When someone decides to quit smoking, an effective clinician focuses on the individual's internal motivation. Rather than simply providing instructions, the therapist asks why the person wants to change and what they hope to achieve. This process helps the person build up their own reasons for doing the hard work required for change. The focus remains entirely on the individual's goals rather than the therapist's expectations.

Someone says, I want to quit smoking. A good clinician will say, why would you want to do that? Tell me, what do you want to get out of this? Because it is work. I am happy to work with you, but what are your motives?

Social environments also play a critical role in behavior change. Joining a group of people who are pursuing the same goal, such as a jogging club or an Alcoholics Anonymous meeting, provides both support and accountability. Being part of a community makes it harder to skip a commitment because others will notice and ask why you were not there. This shared journey is beneficial for any type of personal growth, from losing weight to exercising more.

Addiction is often used loosely in everyday conversation to describe things we do frequently. However, the true definition of addiction is the persistence of a behavior that is harmful. This goes beyond simple repetition or compulsion. It is the act of continuing a behavior to the point of destruction, even when a person would normally be expected to stop.

It is not just stuff you do a lot, which we sometimes colloquially call addiction. It is the persistence of doing something that is harmful. It is not the doing things over and over or even being compulsive. It is doing them to the point of destruction. When you would normally any other behavior, you would think you would just stop doing that. But people don't.

Keith describes addiction as a progressive narrowing of the things that bring a person pleasure. In this process, natural rewards such as relationships, work, and housing start to disappear. This creates a cycle where the person becomes psychologically dependent on the substance because it is the only source of reward left. When everything else is stripped away, the moment of taking the substance becomes the only time the person feels good.

You see the other types of rewards, particularly natural rewards, start to fall away from the person's life. I will sacrifice my relationship with my parents or my spouse or my friends. I will stop going to work or I will give up my housing for the sake of this substance. It becomes the one thing left that is still rewarding. Everything else has been stripped away.

There is a common myth that babies can be born addicted to substances like fentanyl. Keith clarifies that while a baby can be born physically dependent and experience withdrawal, they are not technically addicted. Addiction requires a conscious association between a behavior and the drug, which a fetus cannot form. However, genetics do play a massive role in future risk. Adoption studies reveal that children from families with a history of alcohol addiction are much more likely to develop problems themselves, even if they are raised in households where no one drinks.

You'll sometimes read, if mom was addicted to fentanyl, then the baby is born addicted. That is not possible because a fetus has no association between their behavior and the exposure to the drug. So they can be physically dependent, meaning they'll go through withdrawal upon birth, but they're not addicted.

Genetic risks can be either specific or general. For example, many people of Han Chinese descent have a specific genetic trait that makes it difficult to metabolize alcohol, making the experience of drinking physically unpleasant. This lowers the risk for alcoholism specifically but does not affect the risk for other drugs. In contrast, general traits like impulsivity or a drive for sensation seeking can increase a person's risk across all substances because they are more likely to experiment with drugs in the first place.

This underlying vulnerability often persists even after someone stops using a specific substance. Keith notes that individuals who have been sober for decades may suddenly develop new compulsive behaviors, such as overeating or sexual compulsions. This suggests that the internal drive toward addiction has simply found a new way to express itself because the root cause was never fully resolved.

I've known people who have been clean and sober for 20 years. And then all of a sudden they develop a very strong sexual compulsion or they gain 30 pounds because they're just eating and eating. It's like the underlying diathesis has found a new phenotypic expression because it was never actually resolved.

Terminology in the world of addiction can often feel like splitting hairs, but there is a functional reason for the shift toward using the term alcohol use disorder. This term describes a broad spectrum ranging from mild to severe cases. At the mild end of the spectrum, a person might occasionally drink too much or experience some harms, yet their life remains largely intact. This is distinct from severe alcohol use disorder, which aligns with the traditional understanding of addiction.

Keith explains that the medical community introduced this broader classification to encourage early intervention. By identifying lower severity problems, doctors can advise patients to cut back while they still maintain a fair amount of control, potentially avoiding significant suffering later.

Use disorder is broader and it was there to sort of move alcohol like other health behaviors that you might start addressing, particularly in primary care. Just like we would like doctors to intervene when someone is 15 pounds overweight and has moderate high blood pressure so that they don't later develop a more serious problem.

Despite these clinical shifts, the term alcoholic remains central to many in recovery. In programs like Alcoholics Anonymous, identifying as an alcoholic is a key part of the recovery process and identity. Keith notes that while use disorder is a useful clinical term, addiction remains a scientifically meaningful word that the public clearly understands.

Individual responses to alcohol vary significantly based on genetics. About 8 to 10 percent of people experience alcohol as an energizing, dopaminergic event rather than a sedative one. This subset of the population is at a much higher risk for addiction because they do not receive the usual physical signals to stop drinking. They often experience less body sway and fewer hangovers than others.

They don't get that signal. It's less punishing, more rewarding. And you see that across drugs, and this is almost surely genetic.

The internal reaction to a substance can be immediate and profound. Keith notes that while some find opioids unpleasant, others feel that the drug fills a hole in their chest that existed their entire life. This biological reality makes conversations about moderation difficult. People are wired differently for specific substances, and some can function at a high level despite heavy use until their health eventually declines.

Predicting addiction risk is currently most effective through family history rather than advanced genetic testing. Asking if a parent had a drinking problem remains the best indicator of potential risk. While risk can cross genders, the link between fathers and sons is statistically the strongest. However, environmental factors also matter. Genetic risk only manifests if the person begins using the substance.

The only way to determine that a substance will not damage your life is to never use it in the first place. There is always going to be some risk.

The alcohol industry successfully targeted women in the late 1990s and early 2000s. They noticed women had money but drank less than men. To fix this, they created marketing campaigns like mommy wine juice and social media chats. Many of these trends seemed organic, but companies actually engineered them. This push worked, and women began drinking significantly more. Unfortunately, alcohol causes more physical damage to women than men. This is due to smaller body sizes and hormonal differences.

Women's drinking went up a lot and the damage per drink is more for women for most things than it is for men, partly due to body size, but also partly probably due to some hormonal things. And so it's been an exploitation, as I see it, of women.

Keith observes that many young women are now pushing back. They see the impact alcohol had on their mothers and choose a different path. This is a positive shift because the industry only cares about profit. They make their money from addiction. In the United States, just 10% of the population consumes half of all the alcohol. The industry does not profit from occasional drinkers. They make money from people who drink multiple bottles of wine every day.

10% of the country drinks half the alcohol in the United States. So if you're running the industry, you want that group to be as big as possible. You do not make money off people who have half a bottle of wine on special occasions. You make your money on the people who drink the equivalent of multiple bottles of wine every single day.

Data shows that younger generations are engaging in fewer risky behaviors. This includes less alcohol use, fewer unwanted pregnancies, and higher high school graduation rates. While some assume these young people are simply switching to cannabis, the data tells a different story. Most growth in cannabis use is occurring among adults rather than youth.

The idea that moderate alcohol consumption, especially red wine, provides health benefits is a persistent myth. This belief often stems from a news report in the 1990s about the Mediterranean diet. People often point to resveratrol in red wine as a health booster. However, the amount of resveratrol in grape skins is so small that it has no real impact on health.

There's such trace amounts that were just like ludicrous in a grape skin. And so that was just spread and it was just so great for the industry. It's better for you than not drinking. And you know that's just not true.

Research sometimes shows a J-shaped curve where light drinkers seem healthier than those who do not drink at all. This data is misleading because the non-drinking group often includes former alcoholics. These individuals may have existing health damage from their past drinking. It is incorrect to assume they would be healthier if they began drinking again.

Non-drinkers include people who are in Alcoholics Anonymous. That's why they don't drink. They had a wretched experience with alcohol and so they've had different kinds of damage to their bodies. Maybe their health isn't as good, they're not going to live as long as others. But it's not that they would be better off if they went back to drinking.

Keith explains that any minor cardiac benefits are outweighed by the increased risk of cancer. While having two drinks a week carries a very small risk, it does not improve overall longevity. Science has overturned the industry message that drinking will extend your life. There is no evidence that drinking is healthier than not drinking.

Information about alcohol health risks can have a powerful impact when it becomes specific to certain groups. For many women, learning about the link between alcohol and breast or ovarian cancer is often the turning point for deciding to stop drinking entirely. While marketing and social norms suggest that a glass of wine is a harmless way to relax or connect with friends, specific health warnings can override these common perceptions. People often weigh the social benefits of drinking, such as relaxation and shared experiences, against the biological costs.

Health is a reason people still accept as legitimate for changing behavior. You can make that because cancer is scary. And that may be why people quit.

Keith Humphreys points out that people often feel they need a valid explanation to stop drinking in social settings. It is common for someone to be asked why they are not drinking, while no one asks why someone is drinking. Having a concrete health reason allows individuals to navigate social pressure without feeling like they have to defend their choice. This mirrors the historical shift in smoking habits. When the Surgeon General report on smoking was released, it gave people a socially acceptable reason to stop a behavior that was previously expected in professional and social circles.

Social interactions involving alcohol often revolve around vulnerability and trust. Some people do not feel the need to drink to lower their inhibitions. They are already comfortable sharing their thoughts openly. However, when others in a group are drinking and one person remains sober, it can create a sense of unease. Keith compares this dynamic to a trust exercise. In some cultures, coworkers get very drunk together to build trust. This shared state of intoxication serves as a bond because everyone is equally vulnerable.

It is like a trust exercise, like that falling backwards thing, except it is that we are all drunk. If someone were not doing it, it is like, why are you not undergoing any? We are all going to be vulnerable and you are not. Are you going to exploit us in some way? Or I am going to say, I think I hate the boss. Then you are going to repeat that at work because you are the one person sober enough to remember I said that.

There is also a rational fear about power dynamics. For example, if only one person drinks on a date, the other might feel unsafe. The sober person might be seen as trying to take advantage. While these anxieties exist, social interactions should be simpler. Choosing not to drink should be a non-issue. No one should have to explain why they want water instead of alcohol.

Alcohol use in professional settings often leads to negative outcomes. People at health conferences sometimes drink heavily. This can result in visible aging and career problems. Mixing alcohol with work or dating creates safety risks. When a person drinks, their judgment changes. This behavior is often counterproductive.

I just don't see a world where drinking with your coworkers or drinking on a date with somebody that you don't know very well is a good idea. For either of them, it is just like a lack of safety all around.

Keith notes that social norms are changing as more women enter the workforce. Many professionals now prefer lunch meetings instead of drinks. This helps them avoid being around intoxicated colleagues. In dating, people often use alcohol to reduce anxiety. It can make people feel more relaxed and engaging. However, it also makes them more vulnerable.

What I think most people would say is just the anxiety is intense for some people and alcohol is anxiolytic. And so it is probably that. People are feeling they are too nervous.

From a health perspective, zero alcohol is better than any amount. People should weigh small potential benefits against risks like cancer. Understanding these factors helps people make informed choices. Everyone should consider how drinking affects their actions and their safety.

The cannabis industry has transformed significantly since the eighties and nineties. Keith notes that when the drug was illegal, the average THC content was between three and five percent. Today, legal products often average around twenty percent. This represents a dramatic increase in strength. Usage patterns have also shifted. In the past, people might have used cannabis once or twice a week. Now, data shows that about forty two percent of users consume it almost every day. When you combine the higher potency with more frequent use, the brain exposure is sixty five times higher than it used to be.

This is very hard to get across to parents because their view is like, I smoked weed, who cares if my fifteen year old is using it? It is like saying you drank low alcohol beer and you are not concerned that your fifteen year old is guzzling vodka. That is the difference.

While there are likely medical applications for pain and seizure disorders, the higher potency makes the drug more addictive and dangerous than in the past. There is also a significant difference between smoking and eating cannabis. Smoking delivers THC to the brain almost immediately. In contrast, edibles have a delayed onset because they must pass through the gut. This often leads to overconsumption. People eat a piece, feel nothing after five minutes, and then eat more. By the time it hits, the effect is overwhelming.

Keith also points out that manufacturing standards for edibles can be inconsistent. Unlike a standard chocolate chip cookie where chips are spread evenly, a cannabis edible might have all the THC concentrated in one corner. This lack of uniform blending means a user can accidentally ingest a much higher dose than intended from a single bite.

Keith was skeptical about the link between cannabis and psychosis for many years. Early research used data from Swedish military registries to track men who used cannabis as teenagers. These studies showed higher rates of psychotic disorders later in life. While Keith initially thought other factors might explain this connection, he is now more convinced of the risk. The evidence has grown stronger as the drug itself has become more potent. People are using cannabis much more intensely today than in the past.

The evidence has gotten stronger as the drug has gotten stronger. We have to realize people are using it much more intensely. If this effect is there, it is much more plausible that it would be from a much stronger drug used every day could generate higher rates of psychosis.

High doses of strong cannabis used daily are a plausible cause for higher psychosis rates. Because of these risks, individuals with a family history of mental health issues should be very cautious. Keith recommends that anyone with a first degree relative who has schizophrenia, schizoid personality, or bipolar disorder should avoid using cannabis entirely. The risk in those specific cases is likely quite high.

Substance use is most dangerous when the brain is still plastic. Addictions almost always begin during the teenage years or even earlier. This is also the period when the risk of a psychotic break is highest, typically occurring before a person reaches their early twenties. Starting substance use at age 50 carries much less risk of addiction or long term health issues compared to starting as a youth.

Everything is different when the brain is plastic and our brains are most highly plastic when we're young. A lot of these effects, the worst things are going to be because people start when they're in their teens. That's where addictions overwhelmingly start. Initiating a substance when you're 50 is far less likely to end you up with an addiction or some other terrible thing than when you're young.

While some people can use cannabis and remain highly productive, Keith observes that these individuals are the exception. More often, regular cannabis use is linked to a failure to meet normal developmental milestones. This includes finding a sustainable career and organizing one's personal and professional life. Many users struggle to move through the progression of adulthood when they rely on the drug.

The discussion shifts to how frequent cannabis use impacts life progression, often called a failure to launch. This term describes young people who struggle to move out, keep a job, or maintain healthy relationships. Keith explains that while some highly successful people use cannabis, it often functions as a performance degrading drug rather than an enhancement. It can undermine the very things required for success in the modern world, such as short term memory, concentration, and basic motivation.

Overall though, it is like we have performance enhancement drugs. It is kind of a performance degrading drug. It does, with regular use, undermine certain things that you need to succeed in the modern world, like short term memory and concentration and being able to keep track of details.

The impact is especially visible in high achieving environments. Keith mentions a student who went from being a star athlete and math student to losing all interest in those pursuits after six months of daily use. In a global economy, where workers compete with the smartest minds in cities like Mumbai or Tokyo, being slower or losing focus creates a significant disadvantage. There is also a danger in looking at successful users as proof that the drug is safe. High achievers often have more social capital and stronger safety nets, making their experience unrepresentative of the risks faced by the general population.

You cannot overgeneralize from a lucky life or a costed life. Sometimes you can do more of that than you can when there are not many nets between the person and the ground.

Many modern industries are built on the model of addiction. This applies to everything from alcohol and cannabis to gambling and smartphone apps. There is no customer more valuable than an addicted customer. This makes addiction very good for business. While capitalism drives innovation and creates a strong private sector, addictive products require special handling. People can be rational when buying lettuce, but they often struggle to protect themselves from addictive goods. This is why we need smart regulations and advertising restrictions.

If you're making an addictive product, more addiction is good for your bottom line. So us on the other side have to say, we're going to put in laws and regulations so that that is harder to achieve.

Keith explains that comparing the harm of one drug to alcohol is a dangerous logic. Alcohol kills around 150,000 Americans every year. If we use that as the standard for what is acceptable, we would have to legalize many other deadly things. Just because one thing is less lethal than alcohol does not make it safe or good for society.

Alcohol kills about 150,000 Americans a year. So if that's our bar, we should have hand grenades in the drugstore. That would kill tens of thousands, but not 150,000. We should legalize drunk driving because that only kills 10,000 people. That's just a crazy thing to set as the bar.

The shift in gambling culture is a clear example of how regulations have changed. In the past, athletes were banned for even minor betting. Today, sports gambling ads are everywhere. These ads are especially harmful to young men and people trying to quit. We need tools like taxes and marketing limits to protect people from these financial and social consequences. History shows that industries like tobacco will always work to make products more addictive and market them to children if they are not restricted.

Gambling addiction is uniquely difficult because the next bet could truly change everything. For some, the addiction evolves into something more complex than just wanting to win. Some individuals even become addicted to the shame of losing. This process can lead to a state of zombification where players are no longer even actively participating in the game. Some addicts even suggest that every addiction is a form of gambling.

They will just sit there and watch in a dissociative state as it runs and runs and runs until their money is gone.

Keith points to the research in the book Addiction by Design, which explains how technology has perfected the addictive nature of gambling. Modern casinos have largely replaced human dealers with machines because machines provide more precise reinforcement. A human dealer involves social interaction and natural pauses, which slow down the betting process. In contrast, a machine offers exact timing for rewards and can operate 24 hours a day without getting tired.

A machine can give you exact timing between when you press the button and when you get your reward. You can go infinitely 24 hours a day, unlike a dealer who never gets tired.

Modern slot machines rely on novelty rather than the prospect of winning money. While mechanical machines had limited outcomes, electronic systems offer infinite variety. This allows casinos to use a strategy called losses disguised as wins. A machine might trigger lights and celebration sounds for a small payout even when the player has lost money on the bet overall. The brain receives a dopamine reward from the novel combination of symbols rather than the financial gain.

People aren't even really playing for the money anymore. They think they are. They're actually just being stimulated with enough novel combinations that their bank account gets drained, the house takes it all.

Casinos are designed to be high density environments for addiction. They often combine gambling with free alcohol and indoor smoking. Keith describes these spaces as places where the drive to play can override basic human empathy. He mentions an extreme example where gamblers continued at their machines even after a person nearby suffered a fatal heart attack. This illustrates how effectively these environments can capture and hold human attention through specific circuits in the brain.

The distinction between decriminalization and legalization of cannabis is also a significant policy issue. Decriminalization focuses on the individual user and removes punishments for possession. Legalization is different because it allows corporations to enter the market. These businesses use professional marketing and sales tactics to drive up consumption and reach more people.

Legalization is making the production, processing, marketing, and sale legal. Bringing in a corporation is fundamentally different because the corporation is going to have very smart people who are good at selling and they will increase consumption of the product.

The idea that cannabis is a unique gateway drug is a misconception. In reality, early exposure to any substance, including nicotine or alcohol, increases the likelihood of moving to other drugs. This happens for several reasons. A person might enjoy the experience and want to try more. Their social circle might change to include other users. There is also evidence that exposing a young brain to substances can sensitize it, making future drug use more rewarding.

The lie in the gateway drug theory was that cannabis had some unique role that was going to lead you to heroin use. The truth is anything, if you are a teenager and you start smoking or you start drinking or you start using cannabis, that will increase your likelihood of progressing to other substances for multiple reasons.

Society often treats alcohol as something separate from drugs, but it is a drug. People frequently criticize drug users while sitting at a bar, failing to recognize their own substance use. This distinction is useful for the alcohol industry and for politicians, but it hides the fact that alcohol is often more likely to cause trouble for young people than cannabis is.

The conversation around psychedelics often suffers from poor categorization. MDMA is actually an empathogen, and ketamine is a dissociative anesthetic. Neither is a true psychedelic like LSD or psilocybin. While there is a lot of hype surrounding these compounds, they represent a significant step forward in treating depression and addiction. Keith suggests they are among the most promising new treatments available today.

I have always worried about psilocybin and LSD far less as a class of drugs than I do things like stimulants and alcohol. There is no evidence that people get addicted to them. If they have abuse potential, it is extremely slight.

Clinical trials for psilocybin involve specific stages. These include preparation sessions, the high dose experience with guides, and follow up integration. While some find these experiences transformative, they are not without risks. Some people report negative experiences or flashbacks later. However, unlike alcohol or stimulants, psilocybin and LSD show almost no evidence of being addictive. Current research suggests that while microdosing lacks proven benefits, high dose clinical sessions can lead to significant remission for major depression.

After using psychedelics for trauma or depression, patients sometimes experience a significant mood drop weeks or months later. This trough is distinct from the immediate comedown seen with stimulants. It can be frightening for patients who felt they had made significant progress. This highlights the need for standardized care and oversight, which is starting to happen in places like Oregon where practitioners are licensed by the state.

I think people get a little scared of these drugs and they sort of think you can't use them in medicine. We use lots of things in medicine that are a lot riskier than this. It is just a question of what the effect is on the patient and what the balance is.

Scientific rigor is essential for these treatments to gain mainstream acceptance. In the past, some research was hampered by researchers who were too enthusiastic and lost their critical perspective. Keith emphasizes that the field needs scientists who design good studies and let the results speak for themselves without trying to spin the outcome. This objective approach is necessary to determine if these substances truly work.

Practical issues also influence which substances are studied. LSD trials are often conducted in Switzerland because the experience can last thirteen hours, making it difficult to staff in American hospitals. If a treatment takes too long to administer, it is unlikely to scale within the healthcare system. Consequently, researchers are investigating whether the psychedelic experience itself is even necessary. They are looking for compounds that provide the antidepressant effects without the hallucinations or vivid dissociation, which some patients find upsetting.

Mental health treatments such as SSRIs, talk therapy, and transcranial magnetic stimulation all aim for the same goal: brain plasticity. These different approaches are ultimately tools for rewiring brain circuits. While there is significant interest in opening plasticity through psychedelics or other means, simply opening the brain to change is not enough. Plasticity is a neutral capacity that must be carefully funneled. Without direction, plasticity can lead a person in any direction, which is not always beneficial.

Plasticity, which we have naturally the most when we are young, is absolutely a two edged sword. If you start smoking cigarettes when you are 13, you almost certainly will get addicted. If you start at my age, you probably will not. Almost all addictions start when people are young. It is maladaptive learning, but it is learning.

Keith notes that this biological reality is why advertisers target younger audiences. It is much easier to instill a lifelong habit when the brain is at its most receptive. This applies to everything from brand loyalty to addictive behaviors. While a young brain can learn a new language with ease, it is also highly vulnerable to forming habits that can last for decades. As the brain ages and plasticity decreases, it becomes harder to adopt new habits, which can serve as a natural defense against new addictions or compulsive behaviors.

Ketamine is a dissociative anesthetic that has been approved by the FDA for treatment-resistant depression. While it has helped some individuals in deep depression, its overall efficacy may not be as high as some expect. Many clinical trials have shown negative or mixed results rather than a clear, consistent success.

The thing about ketamine that struck me, yes, it is FDA approved for treatment resistant depression. It cleared it. There are some positive trials and I can say I know a couple people whose judgment I trust said it was very, very valuable to them in a deep depression. But I didn't view it as quite the knockout I thought it was going to be before I read all these studies.

Keith highlights that the drug carries a high potential for abuse and addiction. Beyond its mental health impact, it can cause significant physical damage to the body. Urologists are increasingly seeing young patients with severe bladder damage caused by ketamine use. Users as young as twenty-five are presenting with the bladder health of a sixty-year-old.

And then also the bladder damage you get from it, you get young people with 60 year bladders from ketamine and like that is most urologists have seen this. Now why is someone at 25 coming in with this? It is because their bladder has been damaged by ketamine.

For those dealing with challenging mental health conditions, alternative protocols might offer clearer benefits with fewer downsides. Keith suggests that other methods for treatment-resistant depression have more certain outcomes and almost no negative side effects compared to the risks associated with ketamine.

Transcranial magnetic stimulation, or TMS, is a non-invasive treatment that can either activate or decrease neural activity in specific brain areas. The technology is already approved for treating depression and is covered by Medicare, though the machines are large and expensive. This means the technology may not be available in all local clinics yet.

A specific advancement called the Saint Protocol has shown significant promise. This method compresses the treatment into a five-day window where patients receive intensive stimulation throughout the day. Keith notes that this specific protocol has been life-changing for many individuals.

Nolan's genius was to compress this treatment so people would come in five days in a row and have 10 minutes on, 50 minutes off. I believe that is the rate all day long, five days with a theta burst setting. I have seen some people's lives just absolutely changed by that.

One benefit of TMS research is its scientific rigors. Unlike psychedelic research, where participants usually know if they have received the drug, TMS trials can use an effective sham. A patient can have coils placed on their head and feel like something is happening even if it is a placebo. This allows for high-quality data because participants cannot guess which group they are in.

While many people are wary of the side effects associated with SSRIs, Keith cautions against demonizing these medications. They remain highly effective for people with debilitating obsessive-compulsive disorder. However, for those looking for alternatives, TMS provides a scientifically backed option to explore.

The link between SSRIs and mass shootings is often discussed. Keith argues that the data does not support this connection. Many people in countries like Australia and across Europe take antidepressants. However, these regions do not experience the same frequency of mass violence. Australia recently had its first mass shooting in 30 years. Its population has regular access to these medications. If there were significant risks, a country of 30 million people would likely see more frequent incidents.

The mass shooting thing does not fit the data. There was just a mass shooting in Australia. That was their first mass shooting in 30 years. There are plenty of people who take SSRIs in Australia. Why are there not mass shootings in Europe? Many people take SSRIs there as well.

The primary difference is the accessibility of high powered weaponry. Although the United States consumes a large majority of the world's depression prescriptions, Keith explains that the disparity in violence is too large to be explained by medication. It is much easier to obtain high powered weapons in the United States than in the rest of the developed world.

The disparity is so huge in where mass shootings occur that medication is just not going to be the likely explanatory variable. It is extremely easy to get high powered weaponry in our country. It is harder pretty much in the rest of the developed world.

The relationship between adolescent suicide risk and SSRIs is a long-standing and difficult debate. While depression inherently raises the risk of suicide, some legitimate concerns exist regarding how these medications specifically affect teenagers. Many young people clearly benefit from treatment, but a vocal cohort of patients has identified a specific set of symptoms, particularly sexual and mood-related side effects, that persist long after they stop taking the drugs. This pattern of lasting effects after discontinuation is also seen in other treatments, such as medications used for hair loss, where patient experiences often precede official medical recognition by years.

Medications are approved on short term trials. If you look at the typical trial for opioids and pain, it is like nine or 12 weeks. That does not necessarily mean that taking them for a year gives you the same effects because you might become tolerant or addicted. That is a general challenge of how we regulate these medications.

Keith explains that the regulatory system for drug approval often relies on trials that only last a few months. This short timeline makes it difficult to understand the impact of long-term use or identify rare complications from a widely used medication. While doctors can report individual cases to be aggregated, catching up to the reality of what many people are experiencing remains a significant hurdle in medical regulation.

Nolan Williams pioneered research into using ibogaine to treat veterans with PTSD and addiction. This psychedelic experience is unique because it lasts for 22 hours and requires medical heart rate monitoring. It is a very intense process that is not used for recreation. Early data from these studies showed that veterans often experienced a total remission of their symptoms after a single session.

It is a 22 hour long psychedelic experience. You have to be heart rate monitored. Nobody does this recreationally and nobody should do it recreationally.

Keith highlights the importance of using brain imaging to study these treatments. This work was groundbreaking because it documented physical changes in the brain before and after the veterans used ibogaine. This documentation is vital because it proves the brain actually changed rather than just recording how the patients felt. It provides scientific evidence for the dramatic improvements reported by the veterans.

Current studies on ibogaine are open label trials without control groups. Keith points out that many other factors could influence the results. The treatment process often includes a sense of ceremony and camaraderie among the soldiers. It can feel like a final mission they complete together in Mexico. Future trials need to separate the chemical effects of the drug from the benefits of the supportive social environment.

There is a lot of ceremony around this. It is like the final mission for the soldiers. They go down into Mexico and there is a lot of camaraderie. Is that part of the therapeutic experience or is it entirely a chemical experience?

Caffeine is the most widely used stimulant in the world. While it is rewarding and technically has addictive potential, it rarely leads to the profound loss of control seen with other substances. Most people who experience negative side effects like jitters, stomach pain, or sleeplessness simply choose to stop or reduce their intake. Keith explains that he has never met a true caffeine addict in the clinical sense because the stimulant is not intense enough to override a person's desire to avoid physical discomfort.

I have never met a true what I consider a coffee addict person because it is not that intense of a stimulant. The GI symptoms and things like that would be the main thing. Almost everybody who experiences those seems to quit.

The broader field of stimulant addiction treatment has seen surprisingly little progress over the last forty years. Keith recalls working in Detroit during the crack cocaine epidemic of the late 1980s and notes that the treatment options today remain largely the same. There is still no proven medication to help people stop using stimulants like cocaine or methamphetamine. Psychotherapy and support groups provide only modest benefits, which remains a significant disappointment for experts in the field.

One of the few effective methods is contingency management. This approach uses small, tangible rewards to encourage abstinence. Patients might receive a small payment for providing a clean drug test, with the reward amount increasing for every consecutive day they remain sober. This technique proves that people struggling with addiction often have impaired control rather than a complete lack of it. They can still respond to incentives even when their self-control is compromised.

If you transported me back to the late eighties and someone asked what new treatments would be available in forty years, I would have to say basically nothing. That is really disappointing.

Stimulants like Adderall and Vyvanse are difficult for parents to navigate. For some children who cannot sit still or complete schoolwork, these medications are transformative. However, Keith expresses concern that these drugs are also over prescribed. There is a decreasing tolerance for natural variations in how different brains work. Instead of seeing a child as just active or shy, society often medicalizes these traits and applies diagnostic labels. This puts pressure on parents to medicate children who might not actually have an illness.

There is probably people who could benefit are not getting them and there is a lot of people who are getting them that I think there is just less tolerance for some variations in how all our brains worked in medicalizing everything. And I noticed that a lot, which makes parents anxious.

There is a theory that untreated ADHD poses a greater risk for addiction because it leads to higher impulsivity. While Keith acknowledges this may be true, he also highlights the dangers of substances like nicotine. Nicotine is highly addictive and acts as both a stimulant and a relaxant. Some people use it for its potential protective benefits against neurological diseases, but it carries significant physical costs. It can cause throat spasms, damage oral health, and age the skin faster through vasoconstriction.

A major issue with addictive substances is that users often mistake the relief of withdrawal for a positive drug benefit. If someone wakes up feeling anxious and finds that a cigarette or nicotine gum makes them feel better, they assume the drug is helpful. In reality, they are often just stopping the symptoms of withdrawal. This same cycle happens with cannabis and opioids. Keith suggests that people should try to ride out the withdrawal period to see if they truly have an underlying condition or if they are simply trapped in a cycle of dependence.

What you are doing is just the withdrawal that makes you agitated and angry and annoying goes away. And you attribute that to the use of the nicotine, but it could just be you are dependent on this drug.

Validation and optimism are the first steps in treating someone who worries they have a problem. Many people feel shame or think their experience is odd, but addiction is extremely common. There are roughly 24 million Americans currently in recovery. These individuals are often invisible because they have returned to normal life as teachers, accountants, or police officers. There is a lot of reason for rational hope, especially when addressing a problem early.

Surveys give something like 24 million Americans are in recovery. We just don't notice them because someone in recovery looks like anybody else. We notice them when they're actively addicted, but not when they're in recovery because they just look like a school teacher, an accountant, or a police officer.

Recovering is much easier before a person's life has been completely disrupted. If someone still has family support, a safe place to live, and a meaningful job, they have the accountability and resources needed to rebuild. When working with patients, Keith focuses on their personal motivation. Instead of telling someone why they should quit, he asks them what they hope to gain. This might involve saving money for a vacation or simply wanting their clothes to smell better. Building these internal motives helps a person stay committed when the process becomes difficult.

If you don't want to do it, it doesn't matter what I think. I'm happy to work with you, but what are your motives? If a year without smoking gets you that $2,000 trip to Cancun you have always wanted to take, that helps motivate you.

Behavioral analysis is another key tool. This involves looking at where and when a person uses a substance and identifying places where they never use. If someone never drinks at their mother's house or on holy days, they can use those same techniques in other situations. It also helps to make the behavior physically harder by removing triggers from the home. Finally, joining a community of people making the same change, such as a support group or a hobby club, provides the social reinforcement necessary for long term success.

Participating in recovery groups like Life Ring or Smart Recovery offers more than just community. These groups provide a crucial balance of support and accountability. When you are part of a group, people notice if you miss a session. That sense of being watched over helps keep you on track. It is similar to having a jogging partner. If you do not show up on Tuesday, someone asks why. This combination of support and responsibility is vital for lasting change.

For a long time, society viewed addiction as a character defect. While individuals struggling with addiction certainly have flaws, they do not have them at a higher rate than the general population. Everyone has character defects. The struggle is often worsened by how others perceive the condition. If someone finds it easy to quit a habit, they might unfairly judge someone who cannot. This leads to the harmful mentality of telling someone to just quit, which ignores the complex biological reality of how the brain works. Addiction often masks who a person truly is. When someone achieves sobriety, their true personality often emerges in spectacular ways. Keith notes that addiction is not the person's identity but something that hides it.

When these people get sober, it's spectacular how the real person seems to emerge, which points to the fact that the addiction masks something about who they truly are, not the other way around.

The pain caused by addiction extends far beyond the individual. Family members and friends often suffer immensely. People in the grip of addiction do things they would never otherwise do, such as lying to loved ones or neglecting important promises. It is important to acknowledge this harm without using the disease label to silence victims. Calling addiction a disease should not diminish the very real anger and grief felt by those who have been hurt. Even if a behavior stems from an illness, the pain it causes others remains real and valid. Public messaging must acknowledge that the pain for families is enormous and their reactions are understandable.

People struggling with addiction often have a hard time imagining long-term benefits. They might see the sticks easily, like coughing from smoking or spending too much money. However, the carrots or positive rewards can feel like a fantasy when they are years away. For example, a country music singer named Jelly Roll lost over 300 pounds and became a transformed person who runs 5Ks. Someone still struggling with a large body might not be able to imagine those rewards because they have never experienced them. This is why focusing on immediate goals is so important.

Keith notes that people in addiction discount future rewards more than most. If you ask them whether they want five dollars today or twenty dollars tomorrow, they often choose the immediate five dollars.

In addiction, if you ask people whether they would take five dollars today or twenty dollars tomorrow, they are more likely to say five dollars right now, almost as if tomorrow does not exist.

To help someone move forward, it is better to focus on immediate rewards. This includes things like having more money every day or the instant removal of arrest risks. Social status also plays a huge role. Keith points out that the 12-step fellowships are clever because they offer immediate respect and status based on how many days a person has stayed sober. The one day at a time approach works because it turns an inconceivable lifelong goal into a manageable task for today. A person cannot easily quit drinking for the rest of their life all at once, but they can choose not to drink today and go to a meeting for a reward.

Many people use substances because they believe it helps them function. Some might use alcohol to lower social anxiety or use stimulants to focus on work. This is common even in competitive environments like Stanford. When talking to someone about their addiction, simply saying that drugs are bad can make them feel judged. A more effective approach is to ask them what they actually like about the substance.

You get them to articulate, well, clearly you like some things about it. What are they? And put them on the table.

By acknowledging the fun or the social connection found in using drugs, it creates space for a more honest conversation about change.

Recovery involves acknowledging the real costs of sobriety. It is not just about stopping a bad habit. It is about grieving the loss of social circles or even relationship dynamics that only functioned during active addiction. Some partners might even leave once someone gets sober because they realized they preferred the control they had when the other person was incapacitated. Keith notes that drugs always serve a function, however crude, and removing them fundamentally changes a person's life.

The concept of codependency is often misunderstood. Keith highlights research showing that what looks like a codependent personality is frequently just a reaction to living with an addict. Families become hyper-responsible because they have to be to keep their lives together. Once the addiction is removed, these partners often return to more standard behavioral patterns. This suggests that people are more psychologically plastic than we often assume.

The brain was reporting levels of dopamine activation that predicted whether or not the person would relapse better than their own self-report of the subjective feeling. They don't have complete insight to what's going on on the inside of their brain like anyone else.

Long-term substance use significantly rewires the reward circuitry of the brain. Keith shares a study where brain imaging of the nucleus accumbens was used to predict relapse in people recovering from methamphetamine addiction. The scans were more accurate than the patients' own reports of their cravings. This helps explain why someone can sincerely want to stay sober but still struggle; they lack full insight into the powerful signals their brain is still sending.

Relapse is often misunderstood as a lack of willpower or honesty. Instead, it frequently stems from a brain that has been physically rewired by repeated drug exposure. This rewired reward system becomes highly sensitive to external cues, such as seeing drug use on television or smelling tobacco smoke in a neighborhood. These environmental triggers activate the dopamine reward circuitry in the nucleus accumbens, making it incredibly difficult to avoid a relapse when the environment is saturated with signals that predict use.

The one who relapsed didn't necessarily lie. It may just be I didn't realize how deeply my brain has been changed. It is pretty hard for me to walk around and see no one using drugs ever. I am going to relapse because I have rewired my reward system.

This phenomenon extends beyond substance use to modern behaviors like endless scrolling on social media or playing video games. These activities act as brain candy that provides no real nutrition but remains highly seductive. The conflict between one's idealized self and actual behavior is a common human experience. However, it becomes a serious concern when it results in self-inflicted harm, such as failing an important exam because of a multi-hour digital binge.

You start to worry because now you are going to do damage to yourself for the purpose of consuming this brain candy, which has no nutritive value at all, but is clearly seductive.

The challenge in treating addiction is that it utilizes the same system humans need for learning and survival. We cannot simply eliminate the reward circuitry because we could not survive without it. Keith notes that future treatments might involve brain stimulation devices that tune the specificity of reward. By using techniques like transcranial magnetic stimulation, doctors could potentially dampen the rewarding properties of harmful addictions while ramping up rewards for positive behaviors like family connection or community service. Even with advanced medical implants, recovery often still requires a combination of medication and community support groups.

In the current economy, the people experiencing homelessness often face significant mental health and addiction challenges. When unemployment is low, those who simply needed work have generally found it. This leaves a population that cannot find or maintain shelter even in a strong job market. Keith points out that addressing this requires a combination of stable housing and recovery culture. One successful model is Oxford House, which is a peer-run community. Residents contribute to rent and follow rules against violence and substance use. This environment provides a clean place and a supportive community for those willing to make the trade.

Some people will leave the streets and live there and make that trade. You can't use your drugs anymore, you can't drink anymore, but at least you have a nice clean place with nice people who like you and will support you. That can help people.

For others, legal or civil intervention is necessary. This can happen through civil commitment for those who are gravely disabled or through drug courts for individuals who commit crimes. Keith argues that we must get comfortable with using pressure to push people into treatment. He compares this to helping a person with Alzheimer's disease who wanders away from safety. We bring them back because the disease impairs their judgment. Addiction functions similarly by altering brain circuitry and making it difficult for a person to choose recovery on their own.

We don't have to press people to seek care for chronic pain. Chronic pain sucks. Everyone is happy to leave chronic pain. But people are ambivalent about giving up substances because it is rewarding. That is why people do it. And so that press is necessary.

Research shows that almost all people seeking help for alcohol issues do so because someone else leaned on them. This might be a spouse threatening to leave, a boss threatening termination, or a judge overseeing a legal case. Because drugs and alcohol are rewarding to the brain, internal motivation is rarely enough on its own. Using legal and social leverage can help people regain their reason and eventually make better decisions for themselves.

Since 2008, the United States has seen a significant shift in how addiction is treated through legislation. The introduction of parity laws has forced private insurance companies to cover mental health and substance use services at the same level as other medical care. Previously, it was common for insurance plans to charge higher co-payments or set much shorter limits on hospital stays for addiction compared to physical ailments. These practices are now illegal in almost all plans, making it much easier for families to access the care they need through their workplace insurance.

It used to be a plan could say your co payment for an outpatient visit is five bucks unless it's mental health or substance use. In that case it's 25 bucks. Or you're allowed to have up to six months of hospitalization a year unless it's mental health and substance use and you're allowed to have 14 days. Those kinds of things, which made very skimpy benefits, are now illegal in almost all plans.

Keith explains that while private coverage has improved, Medicaid has become the backbone of the substance use treatment system. In states like West Virginia, Medicaid is the primary funder for addiction care. This integration helps treat addiction as a mainstream healthcare issue. However, Keith expresses concern regarding recent budget changes that plan to remove approximately a trillion dollars from Medicaid over the coming years. This contraction creates uncertainty for how low income Americans will continue to receive necessary addiction services.

Traditional healthcare systems are often poorly designed for the impulsive and ambivalent nature of addiction. If someone decides they want to quit drinking on a Saturday morning, a university psychiatry department is usually closed. By the time Monday arrives and they navigate a waiting list, the initial motivation to change might have vanished. In contrast, Alcoholics Anonymous is structured for immediate access. Meetings are available throughout the day in almost every city and online, requiring no insurance, paperwork, or pre-approval. This allows individuals to act instantly on a desire to change and receive immediate social rewards for taking positive steps.

For a condition characterized by ambivalence and impulsiveness, I want to quit now. Two hours later, I don't. That's like, this healthcare system's the worst possible design. Whereas how is AA design? Be like, I'd like to go to AA. You can go on the AA website, look in the area. Oh, my God, there's like 15 meetings today.

Keith highlights that despite historical skepticism from medical professionals who viewed 12-step programs as mere folk medicine, the scientific evidence supporting their efficacy is robust. A Cochrane Collaboration review, which is considered the most rigorous standard of evidence in medicine, found that 12-step programs and facilitation counseling often result in abstinence rates 50 percent higher than traditional clinical approaches like cognitive behavioral therapy. While 12-step programs are the most widespread, other options like Smart Recovery and Women for Sobriety offer similar benefits of mutual support. The core power of these groups lies in the wisdom and authenticity of people who have lived through the same journey and can provide hope to those just starting.

And it just keeps coming out really, really good in studies. And so finally, a few years ago, me, John Kelly and Marika Ferri did what's called a Cochrane Collaboration review. This is the creme de la creme, most rigorous review of evidence in medicine as a method. And looked at all these studies of Alcoholics Anonymous... and it came out extremely well relative to very good therapies like the one I was trained to do, like cognitive behavioral therapy.

Alcoholics Anonymous (AA) offers open meetings that anyone can attend. These sessions are open to those who are curious or struggle with different types of addiction. Because AA is more established than other recovery groups, it provides a unique look at how people can support each other without professional intervention.

It is just a shining example of humans self-organizing into something that keeps going. There is no GoFundMe and no tax dollars. They stay out of politics.

The organization survives through purely internal support. It does not rely on public funding or government tax dollars. This self-sustaining model allows the group to focus entirely on sobriety while avoiding the complications of political involvement. For many people, this community-driven approach is the only method that has successfully helped them maintain sobriety.

While Alcoholics Anonymous has a strong base of evidence, data for other 12 step programs like Narcotics Anonymous or Cocaine Anonymous is more limited. Studies suggest that it is often harder to get people into these drug-focused groups. When researchers use 12 step facilitation counseling to introduce patients to a program, the success rate for alcohol programs doubles or triples. However, the uptake for illicit drug programs is much smaller. Keith explains that while long-term attendance correlates with better outcomes, these findings lack the rigorous randomized trials available for alcohol treatment.

I feel comfortable saying I know positively it has a causal effect on alcohol. I have no doubt about it. I am less sure whether that is true for other drugs. On average, it was harder to demonstrate that effect.

Critics sometimes label these programs as cults because members often undergo a total lifestyle change. People in recovery may adopt a new vocabulary and a new social circle. Keith notes that while some specific groups might develop unhealthy dynamics, the vast majority of these shifts are positive. This change in social environment is usually a healthy way to support long-term sobriety rather than a sign of a problematic cult.

A central part of 12-step programs is the requirement for individuals to acknowledge they are not in control of everything. This involves the concept of a higher power. Many people worry this requires formal religion. However, the definition is very flexible. A higher power can be nature, the universe, or even the collective group. Keith explains that this makes the program spiritual rather than religious. In a religion, core beliefs are non negotiable. In AA, the steps are described as suggestions.

The 12 steps are but suggestions. In a religion, beliefs are non negotiable. In AA, everything is negotiable other than what you believe. It is what you do that matters. Go to meetings and stay sober. The God in AA can be anything. It could be Buddha, it could be Jesus, or it could be the doorknob. It just cannot be you.

This focus on a higher power aims to break the narcissism and ego that often accompany addiction. The critical point is for the person to admit they have lost control. Additionally, Keith clarifies that AA is not a cult. Cults typically take money from members and prevent them from leaving. AA does neither. The organization is often broke by design and individuals are free to walk out of any meeting at any time. The founders understood the balance of narcissism and shame in addiction, and their work changed the country.

Open Alcoholics Anonymous meetings allow the public to observe the recovery process firsthand. Visitors can participate as much or as little as they like, often just identifying themselves and stating they are there to learn. This transparency is particularly helpful for friends and family members who want to understand the program before encouraging a loved one to join.

Sometimes it's easier to get someone to go to 12 step if you yourself have gone. And if you're not an addict and you want someone to go saying, I went and I'll go with you.

The 12-step model is a unique and highly effective invention because it is entirely free and accessible at all times. It offers a rare resource that requires no financial investment while providing significant community support. This accessibility makes it one of the most efficient tools available in the field of public health.

It is the closest thing we have to a free lunch in public health.

GLP-1 peptides are revolutionizing weight loss by addressing the biological drive for overconsumption. These drugs prove that weight loss follows the laws of thermodynamics. If you eat less than you burn, you lose weight. GLP-1s make it significantly easier for people to maintain that balance by quieting the constant desire for food. Some people use compounding pharmacies to lower costs or share doses to achieve results. While weight loss is the primary focus, many users find it helpful to pair the medication with resistance training to prevent muscle loss.

Keith expresses deep interest in how these drugs might treat substance use disorders. He shares that addiction patients often describe their goal as wanting not to want. They wish to remove the intense desire for a substance rather than simply trying to overpower it with willpower. A friend of Keith's on GLP-1s explained the shift in mental effort.

I used to spend all day not eating, and now I don't think about it. It was effortful all day long. Don't eat, don't eat, don't eat. And now that voice is just gone.

This reduction in food noise could potentially translate to reducing the urge for drugs like cocaine or alcohol. Research into alcohol use shows promise, particularly because drinking is behaviorally similar to eating. Keith is working with organizations like the VA to study these effects further. Many patients are highly motivated to take the medication for weight loss, which then provides a secondary benefit of reducing their alcohol consumption. Because these drugs have existed for nearly 20 years, they have a long safety record that makes them a promising tool for future addiction treatment.

While some people associate sugar or carb cravings with a desire for alcohol, Keith suggests this is likely not the primary driver of addiction. Instead, the fundamental drive comes from the subjective effect of the substance itself. This desire for quick fixes is often fueled by the unique media environment in the United States. Only two countries, the United States and New Zealand, allow constant pharmaceutical advertisements on television. Keith points out that these ads create a misleading sense that every health problem is perfectible if a patient simply pushes their doctor hard enough for a specific prescription.

I think it can create a sense that everything is perfectible if you just bully your doctor enough. And that is just not the truth. So that is the downside to worry about them.

This history of over-promotion was a major factor in the opioid crisis. While Keith emphasizes that opioids are essential for hospice care and pain management, the lack of separation between the industry and medical institutions led to widespread issues. Today, a similar concern exists regarding digital addictions, such as social media, gaming, and gambling apps. Keith notes that social media has become a social trap. Many young people feel they must be on these platforms simply because their peers are there, even if they realize the apps are harmful to their mental health.

I will quote a perceptive Stanford freshman who said to me, I hate social media. I think it is bad for my mental health but I have to be on it because everybody else is. And that is really tragic.

Because these digital platforms are relatively new, it is still unclear if people will mature out of these behaviors. For example, many college students drink heavily but eventually reduce their consumption as they enter adulthood and take on more responsibilities. It remains to be seen if social media addiction follows a similar developmental path or if it creates a more permanent shift in how people interact.

The maturing out effect for social media remains an open question for younger generations. People who grew up with smartphones from a young age may find it harder to disconnect as they enter adulthood compared to those who lived without them for decades. Keith shares his method of using a physical lockbox for his phone to curb the impulse to check social media. This simple tool helps recover time for work and relationships by removing the immediate opportunity to look at the device.

I finally upgraded my phone and I took my old phone and I put X and Instagram on that phone. It remains much of the time in a supermax prison lockbox that you can't code out of. It is very helpful because once it's locked away and there's no opportunity to look at it, the impulse to pick it up is blocked.

Society needs to develop social norms around digital usage similar to those for alcohol. Just as most people agree not to drink before noon or drink and drive, we should establish rules like keeping phones away from the dinner table. This problem cannot be solved by clinical medicine alone. It requires collective habits that make sense for a generation raised with these technologies.

There are many successful ways to escape the vortex of digital addiction. Some young men who struggle with a failure to launch have found success by quitting video games and YouTube for long periods. This allows them to recapture their attentional capabilities and their sense of agency. Whether it is quitting smoking after becoming a parent or healing from drug use during a period of forced abstinence, the brain needs time away from the stimulus to recover.

Building some norms about social media is going to be the task of this generation that has grown up with them. Just like we've built a lot of norms around alcohol. We've built norms like don't drink and drive. That's one that most people now broadly find believable.

Many people find it surprising that most individuals who successfully overcome substance problems do not use formal treatment pathways like psychiatry or specialized clinics. People change for many reasons and through various methods. One common way is finding a replacement behavior. For example, a person might trade an alcohol or cannabis habit for a dedicated fitness routine. This shift can lead to profound improvements in parenting, professional success, and self-worth.

Genes are risk, they're not destiny. And that's very important. Even if you come from 100 generations worth, that doesn't mean that your life is necessarily going to come out that way.

Keith explains that it is possible to break a generational cycle of addiction in just one generation. As recovery progresses, individuals begin to accumulate more reasons to stay sober that they did not have at the start. These include earning professional respect, enjoying a steady income, and being mentally present for loved ones. Over time, these positive reinforcements make it easier to maintain a healthy lifestyle.

Intellectual people often struggle with 12-step programs because they tend to overthink the process. While some people can simply follow the steps without question, others try to analyze the strategy or critique the philosophy. AA is designed as an action program rather than an analytical one. It focuses on simple behaviors like attending meetings and staying sober. If a person dislikes that approach, they might find the program frustrating at first.

Your best thinking got you here. Another one is keep it simple. You don't have to do a philosophical critique of the 12 steps. You just have to don't drink and go to meetings. It is an action program.

Keith notes that AA is not a single, uniform experience. Meetings vary significantly depending on the location and the people attending. One meeting might involve people with jailhouse tattoos at a gas station, while another might feature professionals discussing deep philosophy. The key is to find a group that feels right. Keith compares this process to dating. A person should not give up after one bad meeting. It is better to try different groups at different times until they find their community.

The program also relies heavily on storytelling. The Big Book was originally printed on cheap, thick paper, which is why it earned its name. It is filled with stories rather than just instructions. These stories allow people to see themselves in others. When someone hears a story that mirrors their own life, it creates hope that they can also reach a better place.

This book is mostly stories. And we tell stories in the hopes that something in them will catch you and say, gosh, that life is like mine, and look where he or she is. Boy, I wish I were there. Well, they're kind of like me and they got to that good spot. Maybe I can get to that good spot.

Keith worked as a hospice counselor for ten years and found it to be a beautiful and upbeat experience. While many people assume hospice work is depressing, the staff members are often the most optimistic and compassionate people. This is because the reality of death is fully accepted from the start. Since the worst case scenario is already acknowledged, the focus shifts entirely to helping a person and their family have a good death and a meaningful grief experience.

We have accepted the worst, right? And so then we can just do well and help this person have a good death and help their family have a good death and work through their grief experience. And so they are just very upbeat. I never found it depressing at all.

Keith entered hospice care specifically because he was afraid of death. He believes that running away from things makes them scarier, while exposure reduces fear. Working in people's homes provided an intimate look into their lives, from seeing their old wedding photos to hearing about their high school sports achievements. There is a profound honor in being the last friend someone ever makes, and being present for that transition eventually took away his fear. He was then able to radiate that sense of acceptance to families who were struggling with the process.

Being the last friend somebody ever makes is an incredible honor. And I always felt that when I had to say goodbye, I had been honored by them in that way, the last friend they made. It was a profoundly moving experience, and it took away that fear.

In many advanced technological societies, death is hidden and denied, which creates a culture of terror around it. In contrast, in developing countries where death is more visible in daily life, people often exhibit less fear. To reach a place of peace with dying, it is necessary to move past social norms that hide it and instead choose to be with the dying. Acceptance comes from connection rather than avoidance.

Addiction can be viewed as an attempt to escape the fear of death. Humans have a unique ability to think into the future and plan for it. This same capacity makes us aware that we will eventually die. This realization is often terrifying and sad. The state of being high offers a sense of timelessness. It allows a person to feel as if they are operating outside the real world or possess superpowers in their own mind.

Keith Humphreys suggests that heavy substance use often stems from a desire for oblivion. People use drugs or alcohol to get away from unpleasant truths like death and suffering. This escape can also apply to specific traumas, such as childhood abuse or the disintegration of a marriage. Substance use provides a short-term shield against feelings of humiliation or pain.

Oftentimes there's something awful and frightening or humiliating or painful that this is the escape from. And they do provide that, at least in the short term. The high term costs are hard, but in the short, short term, everything could be falling down around you. And if you're high on a stimulant, you can still feel euphoria, at least for that brief moment.

The challenge of recovery is that stopping the substance does not make the underlying problems disappear. When someone stops using, they still face their mortality and their personal struggles. It is much harder to deal with these issues head on than to avoid them through intoxication. This reality can make it difficult for some people to commit to sobriety.

Across nearly every culture, men are the primary consumers of addictive substances and represent the majority of people struggling with addiction. For opioids, the ratio is about four men for every one woman. While the gap in alcohol use is narrowing as women drink more, it remains roughly 60 percent male. The only area where the gender split is closer to equal is with prescription medications.

Men are larger consumers of addictive substances in every culture on earth and are overrepresented in all the major addictions. Opioids probably four men to every one woman. Alcohol probably about 60, 40. It used to be higher, but women have been drinking more.

The connection between addiction and lying is usually practical rather than a matter of brain circuitry. Keith explains that people lie because they find themselves in situations that are impossible to explain honestly without revealing their addiction. For example, a parent might lie about car trouble instead of admitting they were too drunk to pick up their child. In other cases, the way doctors or other professionals ask questions can force a lie. When a professional makes it clear what the correct answer should be, someone with an addiction will often lie to avoid a negative reaction.

When you're addicted, you get very good at reading people. Like, what is this person going to say if I tell them that I use methamphetamine? And sometimes they lie, not because they want to, but because they know they'll get a negative reaction from the person.

Relapse can occur during both high and low points in a person's life. While it is common to associate relapse with failure, success can also be a significant trigger. When things are going well and someone feels they have finally overcome their struggles, they may let their guard down. Keith recalls a friend's father who secured a high-paying job after years of drinking, only to relapse immediately and die in a car accident.

I got money in my pocket, I am happy, I know I am okay now, the problem is behind me. And so I am going to do what I always did and then be shocked that I got the same result I always did.

Broadly speaking, stress remains the most likely cause of relapse. This includes short-term issues like a lack of sleep or a simple argument with a spouse. It also includes larger life challenges, such as dealing with a child who is also struggling with addiction. Whether the stress is minor or major, it increases the risk of returning to old patterns.

Parents often struggle with how to discuss addiction with their children, especially when those children are in college. Keith Humphreys emphasizes the danger of fentanyl, which often appears in the form of counterfeit pills. These printed tablets look identical to common medications like Adderall or Ativan. Because many students are dying from these look-alikes, the safest rule is to never take a pill that was not personally acquired from a legitimate source.

I talk to them a lot about fentanyl because I've known so many families where kids like them have died from fentanyl that they took in the form that it looked like something else. If you didn't personally acquire it, you can't know what it is.

The most powerful moment of choice regarding addiction happens before the first use. While individuals can make their own decisions about substances, the only guaranteed way to avoid addiction is to choose never to start. This represents the maximal point of control. Once a person begins using a substance, the outcome becomes unpredictable for everyone involved.

The only thing I can tell you is you will never get addicted to something that you choose never to use. That is your maximal point of control. And what happens after that point is something I can't know. More importantly, something you can't know.