Ep. 47 - Why Quitting Drugs Isn't as Simple as Giving Up Scallops

Dr. Andrew Rosen and Dr. David Gross have spent decades sitting across from people who genuinely want to stop using drugs or alcohol and simply can't. This conversation gets into why that happens, and why willpower has far less to do with it than most people think.

A specific region deep in the brain called the nucleus accumbens gets reprogrammed by repeated drug use, eventually overpowering the logical, planning part of the brain. That's not a metaphor. It's why someone can leave the emergency room after a cocaine-induced cardiac arrest and stop to buy more on the way home.

They walk through what addiction actually means, including the difference between physical dependence and the full picture of compulsive use that derails jobs, relationships, and daily life. There's also a genetic piece that often goes unacknowledged, along with the emotional piece, that quiet feeling that something is missing, which drugs and alcohol can temporarily fill in ways that get remembered.

The conversation also gets honest about what rehab programs often miss. Treating the substance abuse without addressing the underlying anxiety, depression, or other psychological struggles is one of the reasons so many people cycle in and out of treatment. The long-standing tension in 12-step communities around psychiatric medication comes up too, and how that's slowly shifting.

They close on something worth sitting with. The cultural normalization of gummies, edibles, and now psychedelics is convincing a lot of people that certain substances are simply not a problem. Two clinicians who've watched families fall apart over exactly that kind of thinking aren't so sure.

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Email: twoshrinksandamic@gmail.com

Transcript

SPEAKER_00 0:04

Hi, I'm Dr. Andrew Rosen. I'm a psychologist.

SPEAKER_01 0:08

And I'm Dr. David Gross, and I'm a psychiatrist, and we are at Two Shrinks and a Mike. Today we're going to uh talk about a huge topic that has been problematic for a long time, and that's a topic of drug abuse, drug addiction, um, uh going from uh the nature of the problem to people's attitudes about drugs to the whole marijuana issue, which is certainly controversial. And um, you know, as a practicing psychiatrist, and I know that Andy is uh as a practiced psychologist, it's an issue that we deal with all the time. And and how uh on ongoing substance abuse, drug abuse just complicates uh our ability to practice uh because of the impact upon uh the brain, ment the the mental state, uh impact upon family and loved ones, impact upon jobs, school. It's a whole wide spectrum of uh negative problems from drug abuse and uh uh it's it's it's a tough, tough problem to solve. And uh I know that you've you've seen your share of individuals for drug abuse.

SPEAKER_00 1:12

Absolutely. When I came to practice in Florida in early 1980s, I actually joined a practice that specialized in addictionology. And uh majority of the patients were either alcoholic or drug addicted. And it's then that I learned a tremendous amount about the whole process of drug abuse and drug addiction, but also the interface between that and psychiatric problems. They don't always come together, but uh most of the time they do. One sometimes it's the drug problem or alcohol problem that causes the psychiatric problem, and sometimes the psychiatric problems lead to the drug and alcohol abuse. So it's really important for us as clinicians to always be mindful of that issue when somebody comes in for something as basic as, oh, I'm anxious, we always have to look at the picture of how much drinking, how much drugs, because lots of times patients, especially if it's at a level where they don't consider it to be a problem, we'll rarely talk about it. So we always look at that when we first meet somebody. How much drinking and how much drugging do you do? And if so, that has to be the first thing we look at in terms of helping somebody make progress. And it ain't easy, it's very complicated.

SPEAKER_01 2:37

Because the psychological reactions an individual has to drug use, especially if it's uh fairly regular, uh, is denial and avoidance. They're able very successfully to fool family members of professionals like ourselves. Because we we we rely upon what we call a subjective report, you know, what an individual uh tells us, and and oftentimes it's uh it's it's uh obscured by their denial of the nature of the problem, or I can I can stop tomorrow, it's not a problem. You know, I stopped uh one day last week from drinking alcohol and I was fine. So this is not a real alcohol addiction. Um and so that's a big issue. And and that's where uh s finding information for family members can become very important, uh and also getting an understanding of the uh trajectory in their lives. I mean, if somebody comes in and they've said, you know, I've uh lost my third job in in the last five years, you have to become suspicious of uh an ideology like drug use uh getting in the way, the uh not being able to get to work on time, making mistakes at work because of the effect of the drugs. The early days of of uh of of uh drug addiction studies, um because the science of the brain was not fully established, uh uh substance abuse drug addiction was viewed as a social problem. And and it's just a matter of uh dealing with free will and controlling it. And and uh uh that influenced to a certain degree the origins of AA. Um I I view AA as invaluable and very important, but the the idea of uh substance abuse being a social problem uh and a society problem um colored uh the a lot of the development of AA itself. As our understanding of the brain progressed and we began to find ways of actually studying the brain, we now understand that um most drugs, um whether it be uh cocaine, opiates, heroin, marijuana, alcohol, food, nicotine, um, all influence the same part of the brain. And it's been isolated uh to become the to be called the uh nucleosuccumbens, which is a deep area of the brain um involved in pleasure response. But uh it it it we now know that most substances actually reprogram that part of the brain. That's why it's so hard to stop some drugs. You know, that's why it's hard for individuals who are food addicts to stop the addiction, because that same part of the brain uh controls uh judgment and uh and under and better willpower and uh and logic and allows you to get back to continuing to eat uh excessively or use alcohol excessively or any other drug. And that part of the brain, um uh, as I said, is hijacked and actually controls the part of the brain that uses logic and and and and planning and and has the ability to say just stop, and that's the frontal lobe. But that uh nucleus occumbens is so powerful that it overwhelms the frontal lobe's action and takes over. Um and so the that that aspect of of of our understanding of drug addiction has changed the notion that it's not really a a primary social problem, and it has secondary social effects upon family and job and friends, et cetera. But it's uh it becomes a core biological brain problem when it's used excessively.

SPEAKER_00 6:03

Two great examples that I uh learned about. Uh one is uh something called the scallop test. And I'll tell you what the scallop test is. So uh it's a made-up example, but a guy goes to the doctor, his general physician, says, Doc, you have to help me. He said, My life is falling apart. I feel bad most of the time. I'm not sleeping well, I feel sick, my decision making is horrible. My wife's threatening to leave me. I'm just about losing my job, everything's falling apart. I don't know what's wrong with me. You have to help me, doc. So the doctor says, Well, let me do this. Let's give you a physical exam. I'll take some blood, and you come back next week and we'll figure out what happened, what's wrong. Great. So he does that. A week later he comes back to the doctor and he said, Doctor, did you figure out what's wrong with me? And the doctor said, Well, yeah, I did. You know, you wrote down on your intake form that you uh like to eat scallops and you eat a lot of scallops. And it turns out that you have some type of allergy to scallops, so much so because you eat so much of it, too, that it's affecting your brain, it's affecting your liver and just about every organ system in your body. But the good news is if you stop eating scallops over a period of months, you will return to normal. You'll uh everything will get better, your brain, your liver, your decision making, you'll feel healthy, and life will become normal again. You just can't eat scallops. So the patient says, Oh my god, doctor, you're a genius. You know, I I love scallops, but if you tell me no scallops anymore, we'll get my life back and everything will be well, I will never ever have another scallop again. So as the patient's about to leave, the doctor says, Well, just one thing. I everything I told you is accurate except for one thing. It's not scallops that's the problem, it's alcohol. You just have to give up alcohol and everything will be fine. So the patient takes a minute and looks at the doctor and says, Well, Doc, scallops is one thing, but I don't know if I want to give up alcohol. And that's the scallop test. A person, when they hear, oh, your problem is alcohol, or oh, your problem is drugs, should be able to treat it just like scallops. I'll never do them again. But drugs and alcohol is a different story. And that's why, Dave, what you're saying is the decision making is not ruled by logic at that point. It's ruled by this other little area of the brain that makes people do things that are inaccurate and bad. Another example was a guy who uh I saw when I first came down here. He was addicted to cocaine, he was abusing it, but he had now uh six months where he wasn't using any drugs. And all of a sudden I get a call from his wife that he was in the emergency room at Brower General, he had relapsed and actually had cardiac arrest. But he learned his lesson, he said on the phone, he said, I know I this is it, I'll never do that again. I promise. So we made an appointment for the following, I think, four days later. On the way home from the hospital, guess where he stopped to buy some more cocaine. The brain doesn't have that free will sometimes to stop these kinds of processes, and that's the problem with alcohol and drugs, especially when it's disguised as being normal and nice, like, well, it's just a gummy. I just do gummies as if because it's a gummy instead of something else, it's benign. So we're fooled.

SPEAKER_01 9:33

You know, the combination of of uh the biology of addiction involving that area of the brain and the potent psychological mechanisms of rationale rationalization and denial together make it so different, difficult. Um I'm not suggesting that um just because you use uh uh marijuana, cocaine, alcohol, et cetera, that you immediately uh reprogram that part of the brain. Uh that part of the brain requires repetitive use before it gets reprogrammed. Uh all of us who were teenagers, high school, college, and can know all about the uh alcohol use and marijuana use and maybe some drug experimentation that goes on in those years. But just because there was experimentation doesn't mean that it uh then leads to uh uh reprogramming of that part of the brain or a true addiction. And and drug addiction is defined as a combination of physiologic dependence, which means um if I stop using the drug, my body goes into withdrawal, which can be very uncomfortable. In the case of alcohol, a person can have seizures. Uh in the case of cocaine, uh there's a terrible depression, low energy uh craving for the for the cocaine and opiates like heroin, um, horrible, horrible symptoms of cramping and and uh and sweating and and uh the malaise and and just feeling terrible, so bad that uh going through opiate withdrawal for most people is horrendous. And that's why they in treatment centers they often will try to give a drug to block the opiate withdrawal because it's so difficult and painful. Um but it it's it's really regular use that leads to reprogramm with that part of the brain. That the bad news about that is that once that part of the brain gets reprogrammed, um, that programming stays. What we don't know is how long it will stay. Um I've been impressed uh that individuals who uh can get into treatment programs if they've had a very severe addiction history and have failed uh numerous rehabs, uh, if they can get into a program where in a step-down model, meaning they go from residential to uh living in a controlled environment like an apartment uh with a day program or outpatient program, and they can do that for months, um they have the best chance of recovery. And I'm convinced it's because, not just because they're they're dealing with the psychological issues of the drug abuse or or the they're they're learning how to live a life uh clean and sober, but it's also because that part of the brain has more of an opportunity to get programmed in a healthier fashion. Um can't have a discussion about uh drug addiction. Oh, let me just finish the discussion of of uh addiction itself. So there's physiological dependence with withdrawal if you stop, and then there's the the using it to get high, to enjoy the effects of the drug. You know, I I prescribe medications for depression, for anxiety, and people ask me if it's addicting, and I have to go through the same definition. So if you if you're not using it to get high, um I tell people there can be for some medications we use for anxiety physiologic physiological dependence, which means we have to then carefully decrease it when the time comes to stop it. So in addition to uh uh the physiological dependence and the desire to get high, um there's the di f interfering with activities of daily life. You know, it it gets in the way. It it's interfering with your job, with your marriage, with uh your pursuit of a career. Uh it gets you to lose friendships and and uh uh have friends not want to work with work with you or talk with you because of the effects of the drug on your mental state. So uh addiction itself is more of a complex process. And it's not just a matter of taking a drug that can lead to physiological dependence. It's it's much more involved in that. And the uh addict will go out of out of his or her way to get the drug any way they can, even if it puts them in danger. I mean, I knew a a young man who was uh uh son of a very successful uh businessman entrepreneur in Manhattan who was so good at procuring the drugs for himself that he probably could have run a major company based upon that uh ability to uh manage uh his drug addiction because he was uh unfortunately an expert at it. And uh that expertise eventually can't kill you because of the effects of these drugs. Um there is a genetic component as well. Uh so that that means that not everybody who goes to a doctor with a uh sprained ankle and needs to be on an opiate-like agent like Percocet or hydrocodone is going to get addicted. Uh individuals can be genetically predisposed to that. And that's one of the factors that puts people at risk so that if you look at your family tree and you can see that you've got a number of individuals who have had opiate addiction, um then you need to begin to concern, be concerned about your own genetic risks. If you have a family history of significant alcohol abuse on one or both sides of the family, then you need to begin to say to yourself, maybe I've got to be careful about my own alcohol use because that could trigger that addiction. We don't really know how that works. Um my suspicion is that it involves uh increased sensitivity of that nuclear succumbens to getting reprogrammed, but I don't think that's been proven yet. So it's uh it's a a complex issue, and uh uh I'm sure that you've seen the individuals who come out of a family environment where that predisposes them to drug use.

SPEAKER_00 15:11

Yeah, and the but uh you know, on the other hand, uh I've always considered drug and and alcohol abuse uh to be an equal opportunity employer, and meaning that anybody can be uh come addicted to drugs and alcohol. And a perfect example of that uh when I learned that uh concept was in the again in the 1980s, I was at the Grand Rounds uh presentation at North Shore Hospital in New York, and they had the medical director from the Hayde Ashbury Clinic. And this was at a time when basically people thought of cocaine as a relatively innocuous, harmless drug that rich people use and and just for fun. And we started to realize, well, that ain't true. But he had an example. He said, you know, I could invite all of you doctors, uh I could load up this podium with cocaine, and I could invite everybody up here to try it. And he said, Some of you would try it and think, this is horrible. Why would anybody want to take this drug? Some of you would try it and say, you know, that was nice and never do it again. And some of you would not leave the podium until you used it all up. And he said, I can't tell you ahead of time, basically, who is that gonna be. Yeah, we can look at family history and say, well, maybe you have a greater chance, but then there's always the the first one who there is no family history and becomes addicted. Why is that? Clearly there's the physical part of it, but there's another piece here that I think is worth to talk about, worthwhile talking about, and that is who can really say that sometimes in their life they feel like there's something missing. Who can't everybody will at some point say, you know, there's something missing. And it could be uh when you're a kid, it could be in your twenties, it could be in your fifties or older. That I don't know. I just feel like there's something missing. And what is that something that's missing? Well, you know, everybody sort of maybe finds a healthy way of filling up that whatever missing feeling is, but if anybody has ever had a drink or anybody has ever tasted a drug or smoked a joint or something, that may feel like that fells, that's filling up what's missing. That feeling I just got, even if it's from one time, that is remembered. And so even though, like you're saying, that part of the brain needs repetition to really get into the whole uh area of dependency, it may be that that one trial learning of wow, that was really I I like that. That may then stay in their awareness enough to say, you know, I I think maybe I'll try that again someday. And then the second time it feels good. So at some point, maybe that's gonna be the thing that starts to fill up that thing that's missing in a person's life. And then it starts to have its own momentum where, you know, I I think I'm gonna go get some more. I think uh I'm gonna see where I can get some more of this and more of that. And and by the way, down the block now they have, you know, I can go in there and they'll give me a card so I can I can get all the pot I want. That's really filling up what's missing. And on and on. So in our society in in in particular these days, uh I think more and more you'll see, because of the preponderance of time spent on electronics and social media and the limited time people spend with people, you know, family and friends or loved ones or or spouses, the limitation to that leaves somebody maybe feeling even more like there's something missing. And drugs and alcohol can easily fit into that spot. And so physiologically and psychosocially, we're probably more vulnerable than ever to the uh use of drugs and alcohol and then it becoming a an addiction process that we're really seriously dealing with in our culture.

SPEAKER_01 19:07

You know, in my early years of training, I got to review the animal studies where they would take a rat and put the rat in a uh uh in an environment where they had uh two spigots. Uh and if they press the bar for one spigot, they would get uh uh sugar water. And they press the bar the second spigot and they'd get cocaine water. Um and you'll see a rat that uh uh it has exposure to the sugar water or cocaine will go to the cocaine repeatedly. And we've actually seen animals that will continue to press the bar until they're dead, until the the the cocaine kills them because of the cardiac toxicity. Um you've seen humans too, though. Yeah, unfortunately. And they won't eat, they won't do anything but stay at that bar. Um uh human beings are uh different, but at the same time, uh when individuals who have significant heroin, cocaine, methamphetamine habits uh will do anything they can to continue to get the drug. Uh stealing uh from their families, stealing from cars. That's why the incarceration of of individuals for substance abuse is so high. Um but the other aspect we need to talk about, we've raised this issue before, you know, we've talked in previous podcasts about anxiety disorders and depression, but it's very not unusual to see somebody, for example, who is extraordinarily shy and turns out to have what we call social anxiety disorder, where they're so worried about what other people think of them in a social environment that they feel uncomfortable and have rapid heartbeat and and fearful and and expect the sky to fall, will go to a party and have a drink, and suddenly it levels the playing field. Uh alcohol itself uh is a tranquilizer. Um unfortunately it has limits and people develop a tolerance to alcohol and have to keep drinking more and more to get the same effect, which is why very often we'll see individuals with social anxiety disorder who develop true alcohol dependence problems. Uh marijuana is the same story. Individuals will find that uh using marijuana will calm them down enough so their anxiety is not as significant. Um and then before you know it, they're using that on a regular basis and it really becomes a crutch, uh, unfortunately, and rather than uh uh directly dealing with the problem in in treatment and therapy. Um depression can lead to the same kind of desire to feel better. You know, the emotional pain of depression has often been described as being worse than physical pain. And anything that diminishes that emotional pain is helpful. And so if the marijuana use numbs you or the uh alcohol uh disinhibits you and tranquilizes you enough, then it decreases the pain. And people who are terribly depressed will do anything they can to get away from that horrible feeling. Um and that's why looking for coexisting disorders is so important. Um just Giving just putting somebody in a traditional drug rehab program without a paying attention to the presence of anxiety or depression or family problems or maladapted personality traits often leads to unsuccessful outcomes because you can do a good job with a 12-step model and help people stay in recovery and move forward. But if you don't address the non-substance abuse, emotional, psychological problems, they're not going to do as well as you'd like them to. So a lot really depends upon uh how good a rehab is at addressing the psychological problems. They're usually very, very good at addressing the substance abuse problems. Uh how sophisticated they are dealing with the uh the the psychiatric or psychological difficulties uh remains to be seen. And sometimes it's very hard for the layperson to evaluate.

SPEAKER_00 22:50

There is a real dilemma in that area as well, because um in the 12-step population community, there like anything, there's different uh degrees of uh orthodoxy. But uh for a long time, probably still present, if you were in a 12-step program, if you were going to AA or NA, you were told do not take any psychiatric drugs. Now that was probably okay when it came to you know, don't use benzodiazepines because people can abuse them. But many people were told you can't even take an antidepressant. And so the the reasoning for that was that uh the antidepressant is covering up your uh your drive, your your for the drug or for the alcohol, and in in real true recovery you should not need anything. They forget to deal with the fact that they smoke cigarettes in the meetings, but but antidepressants are not okay. And so a lot of patients or a lot of people who go to AA uh are struggling with the fact that they're super depressed, even when they're not drinking for six months or a year, they still have depression or they still have mania or they still have massive anxiety and and their anxiety is so bad that they can't go to the AA meeting or the NA meeting because of the social anxiety. So I think with more uh of an understanding of that and more sophistication, there's other aspects of the 12-step programs that say, okay, certain people do need medicine, and that's enabled many people to actually stay sober because they have somebody addressing their psychiatric problem as well. But a lot of the uh uh programs around the country, and especially here in Florida, which is the rehab capital of the country, there's a lot of rehab programs that are run and they really don't have good clinical staff that understands and can treat psychiatric problems. They're really good at the addiction part, but uh give lip service to uh you know having staff that really knows much more about psychiatric problems. So hopefully as time goes by that will improve as well. But uh who doesn't know? I think the big question is who doesn't know somebody who's had a child in the throes of addiction and no matter how many treatments, no matter how many recovery programs, no matter how much money is thrown into it, it still intermittently or continually goes out and uses again. And how many of us know some people, and I've had friends as well, who've lost their children due to drug and alcohol addiction? It's it's really serious. And my big concern today is that there are certain drugs that are considered to be no problem, like the gummies and and e even some of the research dealing with uh psychedelics, hearing psychedelic, has made a lot of people think, oh, I can just go get some psychedelics, and that's okay now. So because of the billions of dollars that people make on on uh dispensaries for marijuana and other drugs, and and also social media t telling a lot of people that, you know, gummies are fine, this is fine, that's fine. I think we're gonna be finding more and more people stuck in the throes of addiction.

SPEAKER_01 26:27

You know, we can't we can't talk about substance abuse problems unless we talk about attitudes within society. And um unfortunately, uh individuals tend to be gullible and will believe what they what they read on the internet now or what they hear in the from uh thought the thought people and influences on on the internet. Um it's a real problem, and both of us have have heard horror stories from families, et cetera. So this really becomes a significant problem, and I think it's important enough that perhaps maybe the next uh next podcast will talk some more about marijuana and some of the other drugs that uh have continued to be a scourge for this country. So I'm Dr. David Gross, psychiatrist.

SPEAKER_00 27:07

Dr. Andrew Rosen, psychologist, and we're at Two Shrinks in the Two Shrinks in a Mic. And thank you for being here. Bye-bye. The Two Shrinks in a Mike podcast is for informational and entertainment purposes only. The views expressed are those of the host and guests and do not constitute medical, legal, or professional advice.

SPEAKER_01 27:26

Please always consult a qualified healthcare provider before making any medical or wellness decisions. Our content is not a substitute for professional medical governance, even though our mothers tell us we have the best advice possible.