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March 4, 2019 - Making Sense - Sam Harris

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#149 — The Problem of Addiction

Sam Harris speaks with Sally Satel about addiction. They discuss whether addiction should be considered a disease, the opiate epidemic in the U.S., the unique danger of fentanyl, the politicization of medicine, PTSD, and other topics. If the Making Sense podcast logo in your player is BLACK, you can SUBSCRIBE to gain access to all full-length episodes at samharris.org/subscribe.

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	Welcome to the Making Sense Podcast.
	This is Sam Harris.
	Just a note to say that if you're hearing this, you are not currently on our subscriber feed and will only be hearing the first part of this conversation.
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	Welcome to the Making Sense Podcast.
	This is Sam Harris.
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	Today I'm speaking with Sally Satel.
	Sally is a practicing psychiatrist and lecturer at the Yale School of Medicine.
	She's an expert on addiction, and she focuses on mental health policy as well as political trends in medicine and psychiatry.
	And her most recent book is Brainwashed, The Seductive Appeal of Mindless Neuroscience, which she wrote with Scott Lilienfeld.
	Anyway, we talk about addiction.
	We discuss the opiate epidemic and the significance of fentanyl.
	We talk about PTSD.
	We cover the intrusion of politics into medicine.
	We also talk about the ethics of organ markets, the buying and selling of organs.
	Anyway, fascinating conversation.
	This is one that I hope will be of practical use to anyone who either has suffered from addiction or knows someone suffering.
	There were a few connection and latency issues that you'll hear, but nothing too terrible.
	This is what happens when you do these interviews remotely.
	In any case, I hope you enjoy the conversation as much as I did.
	And now I bring you Sally Sattel.
	So, so Sally, so you were recommended to me by our mutual friend, Steve Pinker.
	It was a fulsome recommendation of your expertise on many topics that we're going to touch, and here you are.
	So thanks for coming on the podcast.
	Oh, well, thank you, and thanks to Steve Pinker.
	Obviously a great fan of his, and yours.
	I'm a longtime podcast listener.
	So you were reminding me, we met at one of those Beyond Belief conferences at the Salk Institute back in 2006 or so?
	Yeah, I think it was more like 2009.
	It was quite a while ago, and it was very interesting.
	I think I was writing a book at that time with Scott Lilienfeld on the promise and peril of neuroscience in the public square, so that was a very important meeting for me, actually.
	I learned about a lot of people's work there, and I was familiar with yours when I heard your talk, and I remember I spoke on Since I'm a clinician, I'm a psychiatrist, so I try to stick with clinical matters and see most things through that lens, you know, how brain science, how junk science all refracts through a clinical lens.
	So I spoke about post-traumatic stress disorder and how it is both I was both a product of brain and mind, in other words, mechanism, which is brain function, and meaning.
	And that in my field, I think we've tended to be a little reductionist about it and see it largely through the lens of of anxiety, of a fear response that hasn't extinguished after the stressor has gone away, which is to me the essence of, you know, of continuing fear.
	And that's very highly legitimate, and of course one of the best therapies is exposure therapy, which touches on that mechanism.
	But there is so much more to post-traumatic stress disorder in terms of what keeps it alive for people, and that often has to do with meaning.
	So that was my question.
	Yeah, I want to talk about that.
	I mean, there are many intersecting issues here with addiction and the opioid epidemic and PTSD, and so I want to dive into all that.
	But first, more generally, how do you view your work as a psychiatrist, because you're sort of at the nexus of clinical work on these various fronts, but also you comment on the politicization of science and medicine, and you have been, there's kind of a To some degree, a culture war component to what you've been doing.
	How do you summarize your approach to psychiatry?
	Well, very much there is a culture war component.
	In fact, I wrote a book back in 2001 called PCMD, How Political Correctness is Corrupting Medicine.
	And then I collaborated with Kristina Hoff Sommers in 2005 on a book called One Nation Under Therapy.
	And both of those books had a very thick thread of politicized science, or even junk medicine.
	And in fact, in a way, the critiques often came down to explanatory reductionism.
	And as an addiction psychiatrist, that's my main field.
	And I do work part-time in a methadone clinic.
	I've done that for about 20 years.
	And this year, I'm actually spending the year in a small town in Ohio trying to understand the, I even call it an addiction epidemic at this point, not just an opioid epidemic.
	in a small town compared to an urban area.
	And there are lots of interesting differences we can talk about.
	But the overarching, I guess, almost everything I've written has to do with some sort of perversion of the data or some sort of questionable interpretation.
	And so I would just give you an example.
	Take, for example, post-traumatic stress disorder, since I brought that up.
	A reductionist approach, not an incorrect one, but just one explanatory level, would be at the level of the amygdala, at the level of neuroscience.
	And I'm not saying it's illegitimate at all.
	It's very real.
	It's very true.
	But it's just one level.
	And when you reduce things to one level, we do that in addiction as well.
	Now, the dominant view of addiction is that it's a brain disease.
	And anytime you reduce things to one level, it's obviously a precursor to oversimplification.
	And when you're in the clinical world and policy world, that's usually a recipe for a bad policy.
	And it's also a recipe for politicization because it can foster a victim narrative.
	Because if there's a certain level of explanation that can be traced back to a perpetrator, then it becomes a victim narrative.
	And anytime, again, there's someone to blame.
	And in the case of the opioid crisis, there's been much focus on, of course, the pharmaceutical companies.
	And I do think they bear some responsibility, don't get me wrong, but it also very much fits into litigation.
	But of course, as a clinician, I'm most concerned with how it may undermine the best kind of care.
	So pretty much everything I've written about, yeah, it goes to these kinds of oversimplifications and what's being left out.
	Now we have to be more nuanced.
	Right.
	So let's start with addiction because it is obviously an enormous problem and many people listening to this podcast will either have some first-hand experience with it themselves or know somebody suffering with some version of it.
	What should we understand about addiction at this point?
	I should reference another podcast I did, which, I don't know, you may have heard.
	Do you know Johan Hari, the journalist?
	So he's written a couple of books, one on the war on drugs and addiction, Chasing the Scream, and the other on depression.
	Yeah, Lost Connections, yeah.
	He came on the podcast and he's a great speaker and a very interesting guy, but he's taken a line through both of those topics that seems to de-emphasize the role of biochemistry and the disease model, certainly, of addiction, and puts the blame far more on the lack of meaning and lack of connectedness that someone may experience in their life.
	He draws a lot of motivation from a few experiments.
	One is famously described as the Rat Park experiment, which you probably know about.
	So, in the aftermath of that podcast, I received some angry pushback from people who, you know, didn't like that line at all.
	And I mean, in Johan's defense, he doesn't actually discount the role of biochemistry, but if you get him talking, he can certainly seem to.
	My one question off the top is, is there much daylight between your view of addiction and the one he's putting forward?
	And whatever your view is, what do you think people should understand at this moment about addiction?
	Yeah, I think there's a little daylight.
	I agree with you.
	I think one could walk away from his Excellent work.
	I admire him very much.
	But you could walk away from that with perhaps an undue emphasis on the cultural, social, or psychological dimensions.
	However, I think that my profession or the addiction field has over-medicalized addiction.
	And I don't say that as someone who is not in thrall to the technology of brain imaging, but I think we have over-medicalized it to the point where we put too much emphasis on the, I'll call them anti-addiction medications, people call it MAT, and I'm referring there to methadone, buprenorphine,
	And then there's another medication, naltrexone, which is an opioid blocker.
	These are all excellent medications, and I use them every day.
	I mean, I prescribe them.
	And occasionally, there is a patient who gets on methadone, and I would say he would fit the classic medical model, which is to say that addiction is something almost imposed on you.
	Even we call it a person with substance use disorder.
	And I realize in medicine, we have to we have to give things shorthand names.
	But I even cringe sometimes when I hear that, because it makes it sound as if it's something that happened to you.
	And addiction is a very intricate and deeply personal kind of affliction.
	So, for example, basically I see things on a large spectrum.
	And as a clinician, you take people as individuals.
	But occasionally I'll see a person who says, all I need is the methadone and I'll be fine.
	Usually that's not the case.
	They're on the methadone.
	So what does that mean?
	Methadone, of course, is an opioid replacement.
	It's a synthetic opioid.
	Actually, can you remind people, why is the transition from heroin or another opiate to methadone advantageous at all?
	Why is it given as a treatment?
	Well, if one is abruptly withdrawn or one loses supply to opioids and they've been on it chronically and on a substantial dose for a while, even though some people Low doses can even precipitate withdrawal when they stop it abruptly.
	And that's basically just your body, which is already adapted.
	There's been neuroadaptation to the chronic exposure, and so there's a withdrawal syndrome.
	And it can be very intense, extremely intense.
	To the point where some people will continue using drugs just to avert the withdrawal.
	People feel extremely ill.
	It's been called the worst flu you've ever had.
	Nausea, vomiting, shakes.
	It lasts about 72 hours at its worst, and then it's over in about a week.
	Some people have documented what's called a protracted withdrawal syndrome, which is sort of a low-grade withdrawal, which could go on even for months.
	And so it's highly destabilizing, and you can't break the cycle.
	A lot of people can't break the cycle on their own.
	I should add, many people do, and clinicians don't see them.
	But the folks we see, obviously, have a very hard time stopping drugs on their own.
	So, to suppress the withdrawal symptom, there's this replacement opioid.
	It's called methadone.
	And buprenorphine, which is a partial agonist, methadone is a full agonist of the mu receptor, will suppress the withdrawal.
	And it also suppresses craving.
	So, as you can imagine, that's an excellent way to break the cycle and stabilize someone.
	For most people, it's not enough.
	It's necessary, but it's far from sufficient.
	They have so much repair work to do.
	Not only do they have to repair all the damage to their life that was done while they were addicted, you know, all the bridges they've burned, all the relationships they've destroyed, all the jobs they may have lost, the reputation, the health.
	There is also the problem of what predisposed them to using in the first place.
	And this is where I'm very much with Johan in saying that most, but not all, but most people I've treated, most addiction memoirs, well, all addiction memoirs I've read, talk to a kind of psychic, profound psychic distress.
	It often takes the form of self-loathing is one of the most prominent themes, but other people want to repress painful memories.
	Some people, I think, just should have been on a better dose of Prozac or something else because they're using it to deal with anxiety and depression.
	And sometimes a conventional medication can be what they need, but other times it's a more existential kind of lostness.
	And these drugs really help.
	They really do.
	And sometimes they're a very good You know, they're just a good numbing agent.
	In fact, I refer to them as oblivions.
	I mean, you've heard of stimulants and depressants, and I have a new class called oblivions, and that's what, in fact, that's what morphine is, right?
	It's Morpheus, I mean, from the god of Morpheus, who lived by the river, I'm going to mispronounce this because I'm not a Greek scholar, but Lethe, and that's the river of oblivion.
	So, and these drugs, of course, have a profound history.
	So, that's what replacement opioids do, and that's huge, but it's rarely enough.
	Now, occasionally, there's a person for whom it is enough.
	This is a person, let's say, for whom the withdrawal was so, or the avoidance of withdrawal, was such a powerful engine for continued use that once you took care of, as a clinician, you know, once we basically treated the withdrawal, the person had enough social capital, enough Hadn't, you know, just had enough of a social network to be able to get back on his or her feet just with a medication.
	That happens to be rare in my experience, but it would happen.
	And in that case, I would say the person fit the medical model more snuggly.
	But in most cases, in fact, we think of addiction, or I say we because Scott Lilienfeld and I have written about this quite a bit.
	We think about it as operating on many different levels simultaneously, obviously on the neurobiological plane, but on the psychological one, on the behavioral one.
	It's incredible how important cues can be, how important conditioning is in perpetuating drug use and also in treating drug use because, of course, one of the first things you try to get patients to work on is identifying the kinds of situations, the kind of internal mood states, the kind of people they're around that get them craving.
	And that's a pure Pavlovian phenomenon.
	And that's part of cognitive behavioral therapy for addictions, to get people to recognize these things.
	And sometimes they're obvious.
	You don't drive by your dealer's house.
	I knew of a school teacher once who had to get a marker board as opposed to a chalkboard because the chalk dust reminded him of cocaine.
	Right, right.
	Wow.
	So what is the role of AA in kind of framing our beliefs around addiction?
	Because there's this model that specifically an alcoholic is somebody who is irretrievably suffering from a kind of disease,
	And once an alcoholic, always an alcoholic, you know, I actually don't have direct experience with AA or addiction, but, and so I may be getting it slightly wrong in terms of just how they place emphasis on this, but what's your view of the role AA has played in all of this, and in what sense is addiction a disease, and in what sense does that analogy break down?
	I actually don't consider AA the source of what I think is a problematic medicalization.
	I attribute that to the National Institute on Drug Abuse, and we can get back to that.
	But as far as AA is concerned, interestingly, in the early 30s, it did not use the word disease.
	But in any case, if you look at the 12 Steps, they do have a spiritual dimension to them.
	There's a big emphasis on the so-called moral inventory.
	Not moral as in you're a morally flawed person, or that addicts are morally flawed people, just that Is it just that in many cases, so many, I'll use their word, amends need to be made?
	And going back to, I suppose, what Johan would, where I agree with him, is that so much addiction flows from so much personal unhappiness that you want to also go back to the origins of why you even became addicted in the first place.
	So, I find AA, I personally have trouble with, you know, a higher power.
	I don't quite understand that, and I don't understand the surrender when in fact you're doing all the work.
	So that, because they have that in one of the steps, I surrender my will, I believe.
	In any case, there seem to be paradoxes, but the point is so many millions of people have found it useful.
	But as far as it being a disease, I mean, I think if you took a poll, the majority of Americans see it that way.
	And I try not to debate it.
	And I do make a different distinction between disease, which is somewhat metaphorical, and a brain disease, which reifies it much more as a physiological problem and a physiological problem almost only.
	But when people say to me, and I found this very interesting in this small town I'm working in in Ohio, that a few of the nurses and social workers have said to me, they kind of lower their voice because they know they're being a little politically incorrect here, but you know, do I really think, you're a psychiatrist, is addiction really a disease?
	And I like the fact that they asked me that question.
	Now, if there were some crusty old sheriff, you know, who just wanted to lock people up and didn't want his deputies to be administering naloxone, you know, the overdose reversal drug.
	And didn't want to be bothered with these folks.
	That would be a whole different discussion.
	And there I'd say, yes, it's a disease.
	Because my usual response to that question is, what are my choices?
	Because if my choice is that it's a moral failure or it's a sin, well then I'm going with disease.
	But I'd like to be able to be more nuanced about it.
	So, when I have these conversations, I'll just stipulate.
	For some people, it's very important to embrace that disease model.
	For others, less so.
	But I just say, so if addiction is a disease, then it's most important for us to say, well, what kind of disease is it?
	Because unlike One of the many slogans one hears lately, addiction is not a disease like any other.
	And that's important to know.
	And I'll get into that in a minute.
	But I would like to say that I acknowledge why the National Institute of Drug Abuse, which is responsible for this brain disease formulation, And so many other advocacy groups endorse that, that I do see the virtues in it.
	I understand that they were trying to, you know, wrest it out of the realm of criminal justice, and I'm all, of course, I endorse that.
	They wanted more funding for treatment and research, and those are completely laudable goals.
	They think it can erase stigma.
	I don't believe it can.
	And there's a lot of interesting research, some of it by Nick Haslam, who's an Australian cognitive behaviorist, and others, who have shown that the more you medicalize a behavior problem, actually the more you increase social The desire for social distance on the part of others, and the more it induces a sense of therapeutic nihilism.
	And there's also research showing that patients who endorse a disease model for themselves actually don't quite do as well, because there's a loss of self-efficacy that goes along with that.
	But again, these are studies, and as a clinician, you deal with everyone on a personal level.
	To be honest, Sam, it never comes up when you're treating someone.
	These concepts just never come up.
	You just deal with how do you put one foot in front of the other, and what are the skills you have to use to stay clean.
	And then at some point, people get enough sober time, absence time, Where they can start exploring, if they're interested, what are some of the kinds of problems that preceded their drug use in the first place because some of those vulnerabilities still exist and put them at risk.
	But we don't do, you know, classic depth psychotherapy.
	We're not getting into childhood traumas or primitive events because those are anxiety-provoking.
	And that's the last thing you want to do For a person whose habit has been to look for a drug when they feel anxious.
	So for many years of therapy, I'm not saying people have to be in therapy for many years, hopefully they internalize a lot of these skills for themselves, but the effort is very much pragmatic and I would say cognitive behaviorally based in terms of therapy therapy.
	And then in terms of rebuilding their lives, you know, again, vocationally getting their kids back if they've lost them, getting jobs back, regaining trust, establishing a healthy social network, these kinds of things.
	But that's interesting.
	So, classical talk therapy, you're saying, in this case, certainly in the acute stage after cessation of drug use, is counterproductive because just kind of endlessly taking an inventory of all of your past suffering that may or may not explain how you got here just produces the negative mental states that people want to self-medicate away from in the first place.
	Exactly.
	And some patients have said to me, well, you know, shouldn't I be talking about, because they see a psychiatrist and they have this, because most people in the addiction world are not treated by psychiatrists.
	They're treated by counselors or social workers, but I'm the psychiatrist.
	So they, you know, maybe they have Freudian images.
	I don't know.
	But, and they say, maybe I should be talking about my childhood.
	And then I explain just what I said to you.
	I explained to them and they say, you know, that makes a lot of sense.
	And I say, that's a luxury you'll have after you're stable for quite a while.
	If you still feel that's important to you, then you can pursue it.
	And luckily, they seem to accept that.
	And of course, they're free to go to someone else who will do that with them.
	Although I think most people who are sophisticated about working with people with drug problems would not do that kind of exploratory work in an early stage.
	Is it simply an empirical fact that people who cross some line into a clear substance abuse pattern can't then go back and, you know, let's take alcohol as the normal social lubricant Is it possible for someone to become a, quote, healthy social drinker after having had a problem with alcohol?
	Or is the AA model of once an alcoholic, always an alcoholic, a fair description of the pattern?
	No, I would not say that's fair, although it's very common.
	Certainly, it is probably not a good idea for someone who's had a severe alcohol problem to attempt moderate drinking.
	Presumably, they tried that along the way.
	However, there is a group, and it's I think it's legitimate.
	It's called moderation management, and it does have membership, and there certainly is a sub-population of individuals who can return to controlled drinking.
	As a clinician, by the time someone gets to a clinician, you have to remember there's so many layers at which people have peeled themselves off.
	I mean, let's take this situation of two people who go, they seem to be matched on almost every variable, and they're both curious about, like, what, let's say cocaine, because most people have, I suppose, experienced alcohol, but they're going to a party, and they know there's going to be cocaine there, and they both say, look, we'll make a pact, we'll both try it, see what it's like.
	And one of them tries it, and his reaction is, Eh.
	Which is actually most people's reaction the first time they try cocaine.
	And most people's reaction the first time they use heroin is they throw up.
	But the other friend tries it and says, oh my god, this is fantastic.
	Now that's very interesting.
	And that's why I think more biologically oriented folks stop.
	And frankly, you could build a whole career on figuring out, why are those reactions different?
	Because I think they're mediated, you know, through neurochemistry differently.
	But now here's another scenario where these two friends, two more friends, go to a party.
	They know there's going to be cocaine.
	One of them tries it and says, "Oh my God, this is fantastic.
	Give me more." And the other one says, "Oh my God, this is fantastic.
	Get it the hell away from me." And that's very interesting.
	So that's someone who peeled off at the very first step.
	Then you have people who peel off in terms of quitting use after they've used a few times and they came home late and their wife gives them a dirty look and says, "What have you been doing?" And they don't think, OK, I don't want to go down this road.
	Well, you can see where this is going.
	Then there are people who lose their job or about to lose their job and they think, wow, I better get it together.
	And then there are the people I see who, despite so many of these consequences, didn't quite get it together.
	Now, there's always one consequence that brings them in, and why that one and not the one before is the alchemy of addiction.
	I don't know why.
	There are too many variables.
	Because everyone who's walked into our clinic practically is there because a spouse is going to leave them, a boss is going to fire them, or a probation officer is going to violate them.
	And that goes to one of the reasons why I find the brain disease formulation, which privileges so much the neurobiological level, why I find it problematic.
	Because it takes our eye off several other levels of explanation.
	One of them being that addiction is a behavior that responds to consequences.
	It responds to sanctions and incentives.
	And so, if you read the early papers, in fact, the brain disease was officially unveiled in 1997 in an article in Science.
	The definition why it was a brain disease is, I kid you not, because addiction changes the brain.
	Well, this conversation changes the brain, so that's absurd.
	But you could then more generously say, well, okay, in what way does it change the brain?
	Does it change the brain in which people have no choice but to use or but to continue to use?
	And we know that's true just because of what I told you.
	Because there's an enormous literature on contingency management.
	Which is how you manipulate the incentives and sanctions to help people stop.
	And one of the most fascinating... I'd say if I had to sum up all of addiction science in one vignette, it would be the Vietnam veterans experience, which I'll tell you.
	This was 1971, and I remember the New York Times in the spring of 71 ...reported on the Department of Defense research on all the veterans, all the GIs in Vietnam that were addicted.
	Addicted!
	Not just using, but addicted to opium and heroin and really good high-grade Southeast Asian stuff.
	And that's no surprise, in a way, because what is war?
	It's terror and boredom.
	And what are drugs good for?
	Terror and boredom.
	Plus, this was towards the end of the war, and there was so much demoralization and such a sense of betrayal by so many that there was just a simmering rage that a lot of these men had.
	So drugs worked for that.
	Drugs were totally normalized in the military at that point, in Vietnam.
	They were abundant, so every possible variable that lowers the threshold for using a drug was there.
	They had access, it was normalized, it was good quality, and they had a reason for using it.
	Well, Nixon was terrified, and there was already a heroin problem in the urban centers, and he was afraid that these men would come back and just seed that population even further of heroin users.
	So he instituted a program which just has the best name in the world, Operation Golden Flow.
	And as you might guess, basically it said, you know, for those of you whose year is up, whose tour of duty is up, you will not be allowed back in the States until you pee in a cup and there's nothing in it but your pee.
	And actually, once they were told this, the folks who were, you know, about to leave, the vast majority of them were able to stop using on their own.
	They did offer some treatment in Vietnam for those who had more trouble, and then they left.
	Now, these G.I.—well, now veterans—were followed by Lee Robbins of Washington University, who wrote a paper in which she said, this has blown—the title of it, or the subtitle, was something like, the date I'm about to present now blows out of the water this once addicted, always addicted meme.
	And what she found following these guys for three years was that very few of them resumed use of heroin, 12% over a three-year period.
	The majority of those who resumed use had a prior use, in other words, a use that predated their deployment.
	And that the reason, and she interviewed many of them, a subset, And they said, well, you know, we had lives to live now.
	We're back in the States.
	We have families.
	We have responsibilities.
	If we wanted to continue to use heroin, we'd have to go into these terrible neighborhoods.
	Now it's easier.
	People will deliver.
	But, you know, and of course it was totally stigmatized.
	And that, to me, is the full spectrum of so many of the dynamics that are involved with addiction.
	Yeah, well the context clearly matters to a remarkable degree.
	What do we know, though, about the behavioral genetics here?
	I mean, is it well understood that there is a gene or genes that govern a person's susceptibility to falling into addiction regardless of context?
	I'm not a behavioral geneticist, but I'm going to say that whenever you're in the realm of behavior in humans, it's rare that one gene is responsible.
	Most things in psychiatry are highly polygenic, but I have no doubt that there are some people whose circuitry It's genetically built so that their reward system is more sensitive, that their locus coeruleus is much more attuned to the withdrawal phenomenon so that it's much less tolerable.
	That we have impulse.
	Of course, there's the issue of impulse control.
	I mean, one becomes a highly steep discounter in the course of being an addict.
	Some people are steep discounters before they become one, and that probably predisposes them.
	But it's usually a combination of many, many, many things.
	We know that, you know, so-called adverse childhood experiences predispose, but they're all predisposing.
	And one could argue, for example, that if everyone in your family were an alcoholic, to the extent that anyone might use that as a justification for why they became an alcoholic, one could just as easily say, well, you saw what it was like, you know, then it was your Job to not drink at all, something like that.
	So that can also go both ways.
	Right.
	So on the spectrum of difficulty in kicking an addiction, where do these various drugs and substances lie?
	I mean, can you generalize about how hard it is to get off of heroin versus the pharmaceutical opioids that people are having problems with now versus alcohol and anything else?
	Well, as far as opioids, a lot of this is obviously dose-dependent and often root-of-administration-dependent.
	But conceivably, it could be as hard to get off prescription opioids, especially if you've crushed them up and snorted or injected them as heroin.
	There should be probably no difference.
	Interestingly, nicotine is considered the most addictive drug, but that is highly conflated with the fact that smoking itself as a behavior is highly addictive, arguably more so than nicotine itself.
	The ritual of it and the social aspect of it.
	Yes, the social aspect of it.
	But also the fact that there's talk about context.
	Of course, it's hard to, of course, the uptake, it's called capture.
	The capture rate for nicotine is about one in four.
	In other words, if you start smoking with some regularity, probably continue to smoke with regularity, whereas with heroin and other drugs, it's more like, you know, one in 10.
	Why would that be?
	Why would it be?
	It looks like when you hear a capture rate as one in four, you think, wow, that must be highly addictive.
	But think about the context.
	Nicotine is legal.
	I mean, in the forum of cigarettes, nicotine is ubiquitous.
	Admittedly, cigarettes are much more maligned, you know, nowadays and for good reason than they were, but still.
	And nicotine, and this perhaps is one of the most important It's not an intoxicant.
	It doesn't affect your performance.
	If anything, it might enhance it in some ways, so that the consequences for smoking are so much less and so much less immediate.
	And that's very important, too, because of course you can get lung cancer and devastating diseases, but they're so delayed, whereas the consequences for intoxicants come much sooner So all these play in to the fact that someone would sustain their use, but that's over and above the base addictiveness of nicotine itself.
	And that's also why cigarettes are so hard to quit.
	And that's been misconstrued as nicotine being one of the most addictive drugs in the world, but that's not true.
	And where does marijuana fit in here?
	Is there an addictive component to it, or is there some other category of compulsive use that shouldn't be categorized as addiction?
	Actually, the physical addiction, the physical withdrawal that I explained before that you get from opioids, that you would get from alcohol, and you would get from barbiturates, you would get from benzodiazepines like Xanax or withdrawal, those were considered the hallmark of withdrawal.
	But ever since cocaine, ever since the 80s, that's been downplayed as an indicator of addiction because cocaine and the stimulants don't have that kind of physiological picture.
	I mean, they have their own discontinuation syndrome, there's no question.
	But, so some drugs have that and some drugs don't.
	I have to say I'm not that expert in marijuana.
	I do know that because the potency is so much greater now than it was when, I'm sure we were maybe a little older than you, but I think we were both, you know, when we were in college.
	We probably had the same marijuana though.
	Yeah.
	So much of this, back to the concept of capture.
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