Transcript of What We're Still Getting Wrong About Addiction | Dr. Jonathan Avery

We don't appreciate, one, all the factors that, that go into substance use. Like, I feel like we talk a lot about the opioid epidemic, youth vaping epidemic, but we don't talk about the real trauma epidemic that's behind a lot of it. And, and really, I think one way through the stigma is just hearing people's stories and hearing all they've gone through. And, and then you're like, oh, I understand completely why you use. And, and, and then you, when you do that, you understand how the response is not just medication, but it's to to what we've been talking about during this talk today. It's about having the right therapy, finding the right meaning for your life, getting the new social connections. And that stuff is almost as valuable and more important than what substance they were using and what medication you're treating them with.

Someone has a problem with substance use disorder, please call One Call Placement. That's 888-831-1581. And if we can't help you, we'll make a referral to someone who can. Please, we're out of time. One Call Placement is affiliated with Carrera Treatment Wellness and Spa and One Method Treatment Centers. Before we start the conversation today, I want to deliver a personal message. Every day, families across America lose someone they love to an overdose. Many of those deaths are preventable when communities have the right education, resources, and support. That's why I've partnered with the CDC Foundation through their COPE— Community Overdose Prevention Efforts— campaign and committed to matching every donation dollar for dollar up to $25,000. I've spent my life helping people recover from addiction, but if we can get to the place of prevention first, this would help save so many more lives. I hope you'll join me in supporting the CDC Foundation's overdose prevention work at cdcfoundation.org/cope. You can also visit the link below in the show notes. To donate. Thank you from the bottom of my heart. Today on We're Out of Time, we're joined by Dr. Jonathan Avery, one of the country's leading addiction psychiatrists.

He's the vice chair for addiction psychiatry at Weill Cornell Medicine, medical director of the NBA's anti-drug program, and founder of a groundbreaking initiative focused on reducing the stigma around addiction. He's also the author of multiple books and host of the Thriving with Addiction podcast. Today we're talking about addiction, trauma, athletes, adolescence, stigma, recovery, and whether we're approaching this crisis all wrong. Doctor, what made you choose addiction psychiatry over any other area of medicine?

The short answer is that, you know, people told me not to go into addiction and that motivated me to, to become an addiction psychiatrist. Like I was always sort of interested. You know, I saw friends and family members struggle with substances as I was growing up. And I had a good role model in my father who was a hospice physician who really talked about helping people at the end of their life tell their story. And then I noticed in the friends and family members who were struggling with addiction that they often felt like they couldn't share their story and felt that stigma. About having that health condition. And so coupled with seeing my dad help other people tell their stories and then really wanting to sort of go to bat for the friends and families that I knew who suffered, I went into med school and then psychiatry residency thinking it was something I was really interested in. I wasn't totally sure having to still learn about the field, but then as I was telling everyone that I wanted to go into it, everyone's like, don't go into it. It's really not where medicine's at.

There's not much we can do for these folks. And I knew that wasn't true. And so I dove in, became an addiction psychiatrist that studies the stigma of addiction and the rest is history.

That's great. You know, I always tell people if you, that's therapy is something you get to do, not something you have to do. There is no stigma in 2026. That's ridiculous. I mean, but then again, you know, You know, I spend my time, you know, or the majority of my life in LA. And then you go to New York and it's like, yeah, that's not a problem there. But the flyover states, sometimes it is an issue. And I forget that. I don't know if this is true, but I'm going to say it anyway. All right. I heard that the treatment industry was born because nobody wanted to treat drug addicts and alcoholics. They wouldn't, they wouldn't show up to their therapy. They'd show up to ER rooms med-seeking. It's a— nobody could help them. So this was born, and you, and you did the most important part of that, right?

Even the most medicalized of treatments for substance use disorders, like a methadone clinic where you need doctors You know, since it was started in the '60s, it's always sort of— people didn't want them in the hospital system proper. They were always a separate building on the side that no one talked about, an unmarked door. And then, you know, for the rest of addiction, it was a similar attitude, like you should go somewhere else than your doctor or your therapist or psychiatrist to solve substance use. And luckily, I think that's shifted over the last, you know, 20 years. I think the opioid epidemic and the attention around The way the doctors contributed to that, um, sort of forced us to take a more active role. But even still, I mean, it's better, but it's still not great in terms of doctors really not engaging their patients meaningfully around their substance use.

You know, you called it substance use disorder. And, you know, I— have you ever heard of a place called Cliffside Malibu?

Yeah, no, I know your story and, and, and, uh, creation of that.

Yeah. Okay. Well, the new, the new place Carrera is like that on steroids, but when I sold my last place in 2018, there was no substance use disorder. We all were drug addicts or alcoholics. And then I went away for 5 years and I come back and all of a sudden it's substance use disorder. And I was corrected on someone else's podcast when I just got back and I said, well, no offense, but I didn't lose. 2 and a half decades to substance use disorder. I was a drug addict. So when you say that, when you said it, I was wondering, and then you use the word addiction. And I know it's just, this isn't the fight. We're not going to, this ain't the hill we're going to die on. But the reason I bring it up is your whole thing is about there's no stigma here. This is how elegant people deal with their stressors. The end. So if it's true, right, then, then why is clarity not the most important thing? Why is taking care of someone's feelings about what they're being called paramount and taking precedence over, you know, knowing who you are.

It's like, I was a drug addict. That was helpful to understand. I didn't want to be a drug addict. Okay, how do I not be a drug addict? When you have a disorder, it's like, it puts you in the victim role. I've got this disorder. You don't, bro, you don't have a disorder. You're a drug addict. Okay. No, I know this is old school or parsing thing.

Yeah, it's interesting. Part of the reason I call my podcast Thriving with Addiction and my book that's coming out Thriving with Addiction is partly to sort of reclaim that word a little bit. And I do think addiction, I do think language is really important and some of the ways we talk about addiction can be stigmatized and especially in the media and different frames. And I think the studies that we've done on clinicians in the hospital setting, when they call the person a heroin addict who's in the emergency room versus an individual who's struggling with a heroin use disorder, their attitudes seem better when you separate the person from the disease. Oh, God. But it's true.

I know, I know.

I am not the word police around that. And I do agree that most people I see don't identify as an individual with a substance use disorder and those who own it. Identify more with, you know, an alcoholic or drug addict. And, and I'm not in here correcting.

I'm sorry, I took a step in the rabbit hole.

It was just, it was, it's interesting though. And, and some people really have strong opinions on it on both sides, I think.

Well, there's a lot of Karens out there with a lot of opinions, but you know, we don't care. All right. Your upcoming book is called Thriving with Addiction: A New Roadmap for Lasting Recovery and Health. Why did you want to write this book now? And what does thriving mean beyond staying sober?

Right. I mean, the spirit of the book is that, you know, well, one, I was a little suspicious of all these narratives of like overcoming addiction and not having it be sort of an active process that one needs to keep working on. Plus, one antidote to stigma, I think, is recognizing that all of us are all have addiction in us and our families. And part of this process, being alive, is just to acknowledge that it exists in us and all around us. And so that's what sort of the book argues, that it's an active process that we all need to play a part in and goes through the latest in terms of definitions and the neurobiology and the different treatment options. And then thinks about recovery in all the different ways that it can exist from complete abstinence to what moderation looks like and sort of gives us sort of an updated take on the field in general.

Most people think recovery just means not using substances anymore. What separates staying sober from truly healing? What do you think about transcending addiction?

Well, to start with, and you may disagree with this, I don't think recovery always means abstinence and complete sobriety.

So I don't disagree with that.

I think transcending or thriving with, with, with addiction is just getting to a healthier place in your life where you can acknowledge the thing you're doing, making sure it's not impairing your function, and sort of addressing all the reasons why you might be doing that— the pain, the trauma, the mental health issues. Um, and, and for me, that's, that's the way through it. It's almost more about the other stuff than the substance choices, in fact, in terms of building the life that's really meaningful.

That was the most measured answer I've ever gotten. That was beautiful.

That's why you have a psychiatrist on, you know, there.

I've had a lot of psychiatrists on, but I haven't had an answer like that yet. What are you doing with the NBA?

Yes, I have a long history of working with athletes. I've, you know, played high school, high school ball myself, and, um, I've always liked sports. And so, and I'm at Cornell, which is right by the Hospital for Special Surgery, which does a lot of the surgical interventions for athletes. And, and so from that connection, I've worked with a lot of athletes struggling with addiction or mental health over the years, and which is incredibly rewarding and fun. And, and, and there you think, you know, really how to maximize performance and its relation to substances as opposed to like a deficit model at times. And then Over the last couple of years, I've been the medical director of the NBA's anti-drug program, which basically means providing education to the players. And, you know, they have this strict monitoring of what they put in their body. That's a part of it as well.

There's something about athletes when they come in, right? The excellence part of it, right? So they understand how to achieve. But what they lack a lot of times is living skills, right? That's all it is. It's very— that's, that's— those are the most gratifying people to help because they just don't know what they don't know, right?

Right. And they do, they do great. I mean, I always think if I was 20 years old and had so much money, I would have caused so much trouble. I mean, it's so hard for, you know, there's so many temptations for these guys and they're so polished. They're so— I mean, the ability to interact with the media and to handle all these pressures, I mean, they're generally so impressive. But yeah, it puts you in this environment where regular life is, is sort of strange almost. So your life becomes quickly very, very odd. That's right. Um, but I think they do well because they're team players generally, and they know how to work in a team. And a lot of addiction recovery is, is teamwork, you know, getting into the groups and, and, you know, getting a new team to help you tackle something. And, and so I, I find them to be great in recovery rooms, great in treatment programs that we have as well, because they sort of understand it's about themselves, but it's really about the people around them as well.

That's why we're so aligned, because I just figured out— tell me if this doesn't ring true for you— all you really needed to know in life, you learn from team sports as a kid.

Mm-hmm. Yeah, it's, it's so true. And I think about all these kids on their phones these days, and they're, and they're sort of, they're in their groups are on online and often with people they don't know well, and they're not like in it trying to win something, you know, both competing with each other, but also on the same team and all those different dynamics. And yeah, I think it's a shame that, that more kids aren't, aren't participating in it. And it's, it's a real answer even for people that aren't athletes when they're thinking about the recovery plan. I always recommend something sort of fun like team sports or athletics, cuz it's, it's a really a new way to sort of think about yourself that can cause a lot of growth.

Yeah, that's, that's, you know, I always say anybody or any place can get you sober. It doesn't take, you know, it doesn't take a miracle to stay sober in a treatment center. Okay. But, you know, what makes, I think what makes, I can't speak for other folks, right? But I know that my vision was after this, okay, what do you want to be? What do you want to do? Where do you want to go? Okay, let's go. Okay, let's, let's, let's find out who we are. Okay. And, and making certain that concretely, you know, I don't like the airy-fairy conversations. This is what you need. You know, I want to expressly tell them specifically, this is what you need to do, right? I mean, you have an agreement. This is what you want. You, you know, you got a menu. Okay. Right. Let's figure out what you've gravitated to and let's design a life for you. And if you stick to this and you get support along the way, you're going to be golden. Otherwise, you're going to atrophy and you're going to lose it. Right? Same.

A similar thought is that along those lines, like if recovery becomes about not using as opposed to becoming the person you want to be and having those goals, it's going to fail because then you're just sort of white knuckling it and life sucks without substances or the different behaviors. But if you can build a life that, that you can be proud of, that has the right sort of people in it. And that can be the focus of treatment. I think that can go a long way. I think too often our focus, especially in more medical settings, is just on stabilization and getting through the hardest part. And we missed all the other ingredients that are so important for recovery.

I'll say something even more controversial.

Tell me.

Right? Sobriety is not its own gift.

Hmm.

It isn't. If you can't replace what you held as most valuable with something of equal or more or greater value, you can't stay sober. Why would you?

Right.

It's ridiculous. Right. You're essentially saying the same thing. Right.

And but sometimes you have to, you have, it's hard for people to believe sometimes when they're in the middle of something really painful and struggling with substances that there is that version of themselves in the future. That is more valuable and does more valuable things than, than the current one. And, and so we need, that's why you're a good example of having someone that's, you know, lived it and then made it to the other side. And, and, and why psychiatrists need to partner with people like you and people in recovery and have so many different people because, you know, you don't always believe the middle-aged bald psychiatrist, but you sometimes can believe that version of yourself when you see other people who have made their way through.

Yeah, but as you know, that's all true. But as you know, no one can hear anything when they're in it and they're, and they're in that state, right?

Yeah.

So, and they're in their brainstem. So as soon as you just— the first step is just containment and alignment, right? And safety. And then after that, you can get to the conversation. So no one's ever going to know anything. But you're right, they don't know because most of these people have living problems, right? They don't even know how to live, right? I couldn't get out of an underground parking garage. I was stuck on my day 1 or day 2 sober in an underground parking garage for a half hour and just started crying. And I didn't know what to do. And thank God I got to at least the top where the phone would work. And I called my sponsor and he helped me get out of this. It's like you just don't know how to live. It's like, you know, and it's their turn. Everybody gets a turn and you just have to be loving and kind and not, you know, we don't treat anybody. We care for them. It's a totally different vibe.

Yeah. And my heart breaks for like these kids that have now been on their phone or digital devices or sports betting, and they've really never learned the skills during their regular developmental window and how to live a life not only that's meaningful, but even around other people and to look people in the eye and to know real romantic relationships. And so it's It's, it's, it's really a big challenge of our field in terms of how to get people out there in the world again in a way that's, that's very different from how they've been living.

I've never seen anything like it. No eye contact at all. None. And COVID made it worse. Social media obviously is the worst. But has this happened to you? I've got an employee, a younger employee, and I'm like, hey babe, why is this? And she's not she's, you know, uh, dissembling, right? She's not answering the question. And so I need to know. So we're all on the phone, like 8 of us, and I keep going, okay, and I'm, and I'm going, okay, and why is that? And why is that? And why? You know, you're playing the why game and you get to the end, right? And the second I had her cornered, and I wasn't even being— I was just trying to get the answer that I'm entitled to. That's it. Okay? So that we could all benefit from it and move on. When I got her to the end, she was so uncomfortable, she looked at me on Zoom and she said, stop screaming at me. And I went, guys, did I scream at this woman? Anybody, please pull me up if I did. And they're like, no. That's the vibe now. Any, you can't even have a conversation that is uncomfortable.

I've never, what is that about?

You know, they're growing. When I was growing up, there was all this friction where you would learn how to interact with folks. Like if I wanted to go on a date with a girl, I had to call the landline in their house and talk to the mother to get to the daughter. And, and, you know, and then I had to go and I had to look everyone in the eyeballs at that house and then take take the girl out. I mean, no one's doing that. Like, there's the friction of that, those relationships. And even in their peer groups, I mean, they're next to each other, but they're on the phone. And, you know, my 13-year-old at home is, you know, their after-school stuff is like texting and being online. It's not being at that friend's house in the same way. And so, and now we have AI, of course, which further takes people's ability to communicate and use their cognitive skills offline. And so, you know, it's, it's a little scary. And, and how that, you know, then results in folks that can't interact with others, can't tolerate conflict. Um, there's just easier worlds online sometimes than the world out there.

You know, I know this isn't your lane, but I'm gonna ask it anyway because I got somebody on, on the air that I, uh, respect. Where do you think this ends, man? How do you think this ends? I mean, you've got kids that can't look anybody in the eye. They won't even drive, okay, which is no big deal because the car is going to be driving. But it says something about their resilience. I mean, you don't need a robust pioneer spirit to drive a damn car, okay? And that's where we are. You can't tell people anything. In the last place I owned, I had 250 people at all times, right? And I knew them all. I knew them all. I loved them all. I knew what their talents were. Okay, I knew their families. Now I've got about 15 people that I deal with in my company because it's a different world. And I'm direct and people can't tolerate that. And I— where do you think this— how do you think this ends?

Well, I think there is starting to be a bit of a cultural change in how we think about social media and people's online and the use of AI. I mean, I've interviewed a couple people for my Thriving with Addiction podcast on this, and I just wrote an article for Stat News on using addiction principles to address some of the social media and AI addictions that we're facing. And I see it like my— and I feel like there's been change. Like my teenager, she got her phone when she was 10, and I have two younger boys about to get the same age, and they're not getting their phone at all. So it's like, it's a, you know, there has been a bit of a cultural shift recognizing that we can't, you know, put these phones in these kids' hands and we've got to get them out in the world. And And some people even equate it to how we used to like smoke in the delivery room and think how unhealthy we were back then. And now, hopefully future generations will look at how online we were and how we weren't interacting with folks and think about how unhealthy we were, we are now, and that we'll be able to make this shift.

But that's, there's so much addictive about the technologies though, and the online gaming and gambling and all that stuff these days that it is gonna be hard to make this change over time.

Yeah. Thank you for that.

I mean, one thing that always strikes me when I see folks with gambling, for example, and the sports bettors of these teenagers is how neurotoxic that online stuff is. People go into frank physical withdrawal when they stop gaming and gambling. They feel flu-like almost. I mean, these things are really neurotoxic in a way I think sometimes we don't appreciate. And I shouldn't point the other finger. This is 45 minutes without looking at my phone. That's going to be hard for me too. Like, it is just so ingrained in our— the way we are these days.

It's the gambling. I haven't even talked about that on this podcast in a year and a half. I think that is the scariest thing ever, because that's ruin in minutes, right? I mean, before the epidemic, you could do coke for years before your heart fell out. Okay, but with gambling, you could lose it all in one minute. Your family's destitute and your kids aren't going to school. I mean, it's just, it's just the worst. I don't understand how we— I'm sorry, I understand exactly how we got there. Let's move on before I want to light myself on fire.

But that's a good analogy to the contaminated drug supply. Like, it's, it's true. It's much this, the way you can gamble and game these days is much less safe than it was historically. Now it's 24/7 on your phone. And you know, you cannot even have a gambling problem and lose your whole life savings, just like you can lose your life if you try one substance just because it's contaminated.

John, I know an idiot who drives a Benz with the big screen in front. He had a huge screen put in. So while he's driving, he can play online poker. Right. Okay. I mean, just, you don't, I mean, it's just bad idea.

Yeah. No, I have people that watch pornography on the TV in their, in their cars as they're driving. There's risk in that.

What have patients taught you about addiction that textbooks never could?

Almost everything, I'd say. You know, I think the problem in part with the way we teach addiction medicine, addiction psychiatry these days is it's very medicalized. Like, we start with the medications, you know, then— and they're good. I mean, that's— and some of the biggest sea change in addiction in the last 10, 15 years has been meds for alcohol, the GLPs, of course.

The best. The GLPs we've been using for 2 years before any— 2 and a half years ago since any of this was happening, and we saw it. I'm sorry, go on.

Yeah, no, I mean, it's a game changer. And, you know, the metzropiids and— but unfortunately we start there and then sometimes we end there in our, our education of of doctors. And, you know, we don't appreciate, one, all the factors that, that go into substance use. Like, I feel like we talk a lot about the opioid epidemic, youth vaping epidemic, but we don't talk about the real trauma epidemic that's behind a lot of it. And, and really, I think one way through the stigma is just hearing people's stories and hearing all they've gone through. And, and then you're like, oh, I understand completely why you use. And, and, and then you— when you do that, you understand how the response is not just medication, but it's to what we've been talking about, um, during this talk today. It's about having the right therapy, finding the right meaning for your life, getting the new social connections. And that stuff is almost as valuable and more important than what substance they were using and what medication you're treating them with.

More important. It's a lot more important. Do you know that? And you said the right therapy, and that's so hard because Therapists, as a general rule, are the salt of the earth. They're the best people I have ever met in my life. Them and nurses. Okay. But unlike nurses, with respect to therapy, there are so few that can actually help anybody. Actually, you know, and they're, and they're so well-meaning. Okay. But the right therapy is everything. It's like, yeah. It's like the right quarterback going to the right team with the right coach, right? It's just, it's everything. And so did you know that during the detox period, I don't know how other people do it, but during the detox period, these people are being monitored by all client-facing staff and the notes are being taken are voluminous, right? And then in clinical, every couple days they go into clinical and they fight. This is, this is bizarre. They fight for that client. So they'll say, I can deal with this, this, and this. And then the other one will say, no, no, no, no, no. But, but I, this is his major issue and I can deal with that.

And they just, right? So it's, it's the reason I brought— I, it came up for me is because, you know, at the beginning when I started 20 years ago, I didn't know about that. I just, whoever had the least caseload would get the new client. That's not the way. That's, that's not the art behind this thing. And so thank you for bringing that up.

Yeah. And I think people sometimes don't recognize that you've got to try sometimes a couple therapists to find the right fit, to find the right modality. And it's nice to have, yeah, have someone that's sort of in your corner and believes in you and you have that good, good relationship. Um, cause it's a relationship like, like any other relationship. And so you, it's worth it to, to try, try a few out. And it's nice these days, you know, for people, no matter where they are struggling or with mental health stuff, you can do it Zoom, you can do it in person. Um, you know, there are a lot of ways to, to connect with, with good help. And when you find it, you know it. You suddenly see yourself, you know, making those changes to really, really improve things.

That's so true. You're like the Supreme Court. You don't know what pornography is, but you know when you— you can't define it, but you know when you see it. Yeah.

And so I, I always encourage—

second pornography, uh, reference we've had in this, in this—

yeah. And by the way, That's a big problem for a lot of folks with addiction, right? I mean, that's—

how so?

Well, I, I think, you know, we would never— I mean, it's, it goes along with the online gaming and gambling. Like, we would never put vodka in a 10 to 12-year-old's room, but, you know, a lot of people's first exposure to online pornography is in that, that age range. And, you know, that really does its causes some problems for the adolescent brain and how they think about relationships and sex. And then a certain portion of folks will really end up stuck on that pornography in a way that— or sex addiction or other things like that— they really get in the way of their function. And even independent of substance use, we see a lot of people that come in for help with porn addiction.

How does that look when they come in?

It looks different for everyone, but predominantly male, predominantly, you know, spending a lot of time, so much time online with pornography that it's getting in the way of them taking care of themselves, having other relationships. They tend to be some of the most dysphoric, unhappy people I see, you know, it's for sure. It's, it definitely can, can get in the way. And I'm not saying You know, all pornography is bad and people should never watch porn, but there just are certain people that really get stuck in a way that really, you know, impacts their life.

Right. It would mean a lot to me if you joined in supporting the CDC Foundation's Community Overdose Prevention Efforts campaign, where I'm matching every donation dollar for dollar up to $25,000. Your contribution helps expand education. Strengthen communities, and give more people the chance to get help before a crisis turns into a tragedy. If you believe every life is worth fighting for, I hope you'll join me and support the CDC Foundation's overdose prevention work at CDCfoundation.org/cope. Just click the link in the show notes to make your donation Together we can make a real difference. Thanks again for tuning in. Are today's adolescents more psychologically vulnerable than previous generations?

It seems like it for all the reasons we've mentioned, sort of the online world and space. And, you know, I think they've just got a lot of things that are tough. It's more academically challenging to be a kid these days. There are a lot of of, you know, things going on in the world, a lot of things in everyone's sort of local environment. And then certainly the way online has taken over, as we've highlighted, I think, I think does make them more vulnerable, or at least there's new challenges that require sort of a new skill set to manage that we had to manage when we were kids.

Yeah. You found an entire program around stigma. Why do you think addiction still carries so much shame compared with almost every other illness?

Yeah, I mean, it's still viewed very different than, than every other illness. And, you know, I'm not someone that says addiction is all a brain disease. And I know you've, you've spoken out about how that doesn't really capture a lot of what goes into addiction. But I think there's still, there still is this view that it's, it's a moral failing, that these are people we should punish, distance ourselves from. I had a colleague here that did a recent survey on the opioid epidemic. And, you know, people still largely blame people who use the opioids. 40 to 50% of people don't want to live next to someone who has an opioid use disorder or opioid use. And so there is this real sense that these are people to be afraid of, that it's a moral failing. And that's been really hard to change over time. While there's been a lot of great efforts that have advanced our understanding of cancer and HIV and some of these other stigmatized things. It still is quite a stigmatized condition. My research is mainly on stigma that exists in the places that should be the safest, like among doctors and lawyers and family members.

And there you would expect attitudes to maybe even be better. You would expect your doctor to have better attitude than the general— Way worse. But they're worse.

Way worse. And tell everybody why.

Because, well, a couple of reasons. One, it turns out when you become a doctor, you're not automatically an angel. Like you're not like blessed with some specialness, right? Like you're still just the same as everyone else.

Well, that's not true. If you ask their Jewish mother, that's not true, but go on.

We doctors use substances more than their age-matched peer. We binge drink on alcohol, we misuse other substances, we're less likely to seek care. So not only do we have the same attitudes, we probably use more substances. And then, you know, we sort of learned through our training to deprioritize this this health condition. And there's a lot of hidden curriculum that people pick up on that, that this is, this is other as they become a doctor and that, you know, real medicine's something else, even as we have the GLPs and these other meds. And these, even as I feel like the delta for people with substance use compared to like the delta for people with other chronic medical conditions is so much greater, but there really still isn't that viewpoint. And then, so part of the antidote we're working on is giving people more rounded narratives. Like they should all listen to your podcast. They should get exposure to people in recovery. They should hear from families. They should hopefully know that there's good treatments and get more training. And so we're trying to work on all that in our program.

I kind of feel like it's when people are in healthcare, especially doctors, the reason they don't come clean is because what will the neighbors think? I think where the stigma is, is in the picking up the first time. So the moral failing is, well, you didn't have to pick up initially. The moral failing isn't, well, once you got addicted, right? You know, it's got you. You don't have it. So that ain't your fault. Where your fault was, your, your part in this was picking up the first time. And in that respect, That's kind of where I, where I live. However, most of the time this happens with children. Right. Okay. And it ain't their fault because their parents were absentee landlords. Okay. So you're responsible for your minor children. You've got a 13-year-old child. I've got a 13-year-old child. Okay. I've also got a 16-year-old.

Child.

How many, how many children you got?

I have 3.

3?

Yeah, that's great.

Yeah, nobody has 3 anymore.

Yeah, no, we're pushing the envelope there.

I had— I, I was one of 3. My mom was one of 3. My father was one of 3. And now everybody's got 2. But you, but you went back in time. You did the 3 thing.

I know everyone's got 1.5, right? Is that what the stats are? But I think it's nice. I was one of three too. It's a whole team we've got.

It is a whole team. That's the greatest, man. That's the greatest.

But you're saying something important. I just want to highlight. I mean, yeah, I think that's what people say is that it's, you know, you've made that first choice and then you need to suffer the consequences. But the reality is that a lot of us either accidentally or because of peer groups or—

That's right.

We experiment and then just some of us because of these certain genetics or environment or trauma or mental health, we we, they get stuck often through no fault of their, their own. And then people that have experimented and haven't resulted in having addiction, they're like, well, I was able to stop, but they don't recognize sort of the critical differences between themselves and someone who—

That's right. That's right. Because when we were kids, you had the luxury of being able to experiment with drugs. Okay. And then as you know, about 1 in 10 of us Right. Started using it excessively. And those were the kids that we kind of stayed away from, right, in high school. Right. So that's why I didn't have any friends. And, uh, um, yeah, unbelievable. Unbelievable. I just do the best I can. Where was I? Where was I, John?

You were sort of talking about choice and stigma and your experiences.

Yeah. Okay. Well, that ended. All right. Um, what do you think modern psychiatry still gets wrong about addiction treatment?

Almost everything. Like, I feel like psychiatrists, psychiatrists still do not know enough about addiction. They don't know enough about how it presents, about the co-occurring conditions that, that exist. And still very few psychiatrists feel comfortable, you know, with the medications that, that target, um, substance use. And they don't really know what 12-step meetings are. They don't know what outpatient rehab is. They're, they're almost intentionally not looking at— and the reality is, and the striking reality is, that most they're probably just missing addiction in their patients because a lot of folks with psychiatric disorders do run into trouble with substances along the way. And, and so, you know, a lot of my work is around educating psychiatrists, um, not just teaching the addiction psychiatrists in my fellowship, but educating psychiatrists about all that they can be doing. Because the reality is there's only 1,500 addiction psychiatrists in the whole country. So we need the everyday psychiatrist, we need the everyday internist, we need the everyday emergency room doc to be, have a good understanding of substance use. 'Cause they're mostly the people are going to be tackling it and, and not sort of us that are formally addiction trained.

Okay, I'm going to name drop, and it's my one— I don't name drop, I hate name droppers, okay? But I have different, uh, people that I revere, and my celebrities are different than other people's celebrities. And when you mentioned that there are only 1,500, um, addiction psychs in the country. I, I was screaming in my head. I had the president on. Do you know Dr. Timothy Fong?

I know him well. He was on my podcast talking about gambling. Um, he's the current president of the American Academy of Addiction Psychiatry. Um, a friend, um, someone that works with athletes too around gambling and behavioral addictions. So, yeah, good guy.

The one thing I can't handle is someone who is desensitized to the process of helping another human being. I can't take it. It's like the, the only rule I have is when somebody comes in, we always say the same thing. Who is the person you love the most in the world? And they, who loves? And we tell them, you need to treat everyone like you would want that person treated here. That's, that's the rule. Because once you get that right, once that's part of your DNA, 95% of the other shit takes care of itself.

Yeah. No, I, I love that. And part of my job in the sort of anti-stigma stuff that I put together is helping people when they lose that. Like when they feel burned out, helping to make sure they have the space to like talk about it and process it and get back to their, their, how they sort of want to be and really helping people. I mean, that happens a lot in emergency room doctors. I've been asked to like interact with emergency room doctors around the country because of my stigma work. And they're often so burnt out. They see so many people coming in intoxication withdraw states, right? And they've often lost that narrative of why they went into medicine to, to help people. And they've also lost sight of people in their family that have struggled with addiction who they love the most. And, and so even just giving people a little space to like reconnect with that part of them that, that, you know, is in it to really help people does, does go a long way.

You know, I have a theory about that.

Okay, tell me.

Sure. The doctor's reason they're losing love in a, in a hospital setting is because they're not being treated, uh, uh, they're, they're not revered the way they, uh, should be. They're being treated in a hospital setting, the administrators and the politics and all the horseshit. I've never seen anything like it. I went with, I went with one of my best friends who works with us, probably the best female physician in the country. Okay. And we're walking in and he's getting jerked around by everybody. And I'm like, bro, how do you deal with this? You just deliver 14 babies that no one else in the city would deliver because they were afraid of the liability. You just delivered 14 of those in 24 hours, and they're treating you like a redheaded stepchild. I— you can't— you can't remember when we were kids and, and doctors were revered. If you made a reservation, I remember making a reservation. And if you, and if you were standing there and someone said, Mr. Such-and-such, he'd go, Dr. Such-and-such. You don't hear that anymore. You don't have— these doctors don't have the self-esteem they used to have because they're not revered the way they used to be.

No, I think that's true. I think, um, and part of it is that medicine has increasingly become a business. And so we're governed a lot by business people and by lawyers. And then the system doesn't really support us. They're trying to like get as much as they can out of us. And that's why, I mean, if we were in it to make money, we would have done something else. You know, where most of us come into it to really help people and feel proud of that. And that does get beaten out of us with the endless notes we have to write and all the administrators we have to talk to. And then, you know, and then the system's not set up great for our patients. And so they get frustrated and they're battling insurance companies and other stuff. And so there's often, yeah, a lot of frustration where in the past we wouldn't have all these barriers.

It's so sad, man. People just— we teach people, okay, they come into treatment, right? They haven't gotten a physical in years. Their, their teeth are destroyed. They're They're, they're in horrible health, right? And so we teach them about self-care and self-love, right? And we're getting them there. And then, you know, they go to try to get help and they just like, this is bull— that just getting jerked around all the time. It's literally meant to vex and frustrate you. Okay.

So yeah, the system's backwards and, and, and really hard for a patient to know how to get care, how to get good. I mean, if We talking about addiction care. I mean, it's really hard for someone who's struggling and not sure where to turn, where to make that first step even still. And that's really, and the price points on all the different options vary, the quality varies. It's really hard for families and people struggling, especially in addiction.

And the part that's so sad is when they're struggling and they're in crisis, and you're a layperson and you don't know, you'll, you're willing to believe anything. And there's so many bad actors in my business. I'm so, it's so bad. And a lot of it now isn't even, a lot of it now, the bad actors now didn't even mean to be bad actors because Google doesn't work anymore. So people are going out of business all the time. Insurance companies are squeezing on the reimbursements. So, I mean, there's this one policy that everybody was relying on to stay alive. Okay. They just cut that by two-thirds. So by the end of the year, in an opioid crisis like we've got, by the end of the year, we'll lose probably another 10%. I'm not kidding. 10% of the treatment centers in this country because there's a convergence of events. That are going to be too difficult for people to navigate, you know. And if I didn't sell the last place, okay, you know, the way I did, okay, that would have been my issue too, right? Some of these people, they're, they're, they're working without nurses. I mean, most of these places don't have night nurses, so it's just not safe.

And they can't— and you— and they can't help it. Because otherwise they're going to have to close down, you know, and they don't know how. What should every primary care doctor understand about addiction that many still miss today?

You can very pretty much start anywhere with primary care docs. I think things are getting better, but a lot of people don't have sort of basic knowledge. They don't feel comfortable with medication.

Tell them why.

Because they don't get a lot of training in medical school and in their—

how much training?

Um, I've heard you quote this, in fact, the, you know, at most a week in, in medical schools, and, and the residencies are—

listen, you're an impressive— you're a scholar, okay? You're much more impressive than I am. Stop quoting me as your research, okay?

The, uh, as you say, the, um, and then in the residencies it's very variable. Some, some programs are really strong these days and they do teach people addiction, and, and there's a pathway to become an addiction provider these days through primary care, through an addiction medicine fellowship.

Yeah.

But still, a lot of people go into it, to these other specialties that are more, that make you more money and are at times people experience them as more rewarding, GI or cardiac or cancer. And so, you know, there's not a lot of push to get primary care doctors that specialize in addiction. And, and that's as a result, there's, there's so few of us, uh, still. Um, I think things are changing. I think the younger generation's more interested. I think the opioid epidemic, as I said earlier, has highlighted the need for primary care docs and ER docs and everyone to be on board, but there's still a lot of work to do.

Yeah. Which doctors make the most money?

Dermatologists, neurosurgeons, um, people in private practice settings. Yeah.

Try again.

Oh, do you, uh, who does make those? Orthopedic surgeons make a lot. Tell, tell me the answer though.

Doctors that do boob jobs and nose jobs.

Plastic surgery.

Okay, the plastic surgeons.

Okay. Sorry.

There's a word for everything.

Yeah.

No, seriously, because there's no insurance involved most of the time.

Yeah, if you can get a private— Yeah, if you can get a cash pay clientele and do surgeries on them, you're making money.

How do you help someone who knows they need help intellectually, but emotionally still doesn't want to stop?

Yeah, we meet a lot of people like this and people who oscillate between emotionally being there and not emotionally being there, being ready and not being ready. And you just roll with it and you recognize the goalposts change at times. You make sure they have their options and you just want to be ready when the motivation and the emotional energy is there to meet them with the resources and a plan that they want to end. And often, even though it feels like people oscillate, part of them is always sort of cooking towards a future where they're ready to step off the substances and live a new life. And so part of it is just maintaining the hope, maintaining that space where they can be there. And that's what we recommend for families. I mean, these days we tell them not to let people hit rock bottom, not to get too discouraged when there's the ups and downs, but be there with a steady hand to then get them to the care they need when they're, when they're ready.

Yeah. They got to notice it though. They got it. They got to notice when there's that moment of clarity when they're in their highest self. Right. And you can, oh, thank you for act. Oh, we just accessed your best self here. Great. While we have this moment of clarity. Okay. And then you get into it. Yeah.

Yeah. But it takes a lot of patience. It takes a lot of patience for families. People need patience for themselves as they navigate the ups and downs. Of it. I mean, your story is remarkable, right? 25 years and then something just clicks at some point. And, you know, it's hard to know what that moment is for anyone. And you just have to hang in there until you hit it.

And everybody deserves a turn. You know what I mean? Like, I had my turn. And that's why, you know, when I did this thing, it was Love is the foundation for everything. We're patient, we're kind, we're loving, we're empathetic. It's safe, it's respectful. It has to be all those things, especially for a drug addict or an alcoholic, because if we feel it's about the money or it's about this or it's about that and it ain't 110% I love you, I got you, then it doesn't work. It has to be that way, I think. Okay. Otherwise it's just, you're going through the motions and you don't, you know, and you don't really, it's gotta be life. You gotta do it like it's life or death or it doesn't work. And if you do it and, and, and, and that's why my folks typically don't stay longer than 7 years, my therapists, because they don't, they don't keep you at arm's length. They don't do it. I have a rule. If you're not emotionally invested in these people, you can't help them. Okay, this ain't, this ain't therapy. This is treatment. Okay, you have, and, and that's just the way I believe it.

And you know why it's that way? It's so to prolong your career, right? Yeah, but they can prolong their career in private practice. They don't need to be in treatment. If you're going to be in treatment, you got to do it this way. And they all bought in. And that's why I've got therapists who have at 3 in the morning will pick up the damn phone and deal with it and come in when they need to. It's like, it's just, you've got to find people with the love. It's just, everybody deserves a turn. I had mine, they get theirs. It's just the way it works.

No, I love that. And it's so spot on.

Yeah. Well, it's just common sense, man. A lot of these people, do you know what the one thing that kills? I I do this all the time. Do you know the one statement that's killed more people than anyone in, in our industry?

What's that?

He's got to do it for himself.

Mm-hmm.

That is the biggest bunch of bullshit I've ever heard in my life, because there's only two types of people that come into treatment: the people that want to get well and the people that want to get the heat off. So, and it's about 50/50, right?

I mean, yeah.

So if that's true, and it is, then the people who wanted to come in to get the heat off would never get sober. And that's not true. About 50% of those people get sober. They didn't even want to get sober, right? So it's just nonsense.

No one does anything, almost anything in life alone anyways. Like, if you want to be successful in anything, you've got to involve others. That's the only way to, to learn. Um, and, and again, that's some of the risks with the adolescents who are used to doing everything alone in their bedroom. Like, you need people to really mature and, and, and reach your, your best self.

You're one of us. You're such a good soul, okay, that if we were kids and you live next door, I would be knocking on your door all day long and asking you to come out and play.

Yeah, we'd go mix it up. Yeah, for sure.

Absolutely. All right, last question. If someone listening has lost hope, what's the first thing they should do?

That's a great question. And I think it varies for the individual, but I would listen to your podcast. I would—

Listen to my podcast? Yeah. You're going to listen to my podcast?

I would. I would tell them, go do anything. Listen to other stories, try different things out. I mean, this life has so much to offer. And often when people are stuck, they don't recognize all that's that's possible for themselves. And sometimes just these little wins, these little points of connection, meeting other people, doing other things is enough to propel it in the other direction. And almost everyone I see who's really struggling, I always say, wait till we talk in a year or 5 years. You're not even gonna recognize yourself and recognize all that's possible. And so I would just encourage people to hang in there start anywhere and recognize that there really is a better, better future out there.

The only thing I want to say is the reason we call it We're Out of Time is because of the fact that, and we are out of time, um, we've got small children and I can't handle, uh, the— can't even discuss it, the pain of losing a child. Yeah, it's too much for me. It's why I do this podcast. Never seen a podcast. I've never listened to a podcast. You know, I work around the clock, okay? But I had to do it. And so I'm just begging, I'm begging the people who listen to this podcast, please, if you have trouble with your child who is doing any drug, I don't care what it is, depending on what it is, you need either a therapist or treatment immediately. There, there is no, he's going to grow out of it. There is— that's over. Okay. It's just too much. So, and there's—

call it—

call SAMHSA, call 988. Okay. Go to this— go to the state. I don't want nothing. Okay. I don't— we're doing fine. Okay. But you gotta, you gotta seek help immediately today. It's too much. Every other pill's got fentanyl in it. And I think 2 out of 10 pills have a lethal amount. And as you know, that's not accurate because what's lethal for a kid who is doing, uh, uh, actively doing fentanyl and for a kid who's never done fentanyl, who's at the rave on the weekend, is completely different. Right?

Now that's the scariest thing about substance use today is that this contaminated drug supply can cause people even without severe substance use or any substance use disorder to lose their life. And so, and yeah, there's nothing more painful than the loss of a child. And so we've all got to stay vigilant, recognize it as the emergency and public health issue it is, and, and, uh, and really all get together to tackle this.

Is there anything we missed or didn't cover today that you want our viewers to know?

No, thanks for having me. I mean, if they want to hear more from me, we have the Thriving with Addiction podcast, the Thriving with Addiction book. I didn't even mention we have a free family support program here at Cornell, sort of doing some of those things you mentioned. It's called the SAFE program. You can find us there with educational programming and assistance as well.

What a blessing you are. Thank you so much for coming on. I'm so—

Yeah, of course. No, thanks for having me. I really appreciate it.

No, I'm so grateful to you. This just been great.

See you next Tuesday. We're out of time. Please subscribe on YouTube, click the thumbs up, and leave a comment. Please subscribe on Apple Podcast and Spotify and leave a rating and a review, and share the We're Out of Time podcast with others you know who will get value out of it. See you next Tuesday.