[Brandon speaking] Hey, everybody, I’m Brandon Thomas Lee and I’m here with Dr. Nora Volkow, Director of the National Institute on Drug Abuse and part of the National Institutes of Health. Today we will be discussing addiction, recovery, mental health and how COVID-19 affects it all. Dr. Volkow, thank you for being here today with me.
[Dr. Volkow speaking] Well, thanks very much for having me. It’s a pleasure.
[Brandon speaking] Amazing, how are you doing today? Are you [overtalking]?
[Dr. Volkow speaking] I’m good, and you?
[Brandon speaking] I’m good. I’m coming to you live from my dark cave in Los Angeles, my evil lair. I’m just kidding. Where are you at the moment?
[Brandon speaking] I’m in Maryland, Bethesda, and it is very light in here as you can see, and I’m very excited to be with you, very [overtalking].
[Brandon speaking] Amazing, yes. In LA, you know, we like it dark and it’s all about ambience.
[Dr. Volkow speaking] We like it loud here, and it’s all about politics, you know.
[Brandon speaking] Exactly, politics, keep the light. So, you know, a couple of really important talking points for us today. Of course, addiction, recovery, mental health and of course, everyone’s pressing issue at the moment, COVID-19 and kind of how it all wraps itself up in one thing.
And the first question I’d really like to talk about, or the first topic, is that our society, when it comes down to it, doesn't really like to discuss topics of addiction. You know, people like to have fun, and drugs and alcohol are a large part of what people imagine to be how they can have fun. But when substances destroy a person’s life, you know, that’s something that needs to be addressed in a loving and supportive way.
My question is: Do you think our culture is able to accept that things may be different for certain people?
[Dr. Volkow speaking] It has been hard to actually get people to change their perspective in terms of the difference that exists between all of us in our capacity to, for example, drink alcohol, and be able to control it, versus individuals that are unable to do so, and they just escalate and drink more or take more and more drugs. And they can no longer exert some control over those very strong urges.
And what has been so very difficult is that we all see the world through our own eyes, and so people see, if I am able to just drink alcohol or smoke marijuana once in a while, why can that person not do the same? If I can do it, that person should do it.
And that has led to a massive misunderstanding, because there are very significant differences in our own biology and our upbringing that will determine the extent to which you actually may be more or less vulnerable to fall into that compulsive pattern of drug-taking. So it has been hard, I think, for people it is very difficult to realize that the experiences that they have are not necessarily the same that someone that is taking drugs and cannot stop it is living or experiencing.
[Brandon speaking] Yes, and I think that’s something that is very hard to grasp, even for someone going through addiction at the time. I know for me, before I went through recovery, I didn’t understand that it was a physical dependence of mine, and an involuntary act, is the point, to where it got to where I didn't know that I couldn't stop. And that’s what it is, and what most people don't understand is that it becomes, sort of, an involuntary act, and it’s very serious.
And some people struggle with it, and some people don't. I think that understanding where the divide is, is where, you know, it’s a little tricky for people to understand. You know, addiction is looked at with a sort of stigma, as a failure of character, as if, you know, people could just get better if they wanted to. Whether that’s really the case, what does the science show behind that?
[Dr. Volkow speaking] The science actually tells us that, first of all, we have a need to explain our actions. So when you have a very strong desire you say or do something, you say, well it is because I had this or that reason. And we also like to feel that we are in control of our actions. So I do this because I choose to do it. So it’s very difficult to actually grab the concept that you may be doing something, as you describe it, automatically, without really being you, the one that is guiding that action.
And by you, I mean, your conscious awareness. So we can fall into these repetitive automatic patterns of behavior, where we are no longer in the cognitive control, the capacity to say, I’m going to do this, and carry it through. And we all are more or less able to do that. I mean, nobody is perfect. We all have moments when we say, okay, I don't want to eat more of those chocolates, and yet, I cannot stop it. And particularly if I’m stressed, that becomes much harder.
So, we have that capacity most of the time of exert self-regulation; when we are very stressed, then we lose it. And there are people who are much more vulnerable to fall into these automatic modes of behavior, and where the control actually, the ability to control is much lower. And that is at the essence of addiction, and at the essence of differences in vulnerability between people to addiction.
I mean, because the question is, a lot of people take drugs and yet a very relatively small percentage, we don't know what it is, ten, 15%, will become addicted. And so the question is, what is the difference between someone that can still control versus someone that has not?
[Brandon speaking] Yes, and why is it that some people become addicted and some people don’t?
[Dr. Volkow speaking] There are multiple factor that actually determine your vulnerability to addiction or not. A very important one is your genetics. So as we know, there are families where there are many more people who have problems with alcohol or cocaine, and this has been recognized for a long time. And scientists like to quantify things, so they say, 50% more or less of your risk may be genetic.
But your environment is also very important. So, for example, if you are brought up in an adverse environment or an environment where you have early exposure to drugs, that will increase your risk of becoming addicted. And indeed, for example, we now know that the younger you start taking drugs, the higher the risk that you have of becoming addicted.
And another element that is very important and crucial to speak about, because it actually can lead us to prevent addiction is, if you have any symptoms of anxiety or depression or you just don't feel well in your skin, that sense of unease, as a young person, that puts you at very high risk of taking drugs. Why? Because you are trying to escape, and one of the ways that you escape is taking drugs. And guess what, when you take a drug all of a sudden you feel much better, and your brain automatically learns to associate that state of wellbeing with the drug.
So the next time that you are feeling depressed or anxious or uncertain, then you have this desire to take the drug, because it has been memorised in the brain resulting in such a way that it leads to an automatic behaviour. It’s a memory that translates into an action, whether you're conscious of it or not. I want to highlight the recognition that symptoms of depression and anxiety, anything that makes you feel, sort of, not well in your skin, boredom, all of them can increase the likelihood that you start to take drugs, and that you will get hooked up in drugs.
[Brandon speaking] Yes, and so we talk about stressors and we talk about, you know, how anxiety and depression and these certain things can trigger or make it much harder on someone who is dealing with these problems. But now, in the environment we’re living in, with COVID-19 and everyone being forced to stay inside, what are we seeing with people in recovery or with substance issues when dealing with social distancing and COVID-19?
[Dr. Volkow speaking] Well, it’s particularly challenging for people that are trying to stay in recovery, for people that are trying to control the drugs they are taking. Challenging for all of us, but it’s even more for them. And we do know now, this is another area that has been widely investigated and corroborated by scientists that stress is one of the factors that triggers drug taking. So when you were asking me, what are some of the factors that increase your vulnerability to addiction, stress is one of them.
And COVID is incredibly stressful, because of the uncertainty, because you are actually also seeing people that you care for suffering. You see the devastation that it’s having on our country, in the world. And at the same time you are seeing, including the economic turmoil, the lack of jobs. And if you're a person in recovery, that is a period that is a state of enormous vulnerability for relapsing. If you are not in recovery, you are at incredible high risk that you start to take even higher number of drugs.
And if you are not taking drugs, it can [inaudible] you to try to experiment. So we know that from past events, and they never had anything as serious as what we’re living right now.
And when that has happened in the past, we see an increase in the number of people that are drinking, smoking cigarettes, smoking marijuana, taking illicit drugs, and increases in the casualties associated with that drug-taking, and increases in relapse.
And we’re already seeing that. We’re hearing from the treatment communities that patients that have been able to stay, basically, in recovery for a long time, are starting to relapse. And then you add, what you said, social distancing. Well, we are social creatures. We love to interact with one another. It’s very powerful. It’s one of the most important reinforcers that we have, and indeed, one of the factors again that increases the risk for drug-taking is isolation. When you are isolated, that is extraordinarily stressful.
And so right now that we have this social distancing, it is much harder to get those social reinforcers that make us actually, that can help a person buffer the strong desires to take drugs. So that is another associated challenge that people that are dealing with drugs have to face, that isolation that in many instances drives people to drug-taking or that drives relapse, or to initiating drug-taking.
[Brandon speaking] Yes, I know for a fact that when I was active in my addiction, I would be, you know, voluntarily isolating myself, and that’s where it got the worse for me. But I constantly think about people who are in the beginning of their recovery now being forced into isolation and it just seems like a recipe for disaster really. I mean one of the things you learn in recovery is to not self-isolate, to reach out, to have a fellowship, to have a community behind you. And it feels very hard to have a personal connection sometimes though a computer or through a phone call.
It sometimes just doesn't do as well as somebody in-person, meeting with them. Being in isolation, I know from talking to a lot of different people, it’s been very hard on people. Certainly for me it’s been hard. I’m a very social person, and ever since I’ve, you know, been sober, I’ve loved to really be able to spend time with people in a healthy way, and talk about my feelings and be able to express myself. And exercise and get outside and feel like a part of a community that I've really worked hard to have a life that you can sustain in that community.
And when it feels like it’s been taken away from you, it’s a very hard feeling, and especially for people that are suffering with anxiety and depression. All of these things get worse, and it’s been a very hard time for us all. And so my question is, what specifically about isolation makes it so hard for the brain?
[Dr. Volkow speaking] Well, our brain actually evolved to maximize social interactions and biologically it’s necessary because we depend on each in order for us as individuals and as a species to survive. So not surprisingly there are multiple areas of the brain that are engaged in social emotions, social behaviors. They’re extraordinarily important.
And so, for example, one of the worst things that you can do to a person, to a human being, is isolate them. And that’s why, when you do something wrong in prison, they put you by yourself in a room, and that is one of the worst punishments that you can give. And the same thing with a child or a teenager, one of the worst things that you can do is neglect them, remove any social contacts.
And that interferes, actually, with the way the brain develops. It’s as important as that. But I think, that when you were telling us your story, and your own awareness that you were isolating, and your own awareness about understanding how the anxiety and the depression play into taking drugs, into generating that desire, you've already done one of the important steps, which is the recognition of what’s happening inside you, and the recognizing of what are the triggers that can lead you drug taking.
So now you are aware that this is a very stressful situation, that the social isolation which is hard on you is one of the danger points.
And so my message in all of this is, first of all to recognize that these are periods of high risk for drug-taking and relapse, and therefore you have to be particularly cautious, and look for alternatives that can provide you the reinforcement that you are not going to be able to get as you used to get it in the past.
So even though it’s not the same, I do think that actually these virtual technologies, this ability to dialogue with friends or to actually go and watch someone… I mean, like you are doing right now, telling us your story, sharing it with all of us. It allows me, as a person, to experience and to learn from you, it creates a sense of feeling part of something else that is very powerful.
So even though it’s not as ideal as being physically present, creating these groups and networks where people can support one another is actually a very positive element that can help someone stay in recovery or not reach out to drugs when they have the strong urges. So we need to adapt to the circumstances, and virtual technology has enabled us to do this.
And you also said something that intrigued me very much, and you sort of said, well, I do know that exercise helps me. And I think that recognizing what type of activities help you, you should try to promote doing them. I mean, now, of course, one of the challenges is, not everybody has access to being able to exercise. But if you are creative, most people will.
But the other element is sometimes when you're stressed, you say, I don't have the energy to go now, and you need to be aware that this is the time that you need to have the extra energy to overcome that inertia of not doing it. So we’re basically being very systematic, and sometimes even if you need to build routines. Routines can help you deal, particularly when things are very stressful. Create a routine and follow it through, and that will carry you through.
Those are some of the advice that I would give to people that are struggling, and we’re all struggling with this whole issue of the isolation and the uncertainty. But as it relates to drugs, these become very valuable activities that you can do, and minimize your risk. And as you…
[Brandon speaking] Sorry?
[Dr. Volkow speaking] No, I was just going to say, because you also say out, I mean, reach out. If you feel that you are really in danger of giving in and taking drugs, reach out for help.
[Brandon speaking] Yes, that’s a very powerful statement. And you know, something that I believe in a lot is the power of opposite action. So, you know, when I feel down and when I feel tired, and I really don't want to do anything, I know that then and right then is the time where I need to pick myself up and do something, because you know, you only get lower from there.
And I think, realizing and trying to be as self-aware as possible, when you're feeling those ways and trying to act in the opposite helps very much, and that’s something that I’ve found a lot of success with.
I think, moving on, a lot of people have this on their mind, is that there’s a lot we have to keep in mind when, you know, different states are starting to reopen. And I know everyone has to balance their own personal risk, and we both stayed away from each other for a very long time, but what’s on your mind when thinking about people with addiction issues as they rejoin society, coming out of this isolation?
[Dr. Volkow speaking] Well, it’s going to be complex for many reasons, and I think it’s going to be complex again also for all of us. One of the things that worries me is that there is an entrenched wishful thinking that can take over in our brains very easily, particularly when you want something very badly. And that can lead you to distort your cognitive operations to justify it.
So yes, of course, I want to go out and I want to go and explore the beaches and go swimming, and so I can see my brain starting to say maybe, well, look at the prevalence, maybe the risk is not so high. Maybe we should be taking the risk.
And I’m seeing myself doing this, and I think that we are all going to, of course, go through it, because there’s a point that we all are tired of being in isolation, and we want things to change. The issue here is that sometimes being impatient is not necessarily the best strategy.
So this is a background that will affect all of us, whether we have a problem with drugs or not. Additionally, for people that are coming back into our society that is opening its doors, is that we are in post-COVID, I mean, we are still in COVID but the isolation, the quarantine, is over. And in the meantime, in that period, we lost many jobs.
And so what are the challenges, because if you want to stay in recovery…? Actually, even if you have not a problem with substance use disorders, in our sense of wellbeing, we do want to have a sense of mission, of value. We want to be self-reliant. We need to pay the bills. And some of us, I mean, depending on where you are, depend on those jobs for survival of your family, and that is an extraordinarily stressful time, and that is one of the things that I’m very concerned about, the lack of jobs.
The decimation also in the process of the support systems that we used to have, even at the level of the hospitals. The level of support that they were doing in the past, they may not be able to carry through at the same levels because of the revenue losses. So those are things that we will, I mean, we don't know yet at the moment, but we will start to learn, and then of course, we’ll need to figure out how to address them. But those are issues that I am very concerned about.
[Brandon speaking] Yes, it’s very interesting because, you know, in recovery a lot of the times people are going through it to regain some sort of stability in their lives, you know, find some sort of success. And when all that becomes threatened and you can't work, a lot of people and certainly even myself at times consider, you know, why try so hard to keep it all together when, you know, I don't have a job, I don't have income, I’m broke? You know, like why? A lot of people could be thinking why keep it all together and why not just throw it all away?
So it’s definitely a very interesting time and it’s a very dangerous time for people in recovery, and I’m definitely scared for a lot of people. And I’m hoping that, through the proper channels, people can be provided the right support and people continue to reach out and stay in contact online, and stay a part of the community, because there is a light at the end of the tunnel and this will end. But it’s just a matter of making it through this very tough time.
And I know you talked a lot about routine, and when your routine gets interrupted it kind of throws you for such a loop if you're a very routine-oriented person, you've built that into your recovery. So it’s definitely a scary time for everybody, and I think it will be very interesting to see what happens. I have another question. So people that are still using drugs while isolated, what are you remember biggest concerns?
[Dr. Volkow speaking] For people that are taking drugs in isolation, my main concern relates to the fact that those that are taking opioids, because opioids depress your respiration, you stop breathing. And we have a very good medication, that if you administer it, you can actually reverse the overdose. But someone has to administer it for you. So if you are by yourself, no one is going to observe when you are basically going through overdose.
And you’ll lose consciousness, so it’s not like you can just administer the medication to reverse yourself. You need someone else to administer it. So I’m horribly concerned, actually, that people may be dying from overdoses that should have been reversed. But the isolation has made that much harder. That’s my main concern. There are concerns also about other drugs, but this is, I guess, at the top of my list.
[Brandon speaking] Yes, and on that note for people that are sheltering in place who have an ongoing problem with drugs and alcohol, or are currently in the beginning of their recovery, how can they get help remotely or continue their treatment, or what if a family member of theirs needs help?
[Dr. Volkow speaking] One of the positive advances that has happened with the tragedy of COVID has been it has forced us to come with alternatives. So, for example, now we very rapidly embraced something that had been going on for several years, which is telehealth, which had been taking on very slowly and gradually. Now it’s all over the place, and that has made it much easier for anyone of us to access a therapist, to access a clinician, and to be able to get that help.
But that does require that you have an internet, and again, not everybody has, but overall it has massively expanded access to therapists. There have also been applications that have emerged, some of them are for free, that allow you to give a psychotherapeutic intervention that allow you to get into support groups, that allow you to get someone to mentor you, to create these social networks.
And again, these virtual applications have provided some alternatives that patients themselves are reporting to be helpful. How do they compare in the long term? We do not know. But for now they are allowing individuals not to feel so isolated and to access care.
And also some of the other changes that have been positive is, now it is possible, if you have a problem with opioid addiction, say it’s prescription opioids or heroine, you can be treated with medications that help you basically inhibit and control the desires for the drug, but also prevent you from overdosing.
They protect you from overdoses. And the physician can prescribe with those medications through telehealth, which was not possible in the past. And so these are some of the positive advances that we’ve seen, as a need to urgently provide support to people who are suffering from substance use disorders.
[Brandon speaking] Yes, and during this time, I think an important question, as everyone is very much at a high risk, is how can we best support those who are relapsing at this time, especially those who are isolated?
[Dr. Volkow speaking] Well, we need to all feel responsible. I mean we all have a responsibility to try to help those that we can help, around us. And I think that lending a hand, being more patient, listening, and certainly not ignoring signs and being there. As you know, I mean, a lot of the support systems that help people achieve recovery are based on that generosity of spirit that leads a person to say, I’ll be there if you need me; reach out to me.
And so, the concept is, be there when someone reaches out to you, but also be proactive. And again, a lot of what we experience, we experienced through our own lives. And what I find myself is when you are walking and you see someone and they smile at you. I mean, it feels so good. I mean, something that in the past you wouldn't even recognize.
But kindness is something that is very therapeutic and very healing, so I would say be kind and reach out to help others. I mean, there is this statement, what is it that we can do for America, right? What is it that we can also do for each other?
[Brandon speaking] JFK said that, right? Where is it?
[Dr. Volkow speaking] Yes.
[Brandon speaking] There we go, so I got some knowledge in me. And I think that’s something that’s very important, and for me, in my recovery, I was blessed to have great friends who were constantly checking on me, constantly worried about me, and I definitely felt the pressure that I wasn't doing something that was beneficial for myself or those around me. And to know that there was someone that cared made all the difference, because at certain points I didn't care about myself, you know.
And sometimes it takes someone to remind you that you should care about yourself, and that there are people sometimes that, you know, rely on you and you should be there to support them as well.
And I’m lucky and blessed that I’m here, you know, and blessed that I was able to have access to the finest treatment and recovery programs, and access to some of the finest people, you know, I’ve ever met in my life. And some people just aren't that fortunate.
So if you do have a friend that's struggling, or a family member or anything, just reach out. Ask them how they’re doing. It makes all the difference. It made all the difference for me and it could for them, and that’s definitely something that I’m very passionate about, is staying in contact with someone who you think might be at risk.
And it’s a very challenging time right now, and I think this is a very tough time, especially when there’s limited communication in that aspect. One of the last questions I want to talk about is that, I know NIDA does a lot of research focused on teenage / young adults’ drug use, in particular. And why is that?
[Dr. Volkow speaking] Because young people starting in early adolescence are much more vulnerable, number one, to experiment with drugs, and number two, if they do experiment with drugs, to escalate into addiction.
So, you're much more vulnerable, as I was commenting before, if you start taking drugs when you're very young, for addiction, than if you take them as an adult. And that relates to how the brain is developing and during those stages it is particularly plastic. That means that it is changed by the environment much faster than it will in an adult, and that characteristic is fundamental for us to learn.
But the negative side of it is that if you take a drug which physically modifies the brain, those modifications happen faster if you're an adolescent, and tend to be longer lasting. And hence why for us, it becomes so important to develop research that can help us guide prevention interventions.
Now, for example, the life of adolescents is completely changed. I mean, adolescence is a period in which you are very much tethered to your peer groups. We’re always social creatures, but in adolescence and young adulthood, that is particularly dramatic. And so, what are the consequences of removing that very strong social interactions in the life of a teenager or a young adult, and how do you compensate?
I mean, what I am optimistic about is the human brain has extraordinary resilience, and I do believe that among the strong components about being a human, not that I say only humans have it, but certainly the connectedness and the sense of responsibility for others, our ability to suffer when someone suffers. We actually can integrate that emotion. We experience it, and that’s what we call empathy. And that leads you to take action.
And I think that that combination of us as humans that can feel suffering from others, and at the same time our capacity for innovativeness and invention will allow us to clearly overcome it. The issue is in the meantime, of course, what is it that we can do to help those that are struggling and [inaudible] thing? I mean, your own experience is how important it was for your friend and for you to feel that someone cared for you. And I think that that will be a very important message. Show others that you care for them.
[Brandon speaking] Yes, and I think a good note to end this on is to, sort of, touch a little bit on the mental health aspect, and for people that suffer from mental health issues, struggling with addiction as well, are their needs being taken into account in planning research and ensuring that promising new approaches move forward and have these issues been forgotten in COVID-19?
[Dr. Volkow speaking] Well, in research I know we haven’t forgotten them, because they are so fundamental in terms of what makes you vulnerable, and also fundamental in keeping you actually in recovery. If you do not address depression, it’s very difficult for someone to achieve recovery.
Unfortunately, now with the COVID and where it has become harder for people to communicate, and certainly to go into a hospital or a clinic, because basically some of them are overwhelmed, others have closed, their therapeutic requirements, their needs may not necessarily be fulfilled. This, as I mentioned before, is somewhat balanced with telehealth, but there is still a need for reaching out and helping those suffering from mental illness by itself or when it is co-morbid with a substance use disorder.
And now more than ever, because of the stress and the sense of hopelessness that can easily emerge if you don't have alternatives, particularly, if you don't feel like you have alternatives, because certainly you may not have alternatives right now, and everything may look very dark. But things change, and tomorrow you will see alternatives. That’s the way that life turns on. But in the moment you may feel that everything is very dark.
[Brandon speaking] Yes. Well, this has been an amazing conversation and I think this is something that should continue to happen, and hopefully we do some of these again. And I just want to thank you, Dr. Volkow, for sitting down with me today and having the time to really just talk about this and bring this to a public stage. And I think this has been amazing, so thank you very much. And thank you to everyone that’s been joining in.
[Dr. Volkow speaking] What I want to thank you for is your willingness to share your story, and also I want to congratulate you on your sobriety and because it is, I mean, people learn from others. Someone can see, if he did it, I can do it too. So thanks a lot.
[Brandon speaking] Thank you very much, that means all the world. And you guys can go to NIDA’s website and get all the information you need, I’m sure, and I’m sure we’ve been running banners down below for all the crisis helplines and all that information too. So thank you very much.
[Dr. Volkow speaking] Thanks.