes wide open and understand what are the risks, what matters to you, and how do you make that calculus? 'Cause if you decide it's a choice you wanna make, you wanna set yourself up for success. So if you decide, like, "I wanna cut back on how much I'm drinking, but I'm gonna go to happy hour every night with my friends and just try to, like, not drink while I'm there," you're probably not gonna be very successful because you're gonna be in a situation that's constantly, like, reminding you of alcohol use, and everyone around you is using alcohol. So try to make some different sort of structural changes in how you set up your life and your week and your day. Um, and you may find that actually you don't miss it that much, that you could cut out three or four days of drinking and still get that social pleasure two days out of the week, and your overall health risk is gonna go down significantly.

  40. 53:36 – 56:40

    Is Rehab Effective for Addiction?

    1. SW

    2. SB

      In terms of treating someone with alcohol, uh, abuse disorder, rehab is often the most widely known form of treatment. Um, m- 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."

    3. SW

      Yeah.

    4. SB

      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?

    5. SW

      Generally, no. Um, so, you know, rehab is this idea that you go away somewhere for a week, a couple weeks, and then you're kind of cured, right? It's almost like people have thought of addiction as an infection where you need, like, two weeks of antibiotics, and then you're done.

    6. SB

      Mm-hmm.

    7. SW

      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 s- stability and remission, and you're almost like a, a cancer survivor, or you're in long-term recovery. And so this idea that you go somewhere for a couple weeks and then you come out and you're all better really doesn't match what we know of addiction. The other problem is that much of what happens in rehab is not all that therapeutic most of the time. So the things that we know are most effective for addiction, one, are medications, which there's a lot of stigma and m- misunderstanding about, and then two are, like, evidence-based psychotherapies. So things like cognitive behavioral therapy, motivational enhancement therapy, you know, working on your underlying trauma. Often in rehabs, the model is really built around this idea of, like, you remove yourself from this environment. You do some groups while you're there sometimes. Often they're based on more of, like, a peer support model. Sometimes the therapies that are offered are frankly not very evidence-based. Like, we actually did this study, it was a Secret Shopper study where we called rehab programs across the country to, like, ask about what they offered, and many of them offer things like, you know, horse therapy or, like, dolphin-assisted therapy, which, like, I'm sure it's-... very nice to swim with dolphins and to work with horses, but it's not something that's been, like, studied and effective, and many places don't offer the things that we know are actually effective, which are, you know, trained clinicians doing evidence-based treatments or medication treatments. So it's a combination of, like, this short-term fix for a long-term problem, and not actually getting the treatment that you need. So what does work, like for alcohol use disorder, most people don't know we have very effective medications that can help you, even if you just want to s- not drink as much. So there's this medication I mentioned at the beginning that actually blocks your opioid receptors.

    8. SB

      Yeah.

    9. SW

      Which seems kind of funny that it works on alcohol, but the reason it does is that, that for people who part of the thing that drives them to drink is that they drink, they feel this, like, pain relief, pleasure sensation from the release of opioids in their brain, and that makes them want to drink more, that if you block that, people don't get sick if they drink, but they just don't find it as rewarding. And so someone named Sinclair, actually, in Europe did some fascinating experiments of even just using it as needed, so rather than taking it as an everyday medication, if you know that when you go to, like, a holiday event, you're gonna drink way more than you wanna drink, you take it, like, 30 minutes before you go. And then what people find is they have, like, one drink and they're like, "Ah, I'm good. I don't have that same urge to want to drink more and more, 'cause I didn't get the same sort of tickle of feeling better and feeling relief."

  41. 56:40 – 57:26

    Psychedelic Therapy for Addiction

    1. SW

    2. SB

      What do you think about psychedelics as a way to-

    3. SW

      Yeah.

    4. SB

      ... counteract addictive behaviors like the ones we've described?

    5. SW

      Yeah. One of the most, like, groundbreaking trials in the last couple years for alcohol use disorder was psilocybin. So there's a big study of psilocybin-assisted psychotherapy for alcohol use disorder, which showed really remarkable effects. So people took psilocybin, they actually compared it, folks came in and they either got a big dose of Benadryl or psilocybin, and then they sat with a therapist for, like, eight hours for this guided, um, 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 impr- 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.

  42. 57:26 – 58:52

    GLP-1 Medications for Addiction Treatment

    1. SW

    2. SB

      Psilocybin is the active compound in magic mushrooms.

    3. SW

      Yes. Exactly.

    4. SB

      Have you heard of ibogaine?

    5. SW

      I have, yeah.

    6. SB

      Which is often associated... Which is another psychedelic often associated with addiction?

    7. SW

      Yes. People have looked at i- ibogaine for, um, opioid use disorder. Um, those studies have been less promising than psilocybin, although it hasn't been tested in the same kind of rigorous ways recently. Partly for opioid use disorder, we have really effective medications that have been shown to improve recovery and reduce death. And so it's sort of hard to be better than that. One really interesting, like, new whole class of medications for alcohol is, um, medications that are being used for weight loss that people have probably heard of, so like, Wegovy, Ozempic, that whole class of GLP-1, um, medications seems to also reduce alcohol use, which is kind of interesting.

    8. SB

      Really?

    9. SW

      Yeah.

    10. SB

      Has, have they studied them?

    11. SW

      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 wanna smoke or drink." Like that kind of urge has gone away entirely. And for some people, they really describe it as being, like, miraculous. They've been trying to stop drinking for, you know, years and years, and for the first time they don't feel that sense of, like, craving and urge. Um, and there recently have been some actual clinical trials where they've done, you know, 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.

  43. 58:52 – 59:49

    Ads

    1. SW

    2. SB

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  44. 59:49 – 1:02:14

    Sarah's Reaction to Celebrity Addictions

    1. SB

      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 some day the TMZ headline's gonna ring out and say that this person has p- passed away. And that happens all too often. We think about, you know, Whitney Houston or, um, I guess Michael Jackson's even been associated with-

    2. SW

      Yeah.

    3. SB

      ... dying from an addiction to, I think it was painkillers or something.

    4. SW

      Mm-hmm.

    5. SB

      Prince, Elvis Presley, Mac Miller, who a lot of people will know as well-

    6. SW

      Mm-hmm.

    7. SB

      ... a- and Nicole Smith, and even now in the public eye there are certain individuals where we're starting to see this sort of erratic behavior they're posting on their Instagrams, they're, they're showing up in society in a slightly different way. When you see that in the line of work that you operate in, what is your natural reaction? How does it make you feel when, you know, 'cause there's a couple of people I'm thinking about at the moment who the world are talking about that, you know, we think they have an addiction, we think they need help. What is your natural reaction to, to that? And what, what is it that those people need?

    8. SW

      Yeah. Well, when I, when I read the headlines of someone dying, I mean, to me it's gutting and heartbreaking. One, 'cause obviously it's a human life that was someone's mother and sister or brother and people cared about, a public figure that people looked up to and cared about. But mostly that it was a totally preventable death. Like really no one should die from a substance-related death. We have tools to treat addiction, we know how to prevent the harms of, you know, drug overdose, for example. And so the fact that someone can die, especially someone that everyone has watched for so long is, I think just, like, a tragic example of how, what the mismatch is between what we do around addiction and what science says is actually helpful.Um, I think, you know, when I see, 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 gonna be like a, you know, you have an intervention, the person goes to treatment, gets better forever, that I think is often in people's minds. It is a process, a journey, like any change. And so really, it is around where we began, that idea of how do you begin to understand, well, this person, how is their substance use getting in the way of what they want for themselves? And how might their life loo- be better for them based on whatever they believe better is if they were to make changes to their substance use?

    9. SB

      I um, I remember I had this one particular

  45. 1:02:14 – 1:04:30

    Stigma Around Addiction

    1. SB

      friend who had an addiction, and, um, I remember always the life of the party, and I remember this one day he came up to me at, at an event and he'd sat down in front of me and said to me, um ... He said, he like whispered to me, "I'm in so much pain."

    2. SW

      Mm-hmm.

    3. SB

      And he told me about rehab and how it failed him, et cetera. But it, it just, it almost f- f- sounded unbelievable-

    4. SW

      Mm-hmm.

    5. SB

      ... that someone with such a big smile on their face-

    6. SW

      (laughs)

    7. SB

      ... would whisper to me, especially a man, 'cause men don't really talk much about their emotions.

    8. SW

      Yeah, yeah.

    9. SB

      "I'm in so much pain."

    10. SW

      Mm-hmm.

    11. SB

      And then funnily, I, I then see how the world treats that individual, him having whispered that to me one day.

    12. SW

      Yeah. Yeah.

    13. SB

      And the world, how the world responds to his behavior and attacks him and criticizes him. But I was privy to the whisper.

    14. SW

      Yeah. Yeah.

    15. SB

      And that f- that, that one whisper helped me to kind of reframe how to, how to treat that person, but also really what, what was at the heart of what was going on.

    16. SW

      And probably gave you so much empathy, you know?

    17. SB

      A huge amount of empathy.

    18. SW

      Yeah.

    19. SB

      'Cause I would've been like the rest of the world. I would've just thought-

    20. SW

      Yeah.

    21. SB

      ... "What an idiot. What a dickhead. Like, why's he doing that?"

    22. SW

      Yeah.

    23. SB

      "That's strange behavior."

    24. SW

      Yep.

    25. SB

      You know?

    26. SW

      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.

    27. SB

      Mm-hmm.

    28. SW

      And that matters so much, 'cause 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, eh, 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 it 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 at stigma, which is one of the main reasons that people don't share that they're struggling with substances, that they don't seek treatment. And so we have tremendous stigma towards 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, 'cause you worry that you're gonna be judged, you're gonna be labeled, you're gonna be misunderstood. In some cases, terrible things could happen to you. You might get your children taken away by, you know, child welfare. You could lose your housing or lose your job. And so that stigma has, like, played into this terrible cycle where people, you know, have to whisper it to someone. Shows how much 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.

    29. SB

      You must have had many cases

  46. 1:04:30 – 1:06:16

    Addiction Cases That Broke Sarah's Heart

    1. SB

      that broke your heart.

    2. SW

      Yeah.

    3. SB

      Can you tell me about one that changed you?

    4. SW

      Oh, goodness, so many. Um, you know, so one gentleman in particular, he was, um, struggled with heroin addiction for a long time, and had been, like we talked about, it had been kind of a chronic illness for him. He'd had periods where he'd done really well, he'd had periods where he had struggled, and had always stayed safe through all of that, and he actually... His, like, one really meaningful relationship in his life that kind of kept him together was a relationship with his mom, and he lived with her and, um, and they lived in public housing. They were, you know, dealing with economic insecurity, like many people, and someone found out that he was staying with her and it would've put her at risk for her housing, and so he didn't want her to lose her housing, so he left, but he was newly homeless. And all of a sudden, because of just social barriers, was dealing with the stress of homelessness and being alone. And, um, even with kind of all of the connection he'd had with his mom and with treatment, he was found, um, dead between two parked cars, had overdosed alone in the street. And I always think, like, if-

    5. SB

      And you knew him?

    6. SW

      Oh, yeah. The cascading effects that, you know, that it didn't have to be that way. And I think there's so many deaths like that where I just think, "It doesn't have to be like this," you know? Really no one should die like this, and, um, and there's so many things that, you know, in the moment feel so out of our control, and I think that's part of what generates my passion for this work, is I can't always save the person in front of me or change issues around homelessness or housing policy, but I can try to work on a broader scale to make things different for the next person. And I think that kind of, that, for me, counteracts some of the distress of, of, of losing people that I care about.

  47. 1:06:16 – 1:07:30

    How Society Should Change to Reduce Addiction

    1. SW

    2. SB

      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, et cetera, what would are those things that you would change about the way that our society is designed? You could change anything.

    3. SW

      Yeah. I mean, starting upstream, the biggest thing would be building resilience and building connection early on. So, you know, I think these things that feel so not related to addiction per se are actually deeply related when we think about adverse childhood experiences. So when we think about prevention for children, you know, often people have looked at, like, education, like, you know, telling people, telling kids that drugs are bad. That doesn't work. What does work is actually building resilience in li- young people, so building resilience, building connection. So what does that look like? That looks like affordable housing. That looks like parks where people can get outside and play sports and exercise and build relationships. That looks like, you know, supporting families so that families can stay together and so those early relationships and attachment can be well-formed. That's, like, the true prevention work, is trying to break the cycles of intergenerational trauma, poverty, substance use, and actually supporting families, communities at the very start.

  48. 1:07:30 – 1:12:32

    What Is Rat Park?

    1. SW

Episode duration: 1:47:04

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