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Expert Insights on Drug Abuse: Dr. Nora Volkow on Addiction | Conversations with Cumberland Heights · Conversations with Cumberland Heights

0:00
Hello, guys.
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How are you?
0:02
Doctor Volkow, how are you? Welcome.
0:05
Thanks. Hello.
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Thanks very much.
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I was on the other one than the themes and I was waiting.
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So then I saw that you had sent us some.
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Well, I apologize for that.
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Thank you for waiting and being patient.
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I was actually commenting with.
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Well, I want to give a special shout out to Katie through your office because
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she is a magician and made things connect. So,
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but I imagine that you have to be a master of your schedule,
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maybe an expert time blocker to not get tempted to dive into your email.
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And I guess, I don't know, I'm not a master of that,
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but I, I can not that, escape email. So
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yeah, I bet it takes.
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I bet it takes a village.
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Well, sorry we didn't get to connect in Orlando.
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I'm sure that you were happy to avoid Milton.
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I think we were. Or were you there?
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I was there, I wrote it out.
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So you say that you saw the here I can come in and the water and everything.
0:59
Well, in Orlando,
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you know, being in Central Florida, it wasn't by the time it got to,
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you know, we weren't in Tampa, but it was, it just came through overnight.
1:09
And actually, Ryan, our executive producer, was there and we had, you know,
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kind of made it a family trip to Disney and all that. But,
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it was just fine.
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But I, I don't blame anybody for opting to not fly in.
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I think you're flying in maybe the evening before.
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So you probably were like, I'm just going to stay all.
1:27
No, I think they canceled the flights.
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I think. Oh, wow. Yeah.
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Well, well, there was no way of getting in there, but,
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Yeah, well, nature girls always behave.
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That's what I hear.
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Yeah, well, thank you so much.
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And it's it's Volkow. Correct.
1:42
We don't have Volkow.
1:44
Yes. Volkow with an F.
1:46
Well, welcome.
1:47
Thank you so much for spending time.
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I do want to be sensitive to your time.
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I know you're a busy person.
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I spent the last few days
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reading about you and your life, and, I actually watched another podcast
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you were on with Tim Ferriss, which I enjoyed, your conversation.
2:05
But there's a couple things that I wanted to point out in leading up
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to our first question about who you are as a person, if you don't mind.
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So first, I learned that you're Mexican-American, born in Mexico.
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And correct me if I'm wrong, you're a psychiatrist.
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You went to medical school in Mexico, and I think you did a post-doc at NYU.
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And some of your work,
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that you're very famous
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for is along the domain of Pet scans and prefrontal cortex
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activity as related to addiction in the 1980s.
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There's I think I saw a paper cited in 1988, one of the seminal publications,
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sort of allowing us to better understand addiction as a disease.
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And I wondering
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how your personal context,
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you know, culturally and as a function of your training, impacted
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the area of research you were interested in and
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and how that impacts Naida today?
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Well, I guess it is.
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You're asking me in a way
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to try to give an explanation and understanding for my behavior.
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Based on where I was born and all of the experiences that I had,
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which of course impact each one of us differently.
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And I think that I've always, I think that the basis of my interest
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in science is I'm a very curious person, and I was very curious
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since I was a child, and I wanted to understand,
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the nature of things and comprehend them.
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And I particularly was fascinated by by human behavior
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and what made people react or feel certain things and, and why each one of us
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was seen in a way so different, even though we had very common elements.
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So it was very natural that I would be drawn to, science itself.
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I in terms of why did I choose medicine?
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Well, to me, medicine is the discipline
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that allowed you to get closer to a human being.
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Because it's ultimately,
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that interaction between a person that's suffering from a disease
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and a doctor that in principle, you want to trust,
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that allows for the greatest level of honesty and perspective.
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So to me, that was one of the issues that I felt was a privilege for physicians
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to have the capacity of having those interactions with others,
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and that that in itself
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is an opportunity to be able to understand what makes us ultimately human.
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So I, and that was at
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at the basis of my curiosity and interest of what
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what is it that constitutes what is it in our human brain
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that makes us who we are? And,
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and then if you if you think about it from the perspective of
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how do you pose that question, which seems like an impossible question
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to answer, you come to realize,
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that there are diseases, and, pathological conditions
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offer us an opportunity to understand how a particular pathology,
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by influencing the brain, affects behavior.
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So it gives us an insight of how our brain, works.
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And so to me, I was, in, in at the same time,
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because we're giving always explanations of why we do things,
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but there are multiple things, and it's complex
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that, may have played a factor
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that may have led me for choosing, addiction was in my family.
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There is a family history of addiction on my mother's side.
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There is alcoholism.
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His father had basically was an alcoholic
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who died of his alcoholism, due to suicide.
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His brother, my mother's brother, also was an alcoholic all his life.
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And actually,
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believed the long life and ultimately
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but was never able to overcome the alcoholism.
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And to me, it was a difficult time growing up as a medical student
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and then in psychiatry, because no one in my family will speak about it. And,
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And there was this, this parade,
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the reaction of people I,
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I love my uncle, but nobody there to speak about him.
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It was like, there's this secret in the family.
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And it was very frustrating that, there was this intolerance
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to what appeared to be something he was not able to control, but
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mistook by everyone as this was his doing.
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And that's where the whole issue of shame emerged.
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And even though, I would see it in my close, close family
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and my mother, who was very close to his brother,
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still have that sense of, not speaking about this,
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got a sense of shame regarding the the alcoholism.
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And even though she knew, she knew that I was,
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there was a doctor and a psychiatrist and working to understand addiction. So,
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that that
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definitely played a role in me pursuing as the disease process
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that I wanted to understand addiction because I had
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I it made me very aware how,
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I substance and I says whether it is cocaine, nicotine, alcohol,
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how can a single substance so dramatically change the behavior of a person in a way
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that it actually erodes everything else, and all of the values that we have
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as an individual and in our group and family to sacrifice everything.
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And it was very difficult to use rational thinking
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to explain that in any rational way.
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And and it was clear to me also, if you look at the other
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psychiatric diseases that they share with addiction,
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that sense that you cannot do this per se, your rational thinking to
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to give an explanation of why someone may be hallucinating
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or why someone is so depressed that they want to kill themselves.
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So I guess it defies logic of our everyday life.
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But it's not different from addiction,
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where someone can take the drug at the expense of, losing their family.
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And it's devastating.
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And, and so this, this whole sense that through my experience,
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because I can control drugs or through my experience because I can
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actually control my, my moods
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so that I don't allow myself to go into those dark corners.
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Therefore everyone else has to do it is is very, very naive.
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And I would say it's equivalent to saying, okay,
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if these marathon runner can actually run
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25 miles without having any problem
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in five hours, it follows that you should be able to do the same.
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But but we don't do that with other physical attributes,
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but we do it when it comes to our mental emotional being.
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If I am able to regulate and control these, well, everyone else has to do so.
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This is where where it came to me in terms of how powerful,
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the study of drug addiction could be in providing us,
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I mean, an understanding of why what are the areas of the brain that
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actually get disrupted
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in a person that no longer has the ability to self-regulate?
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That strong, strong, strong desire to take a drug,
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even though they are aware that it will be very consequential negatively.
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And that's how I then jump into that whole science of of addiction.
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And I've been working on it since there.
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I continue to work on it as a researcher and and,
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and it is basically a fascinating because
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out of that research,
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we basically the science in general
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of many people that have been looking at the same question as I have been doing
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whether they use laboratory animals or, they work with, with people,
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that the understanding that it has enlightened
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our understanding about what motivates us as humans in general
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and how we make decisions and why we shift,
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work, can be able to control things in one moment and not the other.
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So it has expanded, where insights into what is it that makes us human,
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while at the same time
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giving us a much better perspective about what drug addiction is.
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And and this in turn is valuable to develop treatments.
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And it's also very, very valuable to help us
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develop prevention interventions.
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Thank you for sharing.
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I first wanted to just say that I'm sorry for your loss and your family.
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But I'm grateful that you chose to share personally because it's very clear
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from the outside looking in that the main idea of that experience.
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And I know that as, as,
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early
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in your career and I think, you know, you're fascinated with anatomy, anatomy,
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fascinated with medical health and how that translates into psychiatry
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and how that translates into really the the maturation of imaging technologies
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through part of your career and how you can kind of you can
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you can trace that curiosity,
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right, to where we are today in terms of unpacking the biology of addiction.
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Which leads me to my first question or my next question,
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which is the really all about Doctor Volkow, the
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the bifurcation between recovery science and addiction science.
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So, as you know, historically, much research has focused on addiction science.
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You know, in other words, examining the causes
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and the neurobiology of substance use disorders.
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However, recovery science,
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studying how people successfully achieve and maintain recovery
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is now gaining attention.
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Why do you believe or do you believe?
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It's crucial to expand our focus on recovery science, and how might that
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understanding of a recovery phenomena influence treatment today?
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Treatment approaches public health strategies
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and support systems for those on their journey to sustained wellness.
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And I choose the word wellness on purpose because I'm trying to,
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big tent definition of recovery because sometimes,
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as you're aware, we can get very,
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strict
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in our definition of what that means to be a person in recovery.
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I'm just curious what your thoughts on the those ideas.
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Well, first of all, I, I support also that
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whole concept of recovery as the aim to achieve wellness.
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And I think it is
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it has become clear that this is an aspect that we need to embrace in general,
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in substance use, in addiction, but clearly in other mental illnesses and
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health conditions.
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And again, when it
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comes to the importance of recovery, in many ways it's
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actually more complex and more crucial than for other medical conditions.
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And the reason why we look at it from the perspective
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of addiction, clearly, drugs modify your brain.
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There's that have been shown repeatedly.
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Right.
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What as your modify your brain, what happens is your behaviors change.
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Right.
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And then your interactions with other get modified by that addiction
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and that actually get modified in terms
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of your capacity to study or your capacity to hold a job
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or your capacity to actually keep, relationships
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and, or, and or making decision or engaging, say, for example,
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in activities that are dangerous and that has a downstream effect.
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So you start to be rejected and that leads to isolation,
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which in turn also leads you to internalize that, the stigma
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that emerges from you being someone that they stroke gets internalized.
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And so you isolate more and more.
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And the normal reinforcers required that actually keep
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you engaged on everyday activity, lose their value.
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And so there is almost like a downstream cascade effect.
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The drugs produce these changes.
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And as your behavior changes, that produces other changes.
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And you are cascading down these road or mountain.
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So when we think about, okay, we're going to be treating addiction.
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And there are many medications for certain addictions, not for others
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that are very effective, but they actually help you.
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They are not the panacea.
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They actually help you regain the stability that is necessary
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for you to start to reconstruct good, reconstruct your surroundings,
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because that without that reconstruction, your brain can recover.
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But you will that isolation will push you towards relapse.
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So that's why it becomes so incredibly important
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to consider the elements that are necessary to achieve recovery.
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And these elements vary from one person to the other, and in a way
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relate to that concept about what constitutes well-being and,
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and and you can get that one and say, and in the sense of well-being in general,
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I would say that most of all would include having,
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valuable emotional connections and interactions,
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which are one of the first ones that goes on to become addictive.
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So how do you rebuild them?
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How do you build hope into someone that then can generate
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a plan of what their life is going to be into the future?
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Because if you do not have that plan,
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if there's you basically happen to have nothing and you cannot
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look at nothing into the future, there's nothing that drives you,
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then there are not many leverages that you can take
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to modify change, to have the incentives to change.
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So recovery is I mean, building up on the capital for recovery,
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which is has very strong linkages to build up social interaction
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as a key component is crucial.
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And, what we are doing right now is not an area
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where we have to focus from the perspective of research.
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But now, because we didn't really have the tools
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to, assess the questions about why are these, for example,
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social interactions so very important to allow you to achieve recovery
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when we know that it is extremely important.
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But what do they do to our brain
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and to our reactivity as individuals that lead you to actually,
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be so sensitive to it?
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And that's what now researchers is working towards.
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And we are coming to recognize, the,
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the neuro biological processes underlying something that we take for granted,
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which is how extraordinarily important it is for all human beings.
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Many other animals, the, the social, the social media
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in which we live being part of something that values so,
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so being on a mission that can help that,
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that, that group that we are part of.
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So that aspect of our social being
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is crucial for our well-being and certainly crucial for achieving
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recovery in, in, in addiction and, and other mental illnesses.
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Yeah. It's a thank you so much for that answer.
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I appreciate,
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you mentioning community, you mentioning relationships.
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You know, especially, you know, I'm a person in recovery.
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For ten years, I was a I like to say, for better or for worse.
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And I'm not, you know, because it's obviously tragic for
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hundreds of thousands of of of, of individuals lives today.
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But I was really born my addiction was born out of the, prescription,
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diversion generation
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of the 20 tens, 20 teens.
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Right after that, of course, was the rise of fentanyl and illicit heroin
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into communities to which maybe weren't participating in the
17:50
at the scale that we saw over the last ten years or so.
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Community absolutely impact it.
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I mean, stabilization, medical and psychiatric
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stabilization, like you said, is, is a foundation I like.
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It's, you know, you got to start at that foundation and the brain will heal.
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But after that, you know, achieving success really is,
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I don't want to say dependent, but a key to success,
18:15
absolutely, is our ability to continue to interact with people around
18:19
us, to help us be better versions of ourselves,
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which kind of gets me to effective treatment of today.
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And, I'm going to ask you a controversial question.
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Katie might get upset at me afterwards, and that's okay. But,
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you know, so we I work for a legacy
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nonprofit addiction treatment provider in Tennessee, and,
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and as such, our history has grown in parallel
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to psychotherapy growth in the United States.
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We were founded in the 1960s.
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So at the time, of course, 12 step programs like Alcoholics
18:52
Anonymous were were pretty much the only vehicle for change.
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And today there are elements of 12 step culture
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that are still ingrained into our program
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that we're proud of and many others across the country.
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But when you think about 12 step programs
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having been a cornerstone of addiction treatment for decades, you know,
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we're we're all well aware that some critics argue
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that their spiritual connotation or their approach
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and emphasis on abstinence in particular, like we talked about earlier,
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may not be suitable for everyone, which which is okay, given how
19:24
maybe evidence based approaches are emerging today.
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Do you believe that 12 step,
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the 12 step model, I should say, or 12 step culture
19:33
and treatment should continue to play a role in addiction treatment?
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Or should we be more moving towards other science based, method based methods?
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And how does Naida view the balance between traditional 12 step programs
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and newer therapeutic approaches in fostering long term recovery?
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Well, I think that the easiest answer is, of course, it should continue to be
19:53
playing a role in treatment programs, and step programs help a lot of people.
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It may not be that they are basically adequate
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for everyone, and there are people that don't want to go to 12 step programs,
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don't resonate with them, but they have saved multiple of lives.
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And you can actually come across I mean, we all know a lot of people for whom
20:16
12 step programs have saved their lives.
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So I think that we need to stop this whole issue
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of holding one treatment against the other.
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In in addiction, we don't have many alternative treatments,
20:29
and we have treatments that work
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even though they don't work for every single person.
20:34
But it's the same in everything on medicine.
20:37
Not, I mean, very effective medications nowadays
20:40
that we're speaking of the awesome fix, right.
20:42
They don't work for every single person.
20:44
They don't.
20:45
So what does that mean.
20:46
We mean we need to have out there and and and why is it that we don't,
20:51
get concerned about it.
20:52
Why don't we in the whole field of diabetes, obesity.
20:55
We don't say you have to have this or that.
20:57
We have all of these alternatives.
21:00
And in addiction we should have several alternatives
21:03
so that people can their therapeutics can be tailored to one another.
21:08
An aspect that I actually, think is very
21:11
I've always been very, very intrigued about 12 step programs because
21:16
they are beneficial for many people.
21:19
That's and they are, of course, that whole notion, as we learn more
21:23
that the, the emphasis in abstinence
21:26
in some instances, the third people do have benefits.
21:30
That's one.
21:31
And the other aspect of it is that some of these programs
21:35
are very categorical and they don't allow for the use of medication.
21:39
So which again is something that we have been aiming
21:42
to provide evidence to show that these are not exclusive to one another,
21:48
and there's no reason why someone that is on medication
21:52
like buprenorphine should not be given the benefits that you get.
21:55
The one of the 12 step programs and I do have encounter patients that are
22:01
that want to continue 12 step programs, but they don't want to stop taking
22:05
their medications.
22:06
And so they are placed in that position
22:09
that they shouldn't have of choosing one or the other.
22:12
When in other areas of medicine, we don't force people to choose one or the other,
22:17
but an
22:18
aspect just in terms of because it is what we were discussing that
22:21
I think there are many valuable components from the start step program.
22:25
If you look at it and that is it gives you a sense of belonging in a group.
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You are part of a group that is actually cares for you and that is not judgment.
22:36
And also you are part of a group where your own experiences
22:40
are to value to the other.
22:41
So you have that essence of how important our social interactions are.
22:47
So by being part of a group that respects you and that embraces you,
22:52
you actually have a very strong solid reinforcer
22:56
of a social of like of that social nature
22:59
that are so very fundamental and crucial and that sense that those
23:04
so which of there is a protection that sense of you are for some people,
23:10
not for others, that someone is taking care of you.
23:14
And if you follow that, the, the whole 12
23:18
step program philosophy, you will be okay.
23:22
That can release, anxiety for many,
23:26
and can actually provide that stability.
23:29
So that's why I mean, in my view, it is clearly a program
23:32
that should continue working in my view.
23:35
Also, at the same time, we need to push the system.
23:37
We need to provide alternatives to people so that they can
23:41
if it doesn't work for them, they can have other interventions and also
23:45
open up the possibility of mixing them, just like we do with cancer.
23:51
We mix multiple treatments.
23:52
Is not once the same thing with infectious diseases.
23:55
We just don't limit to one.
23:58
And shifting to
23:59
that very categorical, inflexible old system that we have
24:04
for addressing addictions would be very, very valuable
24:07
and would expand the number of people that could benefit from 12 step programs.
24:11
Yeah, I have always explained to people that, 12
24:15
step culture is a lot like organized religion.
24:18
You have your you have your different denominations and sex.
24:21
And so I just want to let you know there's a lot of families
24:24
treatment seeking individuals that that, listen to our show and,
24:28
these are, you know, how does treatment work?
24:30
What is recovery? Those are generally the questions that we get.
24:32
And so I just want to say out loud with the director of night on that, you know,
24:37
there is no place in our literature
24:39
that says that you can't be on medications
24:43
and still participate in 12 step culture, 12 step programs.
24:47
There are groups and individuals that carry a message of,
24:51
you need to do it this, that or the other way.
24:53
And I'm just here to say that,
24:55
you know, if you're sick, if you're hurting,
24:57
if you're looking for a place to
25:01
build community, like we're talking about, any 12 step meeting, generally
25:04
speaking, from around the world is a place that you can call home.
25:09
I know we just have a few more minutes
25:11
and just very grateful for your time.
25:15
I want to talk about the future.
25:17
So I read through some of the literature on that is website, and one of the areas
25:21
that was of, significant interest to me was your crosscutting priorities,
25:27
which you say, you know, should substantially inform your mission
25:31
over the next five years.
25:32
And I just want to read some of them out loud for those people
25:34
that don't have them printed out in front of them, highlighted like I do,
25:37
you know, train the next generation of scientists, identify
25:40
and develop approaches to reduce stigma like we've been talking
25:43
about, understand sex, sexual orientation and gender differences.
25:47
Just fascinating.
25:48
Identify and develop approaches to reduce health disparities.
25:52
Understand interactions between substance use, HIV and other comorbidities.
25:56
Leverage data science and analytics to understand real world complexity
26:00
and develop personalized interventions informed by people with lived experience.
26:04
So when you think about the future, Doctor Volkow,
26:09
I was going to ask you what
26:10
your favorite cross-cutting priority might be, but maybe what are 1 or 2
26:14
that you're most excited of that you think will make the largest impact on
26:19
effectively treating people that experience addiction?
26:24
Well, I think that a key component is to keep the science going.
26:27
So in that respect, I think that training to me, so extraordinarily important
26:32
because it ensures that
26:34
there will be a next generation that then will train the next generation
26:38
and that we will build knowledge because it's the way that civilization advances.
26:43
I think the second key, area of importance for me is to achieve health equity,
26:49
because what we're seeing, for example, right now is that finally we have seen
26:53
a 10% reduction in overdose mortality, and that was in 2023.
26:58
But if you look at it overall, that actually
27:02
represents, predominant certain groups.
27:05
If you look at black Americans, so you look at Americans from
27:10
that are from Native American origins or Alaska Natives.
27:14
The mortality is still going up.
27:16
I mean, it is very, very high double that of the general population.
27:20
So which tells me that the initiatives
27:23
that we're doing that are helping to curb the overdose
27:27
epidemic are not being distributed equally.
27:31
And this was also very clear when we were dealing with Covid
27:34
and we were seeing how certain groups were,
27:37
and basically the mortality was much greater.
27:40
Where in these overdose epidemic, we are seeing exactly the same.
27:44
And it's actually being exacerbated as the gap enlarges because
27:49
we're being successful in one group, but it seems like we're neglecting the other.
27:53
And that's why I would basically pick up those two if,
27:57
I, I, you know, at the essence of all of these issues
28:00
is I think that you were speaking about well-being.
28:03
And I think an aspect of, of well-being is the sense
28:07
that they are actually not being treated differently from the other.
28:13
That sort of there is not discrimination.
28:16
And when you have this type of racial disparity,
28:19
there's no no way around that.
28:22
To feel that this is not fair, that you are not given the same opportunities.
28:28
And this is, in and of itself, one of the essential factors
28:31
that makes people more vulnerable to taking drugs and,
28:35
actually develop other, other challenging problems that are associated
28:41
with early mortality, like, described under the diseases of despair.
28:46
So we need to address, health disparities
28:49
because they drive diseases of despair.
28:52
And, if we don't address them, we will have also
28:57
an underlying factor that contributes to continued addiction.
29:02
Yeah. Like culture, like tradition.
29:04
You know, one of the things we do here
29:05
just is disaggregate our data as a function of unique group.
29:09
So instead of instead of,
29:12
you know, I don't want to use this
29:14
in layman's terms instead of ignoring it.
29:16
Now let's identify it and let's try to unpack
29:19
maybe what parts of treatment need to be more
29:22
celebrated or,
29:25
more robust for certain.
29:31
Individuals or groups.
29:32
So again, thank you so much for your time.
29:35
I'm sorry we missed you in Orlando.
29:36
You know, they say it's the happiest place in the world,
29:38
but I'm sure you had much to catch up on, so.
29:41
And, well, I want that to go very well.
29:44
I had everything planned and then correcting came.
29:47
So it was it was very important.
29:51
I was looking forward to it. Yeah.
29:53
Well thanks again. Have a great day.
29:55
And if you get to Nashville, you know we'll send Katie over.
29:58
She's in Knoxville and we'll we'll have a good time.
30:01
So take care doctor. Okay. Sounds good to me.
30:04
Thank you. Bye bye.