Cognitive Dissonance - Episode 473: Opioid Crisis Part 2 (with Dr. Steven Novella)

Episode Date: June 10, 2019

Thank you to Dr. Steven Novella from The Skeptics’ Guide to the Universe for joining us. Check out their website, podcast, and book of the same name.   If you want to hear the emails Cecil sent the SGU back in the day they are Episode 39, 40, and 45. Also Tom knows Dr. Novella is a neurologist, he was just joking saying neurosurgeon.... 👀      

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Makes the news, makes it big, or makes us mad. It's skeptical. It's political. And there is no welcome mat. This is episode 472. Actually, Tom, it is episode 473. Also, can you tell Gary to call me?

We're already off to a struggle. We're off to a great start, great start, great start. And I think it's because you are a little starstruck. I am a little bit. We have on right now somebody who isruck I am a little bit we have on right now somebody who is sort of like a little bit of a hero

for both of us Dr. Steven Novella Dr. Steven Novella thank you so much for joining us oh thanks for having me I gotta tell you can we call you Steve

is that okay Steve is fine okay Steve I gotta tell you a story can we call you Dr. Steve like you're a pediatrician like I'm a TV doctor Dr. Steve oh TV doctor there you go I. Oh, TV doctor. There you go.

I'm going to call him Dr. Steamy. No. Nope. Dr. Stevie? So a long time ago, this has got to be 2006, I want to say, I was at a dead-end job. I was at a job that was not really great. And I had to do a lot of document scanning. And so that meant my brain could do other things while my hands were busy. And so I was listening to, I remembered a long time ago when I was a kid listening to Art Bell, Coast to Coast AM.

And so I thought, oh, you know what? I'll just see if they're on the internet. And so I found them and I started listening to them. Well, in the meantime, between when I used to listen to them and when I had started listening to him again, I had read Carl Sagan's Demon Haunted World. I had taken some critical thinking classes. I had sort of expanded my horizons, let's say. You've got a degree in philosophy, like for example. And so at the moment I start listening to Art Belly, wow, this is fucking bullshit.

Oh my gosh, they're talking about crop circles, they're talking about everything else. And so I'm not kidding. Here's what I did. I was like, I turned off like two episodes. I turned it off. And I was like,

I can't listen to this anymore. So I got to figure out what the opposite of a believer is. And so I, no shit, typed in Google, what is the opposite of a believer? And what came up was skeptic.

And so I did it as the next search I did was skeptic shows. And what comes up was skeptic. And so I did it as the next search I did was skeptic shows. And what comes up is a skeptic's guide to the universe. And I was like, that sounds amazing. And I started listening. And if you like way back when I sent you some email like years ago, and I remember I was super excited when you read it on the air and you kind of inspired us, Tom and I to start a podcast a couple years after that. Tom and I had heard you guys. We really enjoyed it. We listened to it all the time and we thought, you know, maybe we could take a stab at this and talk to a different audience.

That's awesome. We've only been at it 11 years, so I don't know if it's going to take. Still plugging away, yeah. 472 episodes later. You didn't know what you were getting into, huh? We certainly did not. But it's been an incredible hobby. Yeah.

It's been pretty awesome. It's been a lot of fun. Life-changing. So we want to talk to you today about an article that we sent you from The Guardian talking about the opioid epidemic in the United States. I want to start out and frame the conversation. Where do you stand on opioids? Are you pro-opioids? Are you anti-opioids?

Where do you stand on that? Like how many opioids do you take a day? And how many do you take a day? That's the key. Dozens? It's probably dozens, right? You got to calm your nerves before surgery, right? I don't do surgery. I'm an neurologist in case anyone doesn't know. So I just treat brain diseases with medications, et cetera. As a neurologist, actually, I do not use a lot of opioids because the kind of pain that I treat does not really respond well to opioids. But I'm neither for or against them. They are a tool. They're something that we have.

They do what they do. They're very powerful in a good way and a bad way. And if used responsibly, they have a role to play in the management of pain. And I've been doing medicine long enough to have seen this pro and anti-opioid thing come full circle because this is every generation now goes through the same thing. What happens is there's the fear that we're overtreating patients with too many opioids. They're getting addicted. We can see the downsides of overusing opioids. And so then we clamp down, you know, and that's it.

We're not going to really restrict and minimize the use of opioids. And then five, 10 years later, there's this big outcry of we're letting people suffer with pain. We're under treating patients with pain. We're letting them suffer. We need to give them what it takes to treat their suffering. And then the pendulum swings the other way for another 10 years. And then we have another opioid crisis where people are getting addicted and then it swings back. The answer is in the middle. It is rational pharmacy treatment with opioids with a contract very carefully. So in context is everything. So for example, if you're a terminal patient, or if you have terminal pain, yeah, whatever it takes to treat your pain is perfectly fine. If you have post-traumatic or post-surgical pain where there is a limited period of time

where you need to be treated, you know, if you're in a major accident, you have a broken leg or whatever, yeah, you might need opiates to adequately treat your pain. But that should only be for a period of time. And then somebody needs to carefully manage the transition off of opiates towards more longer term pain management if you need it. Sometimes that's where the ball gets dropped. Where opioid use is a problem is in chronic pain, especially chronic what we call neuropathic pain. That's the kind of pain that I would treat where, uh, there's time for the addiction and the tolerance to set in. So the opioids are less and less effective at treating pain over time. Um,

they, and actually the primary effect of opioids is not so much to make the pain go away, but to make you not care about the pain. Yeah. They're disassociative or whatever. Yeah. They, they, they, cause pain is only pain. This is interesting. What makes pain painful? There's nothing inherent about the sensation itself that is painful. That's a negative experience. It's only because the final pathway inside the brain connects it to the emotion centers of the brain and says, you don't like this.

This hurts you. What? This is a negative experience for you. And opiates are really good at blocking that last little connection to the emotion centers that make it a negative experience. I got to pause real quick because that, Cecil and I were talking, we were relaying a couple of stories just amongst ourselves a couple of weeks ago. And that explains so much. So I'll tell a very brief story that I think is, that's, that's just absolutely sheds all the light in the world. And I had meningitis a few years back, which is very uncomfortable and I don't recommend it at all.

And, and, you know, I had viral meningitis. So the only treatment is just, you know, a bunch of pain meds. And so I took all these pain meds and I have, I have very few memories from the, from the first week of the experience. But the memories I do have is that it hurt like hell, but I didn't really care. Yeah. And then I recently had back surgery and I only took pain meds for a day after it, but it was the same thing. It was like, well, that hurts. Have a hydrocodone or two, you know, whatever, whatever the prescription was. I don't even remember. Um, and then I would be like, well, that still hurts, but I just, I kind of don't care. It almost was like, it hurts somebody else. Like would be like, well, that still hurts, but I just, I kind of don't care. It almost was like it hurts somebody else.

Like it was like, that hurts paper Tom. Paper Tom is in a lot of pain. Exactly, yeah. But people Tom does not give a fuck. Doesn't matter. So that actually totally explains it. Yeah. Yeah, that's how it works.

That's where the euphoria of the medication comes in. That's where it becomes a drug of abuse, right? Because those same receptors that it's binding to blocking the dysphoria, the negative experience of the pain creates the opposite effect, which is euphoria. And again, that's what's addictive about it. That's what's psychologically addictive. But also when it does that, it down-regulates those receptors. They get used up. And so then your set point shifts from a good balance to then you're dysphoric all the time and you need the opiates just to not feel like shit. That's where it gets really addictive.

Now you're just treating the opioid addiction. You're not even treating the pain anymore. You're just taking them just to feel normal because off of them, you feel horrible. And that's why it's so hard to get off of them. And people have to be weaned off over a very long period of time because they, you know, go in cold turkey can be just a horrific, horrific experience. And then, you know, that leads to drug seeking behavior and, you know, all the trappings of addiction.

So that's why it's a very, very tricky drug to use long-term. And it's even worse than that because in the last decade or so, again, within the neurological literature, we've demonstrated that chronic opioid use actually causes a chronic pain syndrome all by itself. Oh my gosh. Yeah. So it's like the worst thing you could do to somebody with chronic pain is get them addicted to opiates.

So you have to just use it extremely sparingly, but you can't take it away. We need it. We have very few really effective medications for pain. And it's really challenging to manage, especially chronic pains. And so, you know, we need all the options, but you have to just use them appropriately. And it's really just the abuse of opioids that's the problem. But part of that is that we don't really have a great system in the United States for tracking and managing it, partly because, yes, there is the DEA, which is at the federal level, but it's mostly tracked at the state level, which makes it really easy for someone just to go over state lines in order to,

to, you know, fill a prescription at another pharmacy in another state. And then they, they lose, they, they're no longer being tracked by their home state. They're, they're usually, it's easy. You know, people learn to, to work the system that that's the problem. You know, I want to, I want to touch on something. So I made a joke about you doing surgery and you corrected me that you're a neurosurgeon. I'm a neurologist, not a neurosurgeon. Neurologist, you can correct me again, I'm sorry.

So you're a neurologist, not a neurosurgeon, forgive me. It's a common mistake, common mistake. So, you know, the point I want to drive at is that there's a tremendous amount of specialization in medicine and an increasing amount, it seems as a lay person, of specialization in medicine. And what has struck me anecdotally and in my reading, and also just my personal dealings,

is pain seems to be this thing, and you touched on it, like we have very few options for managing. And it seems to be this difficult, nearly intractable issue. And yet pain is often managed not as a specialty of its own. I recognize there are some pain management specialists, but as something that is managed by people treating other larger concerns, right? So I wonder if that is not a contributing issue. Like I can't go to the cardiologist and get him to take a look at my foot. He wouldn't do it. It would be silly to ask. Why is it that my neurosurgery, so I had surgery recently, like why did my surgeon prescribe my pain meds? Yeah, so you're correct. Medicine is very specialized because it has to be. It's getting so complicated. You have to focus on

an increasingly narrow area in order to keep up, in order to be a true expert in that one area that you're practicing. But all physicians, I mean, we need to know all of medicine to some degree, our general area of expertise to a good degree, and then our narrow area of focus to an extreme degree, right? The more specialized you get, the more you know. But you need to know enough about all medicine to function. And so any physician who's treating pain should be competent to treat pain. Not necessarily an expert, but at least competent. And that does mean a lot of different physicians need to be competent.

And, you know, there's variability in training experience, et cetera. experience, et cetera. But when patients get, you know, too difficult or too complicated for a generalist, somebody who's not a specialist in pain management, but who does it as part of their specialty, like a surgeon, when it gets too complicated, we typically refer to a specialist. So we'll refer to a pain specialist. There are pain clinics. The problem is there are way too few pain clinics to meet the demand. And they often, because now that creates a couple of problems. There just aren't enough pain doctors to go around, but because the demand is so much higher than the supply, they get to be really selective. They can just say, I'm just going to take cash paying patients. I'm not going to take any crappy insurance.

And so now I have patients who just because of their assurance, I can't get them in anywhere. So that's a systemic problem. We need more pain specialists that are more accessible. And I do think also we need a generally higher level of basic competence across the board so that you can handle the day-to-day pain management without creating problems. I'm a pain specialist in a way in that I'm a headache specialist, so I treat headaches. And so I kind of see, like, what do the experts do and what does the generalist do? How do they manage headache? And, you know, I always, of course, would like it to be at a higher level. You'd want them to avoid the common mistakes like getting people addicted, you know, to drugs they shouldn't be addicted to. When, when I was, when I was having a pain of my own, it was difficult not to get an

opiate prescription. Like I had, it was funny how, like how you had to like, you had to push back and like really push on. Like, I don't, I'm not interested in that. Like, what are my other options? And to your point about it being difficult to find a pain specialist, it was a pain in the ass to find a pain specialist. It really was. And they were very selective and there was a screening process. It was this whole fucking thing. And it made me really grumpy

because I was like, I don't, like, I know what I don't want, right? I'm watching this crisis unfold and I don't want to get swallowed up in it. I recognize that there's a supply and demand issue. If there weren't, would it be a, would it be a reasonable goal to say, you know, all right, these kinds of drugs are part of our toolbox and they're effective, but they have, they have dangers associated. As a generalist, you can prescribe, I'm making shit up because I'm just

a guy with an English degree, seven days of Oxycontin or hydrocodone or whatever it is. After seven days, you can't prescribe these heavy-duty pain meds anymore. You really have to refer out to a pain guy. If we didn't have a supply and demand problem, do you think that that would have an appreciable effect on managing that piece with the patients? I don't know if that's specifically what you're out on. I made up numbers.

I know it's just an example, but something like that. And there are feedback mechanisms. Like if you prescribe too many opiates, the state will send you a letter saying, are you aware that your patient's taking all of these prescriptions or that they're getting these prescriptions from other people, which is very, very helpful. Again, you could avoid that by going out of state. And so we need a sort of a national database so that you can't work the system quite so easily. Or, you know, you go into an emergency room because, you know, Friday night at two in the morning because, you know, that's when the system is at its weak point and you're going to be able to work it.

Or you just doctor shop, right? If a doctor is trying to be responsible, but you want the opiates, you just keep going until you find somebody who is either inexperienced or whatever, you find the weak point and then you exploit that. But I do think that if something good comes out of the out of the current crisis that we're having, I do think it's thoughtful ways of having more controls in the system so that at least, you know, and with electronic medical records. I mean, there's other options now where things can get triggered where, you know, it doesn't necessarily trigger a referral to a specialist. That's going to you know, we're also trying to contain the cost of medicine. That's a huge problem as well.

And so specialists are expensive and, you know, we don't want to necessarily build into the system requiring all these specialty referrals. But even if the generalist could have more feedback about appropriate opiate, you know, prescribing, that's at least the first level. That's generally how we handle things in medicine through education, but that's always hit or miss. But if it's sort of built into the prescription process where if someone's been on a prescription

for a certain amount of time, it at least triggers somebody having to look at that or having to review that. This is a role where I think insurance companies play a legitimate role. I know it's easy to bash insurance companies, and I'm happy to do that when they deserve it as well. But they all are another layer in the system where they could monitor what they're paying for and say, hey, this is not within the standard of care.

Are you sure you're doing the right thing here? You know, and that's fine. You know, the more checks you have in the system, the better, in my opinion. Sometimes when you hear the term big pharma, I know when I hear that term, I sort of roll my eyes. And it's because it's sort of used as a weapon by the vaccine deniers.

It's used as a weapon by the people who think that, you know, somebody's hiding the cure for cancer. They use this term big pharma. But things have been sort of coming out about the Sacklers and about Purdue Pharma and sort of what they did. There's sort of been a systematic misleading of doctors using false information or not good studies, studies that are only of like one or two people to push more and more of this OxyContin onto the public. And it's not to push it on, it's to sell it, right? I know that I'm not naive.

I know they're trying to make a profit, right? So they send their salespeople out and the salespeople are incentivized to sell more higher dosages because they make more money. And so there's sort of this feedback loop. What do you think of the term big pharma when that comes up? Because it seems like there's a little bit of circumstantial evidence for some of the stuff that I know I've been arguing against for years when it comes to this. Yeah, it's complicated. You're right. And we tend to make fun of using

the term big pharma because of all that it implies, as if the pharmaceutical industry is this one monolithic industry that they're all sort of conspiring to do things together behind the scenes, like hiding the cure for cancer, impossible, ridiculous, you know, conspiracy things. But at the same time, the pharmaceutical industry is a critical industry that needs to be very closely regulated. And when they're not closely regulated, they will do make horrible decisions. You know, they will exploit the public. They will, you know, push their own agenda. And, you know, before the FDA, for example, the pharmaceutical industry was basically a snake oil industry, right?

That's what they will do if they left to their own devices. They will make money. They will do whatever it takes to make money. So we have a very elaborate system of regulation to make sure they're on the line, man, are they motivated to find ways to cut corners or to stick to the letter of the law, but still achieve their quarterly goal, whatever, you know, they're absolutely going to try to do that, uh, individual companies. And we need to keep an eye on them and we need to slap them in the wrist when they step over the line. And, and when they invent new ways to, to, you know, break the law, we need to adapt and rein them back in.

And if we don't rein them in, they will absolutely abuse the system because there's billions of dollars at stake. That's just the way it is. And they will justify it to themselves. They're not necessarily wringing their hands and cackling. I think that it's motivated reasoning, right? We know about this. they it's motivated reasoning right we know about this is their motive they sort of motivated reason their way into thinking that uh what they're doing is it's good in their in its own way they kind of know they're cutting corners but whatever it's not a bad people need pain

medication to treat the pain they sort of cherry pick the studies they want to cherry pick or they you know they do things that are do big you really like a sign as a scientist i know that's not really legitimate and i don't know at what level they really know it's legitimate or not, but there's always some combination of, you know, they, they, they know they're being shady, but they probably convince themselves is not that bad. You know what I mean? Yeah. So that's why I just, just, you need to be tightly regulated. It's too important a thing, you know, to leave it up to corporate executives. We know what, what that's going to be tightly regulated. It's too important a thing to leave it up to corporate executives. We know what that's going to be like.

I want to ask you a follow-up to that. Reading through a lot of these articles around the opioid epidemic that's going on, and you read through how all this happened, and there's a continuous thread where pharmaceutical companies take doctors on junkets and they, they do these, but beyond that, they do a tremendous amount of education and pharmaceutical companies are, they seem to be from a lay person's perspective, they seem to be the front line in the educational piece to at least a lot of doctors on what the new medicines are in the market and how effective they are and when to use them.

And that seems like as just a guy out in the world, like that makes no damn sense at all. Like what role should a pharmaceutical company have in educating doctors who are educating lay people like me who just don't know their ass from a hole in the ground and really shouldn't have the responsibility to know. Yeah. So that, that is an element of what goes on and it is concerning and that is being reined in actually. But over the last 10 years, especially it's been really incredibly reined in. It's never been like they're

totally in charge of physician education. That's never been true. I know I kind of have a little bit of a biased perspective. I spent my entire career in academia and certainly, certainly academics are the people who are, are doing the research and then mostly doing the education. They educate new doctors, obviously in medical school. And they give like, you know, Yale gives lectures to all of the hospitals in Connecticut. It's, it's academic physicians who are doing it, not subsidized by any pharmaceutical company, not at their, you know, bidding or anything. But what pharmaceutical companies will do is they will find a physician who they, who already agrees with what the, the, the perspective that is most amenable to their bottom line. And then say, hey, how would you like to, you know, give some talks for us?

And we'll give you a, you know, a stipend and et cetera. So they're not telling him what to say, but they handpick them because they know what he's going to say. Right, right. You know, but one of the solutions to that is, I mean, so universities have really clamped down. Like, I don't even see pharmaceutical reps anymore around my office. And you can't give a talk without disclosing all of your ties. So if you were being paid by, you know, a specific pharmaceutical company to give you a talk, you have to disclose that at the top of your talk. So you can't hide that. You

can't use slides that are provided to you by the pharmaceutical company anymore. You know what I mean? Who created the content has to be completely transparent. You can't even use that paper clip. That paper clip from MS Word, you can't even use that anymore. So we are moving in

the right direction. I think 20 years ago this was a much bigger problem, but I've seen over the, this has been my career. I've seen it change dramatically. So I think things are moving in a better direction. But again, pharmaceutical companies aren't just going to give up and say, okay, well, I guess we can't do that anymore. They're going to find more subtle ways to do it. And we just have to keep playing that game, just keep ahead of whatever they're trying to do. But, you know, at the end of the day, ultimately, it is mostly academics who are setting the standards, setting the standard of care, you know, being mostly the providers of information.

But pharmaceutical companies do play a role. But, you know, and the solution there for the time being has been to just make an insist on absolute transparency. We talked, we talked a little earlier about the the, the people at the pain management being a little overtaxed, being able to sort of choose their patients because they have, they sort of have a,

a wealth of choice. They can choose who they want because they're, they, they have so many people that are looking to come to them. Doctors all around seem to be a little overtaxed. I know when I go to see the doctor, they essentially sprint into the room, poke me twice, and then run as fast as they can out of the room. Maybe shower before you go. I know, right? I don't even know. The thing is, I've had doctors come in the room and just be like, and it's like the guy, the old commercial,

the micro machine guy, where they're talking so fast, they can barely understand him. But you know, you have an HMO and this is the people who you get, you know, this is the sort of the doctors that you're getting. And you know, I don't want to bash on the doctors.

I'm sure they do it. They probably have a lot of people that they have to see throughout the day. But the point of the question is, is like, it seems like our medical system has these backups anyway. And I know we talk, there's a fight in this country between socialized medicine or national healthcare versus the insurance system that we currently have. a little quicker than they might normally, like they might normally spend a little more time with them,

but instead they want to sort of turn over the patient. Do you think that maybe that might be a contributor into this? Yeah, absolutely. It's definitely, so we were basically talking about managed care, which has been the last 20 years of medicine in the United States. And it's, the bottom line is you get what you pay for. So as a society, we've decided we're going to pay doctors half what we used to be paying them for just spending time talking with patients.

And so guess what? You get half as much of that. It's like you don't get something for free. And it's not just that physicians are greedy. It's not like their money has gone up. It's that literally in order to just stay in place, you have to see more patients. And you're paying for an office and everything that goes along with it if you're in private practice. And it used to be in academia that you could just,

yeah, you could spend an hour with a patient and there was really no rush. And just even over the course of my career, the last 20 years, the pressure to be efficient, right, which is how it's sold, you need to be efficient at patient care, which is fine. And I do think what we're seeing is we're optimizing efficiency, but that does come at the expense of just, I think, the therapeutic relationship of just spending time, just making patients feel like they're being given enough time. Like I sometimes like I could see patients like really everything I need to know and do, I can do in five minutes. There's beyond that, there's no increase in the quality of care I'm delivering to that patient, but their perception is dramatically

affected by, by how, you know, slow paced the visit seems and and and how much time i spend with them even though i've already gathered all the information i need and i've already made all the decisions i need to make you know what i mean it's it's funny because we don't we don't do that with anything else right so like if if i went to go see the guy to work on my car i wouldn't be happier that he spent more time on it as long as it was fixed and And the same thing goes for literally any other, like an appliance guy. I wouldn't want him in my house for four hours. But you're not as vulnerable.

Yeah, it's very true. Yeah, it's different when it's your body. It's different when it's your body. Because it's scary. It can be kind of terrifying. It'd be like, this thing doesn't work. Yeah. And now it has a growth on it.

I mean, unless you are a physician, you can't judge, you know, really the quality of the medical care that you're receiving. So patients judge it based on the things they could perceive. Like, was he nice? Did they spend a lot of time with me? You know, those are the things that they can experience. So that affects their perception.

And, you know, again, I'm actually even at the good end of the spectrum because I practice within academia. I've seen patients in referral. So they were seen by a previous neurologist. The patient was unhappy with the care they received. They see me for a second opinion. I agree 100% with what the previous physician did. The only thing I do is spend a little bit more time with the patient explaining it all to them. Because I do have a little bit more of a luxury than somebody who's like really trying to survive in practice. And so that's really it. That was the

only added value that I did was a little bit more patient education. But that's critical. Patient education is very, very important. The problem is insurance companies, the system doesn't value and reimburse for the time it takes to do that. And so if you don't pay for it, you don't value it and it doesn't get done. That's the system. This is a systemic problem. One of the solutions that is being implemented to fix this is to use physician extenders, right? So you have a nurse who does the education piece, right?

So the doctor goes from patient to patient, but then you say, okay, now I'm going to hand you off to my nurse practitioner or my whatever, and they're going to spend 20 minutes with you doing the patient education part. Because you don't really need me to do that, to tell you the same thing. Somebody else could do that who's getting paid half as much as I am or whatever, so that it just makes the system more efficient. And overall, we could spend collectively more time with the patient. But to maximize efficiency, you never want somebody doing something that's below their

pay grade, right? Because that's an inefficiency. You always want somebody to always be operating at the maximum of their pay grade because that's when you're getting the most value out of them. Again, just looking at this from a systemic point of view, not a personal point of view. And so that's where the system is moving. And I think that's fine. That's a good solution to it. You know, uh, you know, either that, or we just, we just pay people more because I tell you what, and this is where I get like alternative medicine

practitioners drive me crazy. Like, Hey, we're better. Cause I'll spend two hours with you. Of course you're paying them cash cash You're paying them cash on the barrel. If you pay a doctor that much cash on the barrel, they'll spend two hours with you too. In fact, there are so-called boutique services where you could do just that.

If that's what you want, you can have it. You just have to pay for it. Yeah, it costs money. I want to touch on the insurance piece though because I found a piece of an article and I want to read it to you. Daily opioid use in the United States is the highest in the world

with an estimated one daily dose prescribed for every 20 people. The rate is 50% higher than in Germany and 40 times higher than in Japan. I want to ask you, do you think that the system that we have, profit-based system, do you think that that's a contributor

when we talk about whether... Because clearly in those other countries, maybe the pharmacy companies aren't making as much money or maybe they're not as well reimbursed as they are here. Do you think our system is sort of creating this? I wouldn't say that. I think it's a complicated, dynamic ecosystem and it's hard to say this one thing is doing it. It's interesting the countries that you chose as a comparison because there are huge cultural differences.

And I've spoken to practitioners in other countries, as well as American physicians who have done rotations, et cetera, in other countries. And so there's something else that I think I'd play here. So I think the short answer is yes, but there's other factors. For example, in Asian countries in particular, patients are expected to endure a lot more pain than in American and European countries. So like in Japan, like for example, a colleague of mine did a GI rotation in Korea. So this is a, during this rotation, they were scoping patients. They were sticking a camera down their throat into their stomach to take a look to see if they have an ulcer, right? In the United States, you would be heavily sedated for that procedure. In Korea, they did it without any sedation.

What? You just suck it up. That's baller. I'm telling you. Oh my gosh. You literally suck it up. Yeah. Drink it down.

Why do you, so here's another, I love this anecdote because it has to do with acupuncture. An American physician colleague of mine who was investigating the use of acupuncture anesthesia in China went to China to witness it firsthand. And so he was there with a translator and the patient was getting surgery. They were opening him up, you know, opening up his belly and doing an appendectomy or whatever. And he was getting the acupuncture and that was it. And then the patient is laying in the bed and he's saying, tongue, tongue, tongue. And the guy asks the translator, what's he saying? He leans in and listens to him for a few seconds.

He's saying, pain, pain, pain. And then, you know, the translator said something to the surgeon. The surgeon yelled at the patient and the patient shut up. Oh my gosh. Can you imagine that happening in the United States? Shut your mouth.

I mean, think about it. Sip it up, you. There's pain is very cultural, is the bottom line of all that. And your willingness or ability to tolerate the expectation of how much pain you should tolerate differs from culture to culture. I think in the United States, we're very pampered here. And people expect this pain-free experience, which is fine.

I'm not criticizing that. But that's the expectation. And so I think that's another thing you can't factor that out. You can't compare us to Germany or Japan and not consider the cultural differences between that. But sure, having said all of that, absolutely, the pharmaceutical industry is playing a role too. We know that now. That's been well-documented. But teasing apart all these various factors is difficult. So I wanted to get back to the patient satisfaction piece. So as you navigate, as a layperson, you navigate the medical system,

what seems to be happening is that there is a confusion or a translation between patient and customer, confusion or a translation between patient and customer, where the patient is now providing survey feedback on whether they're happy or not happy with the care that they received. And that has appreciable effects on how doctors are rated to the public and also how they're disciplined, according to the Guardian article I read, at least, how they're disciplined within their own practice or within their hospital. And their credibility is called into question if the patients aren't happy. And as a result, there is, at least from what I've read, there is a push to say, look, we want to make people happy. They came in here. They're

in pain. I'll give them a pill. They'll leave happier. So more pills get prescribed. And that seems entirely logical, but also I want to ask you about this idea of the patient as consumer. I'd just like you to kind of talk a little bit about that. And then I think I have a follow-up that I want to ask you about when you're done. So what do you think about this idea of the patient as a consumer providing

feedback that drives care? Yeah, it's very problematic. And you're hitting upon why it's problematic. And this is something that varies state to state, region to region. There's huge regional differences in practices within the United States because there's cultural differences within the U.S. as well. And that idea, like to what degree is the patient a customer that we're supposed to make happy, I think plays a huge role. Now, of course, there's a layer there that's legitimate and useful. We are providing a service, but it's a professional service. Sometimes people forget that professional part. So we are constrained by professional ethics, by the standard of care. And then within that context, we can meet the patient's expectations, try to optimize

their experience. So there's what we might call patient-centered practice. That's totally fine. We have to consider the patient's experience and what they need and want out of the therapeutic relationship, but within the context of professionalism and quality control. Now, but when the patient as customer gets out of control and takes on, I think, an oversized role, it becomes hugely problematic. And I can't name names, but again, I have colleagues who practice in parts of the country where the culture is way towards the patient as customer end of the spectrum. And it's horrible for medical practice, because then if

you're paranoid about making your patient happy, you can't give them tough love, right? You can't say, no, I'm not going to give you that opiate because it's not the right thing to do. You'll say, you'll do whatever it takes to make them happy so you get a good review. And believe me, that is the pathway of least resistance. I'm there all the time, even in Connecticut, which is, I think, towards the better end of the spectrum. I'm sitting in front of patients on a weekly basis all the time where they're pushing me for narcotics or for benzodiazepines or whatever, addictive medications for one thing or another. And I'm explaining to them why I will not give it to them. And they're not happy.

Sometimes they get downright mad at me. But I have to hold the line. I have to give them tough love because that's my role as a professional. So listen, I will, I will not give up on you. I will keep working hard to do what's right for you, but I can't do this thing because it's not the medically right thing to do. And I get negative reviews. I get, I suffer the negative review. That patient's going to ding me because I did not make them happy. But, but I, and I need to trust that, you know, that my superiors are going to understand that that's the nature of what we do. You're going to make some

patients unhappy because you did the right thing. But there are, there are some, you know, healthcare systems within our country where that is not what happens. What happens is you, you did not make that patient happy. The patient is you, you did not make that patient happy. The patient is always right. Do whatever it takes to make them happy. And so that becomes, that becomes pathological. So that's another element to this whole thing is that culture of, you know, how willing are we to hold the line against, you know, patient satisfaction because it's the right thing, Professionally, medically speaking, it's the right thing to do. So I wanted to,

my follow-up to that would be a curiosity on how you feel. You've got the situation we just discussed, or you just discussed. And then as a patient, the patient is in an uncomfortable spot, I think, right now, too. We've got this opioid crisis. And you look and you read these articles and you can see the ways that it was manufactured

and the ways that a lot of people were misled. And there are other examples of this. Vioxx was another example. There's examples of this where doctors were misled, patients, as a result, were misled. Patients are expected, to to some degree to act as informed consumers. And what I think is interesting on this show, one of the things that we talk about all the time is like, look, I'm not a climate scientist. So I have an obligation to cede to the climate scientists, right? I'm a guy with an English lit degree. I don't get to say anything

except for what are the climate scientists generally agree on. I recognize I can't read that literature. I don't have the tools to read that literature. And the same is true for medicine. But to be an informed patient, that's kind of our obligation. But then that sort of forces the patient between the rock of Google University and the hard place of, hey, I got three different opinions and I don't know how to evaluate them. Or I'm reading reviews, which we just discussed are problematic to try to decide who's right or wrong. And you know what I mean? There's a difficulty there in terms of remaining skeptical, remaining informed, recognizing your limitations in a field that you are not an expert in. I'd love to get your thoughts on that.

Yeah, it's a mess. I agree. That's why the system has to work. That's the only solution. And that's why we need to maintain really rigorous science-based standards of care because there's no other substitution for that. Patients can and should be as informed as possible, but unless you want to go to medical school, and not only that, even going to medical school is enough because you would have to be a specialist in whatever narrow area of treatment you're currently getting. And yeah, it's not practical. You just can't do it. I have to defer to experts even slightly outside of my area of expertise, right? Like I'm a neurologist. I wouldn't treat a patient with MS. It's too complicated. I'm not an MS specialist. I can't ethically treat multiple sclerosis, even though that's a neurological problem. And I'm a

neurologist because it's become so hyper-specialized and I'm not a specialist in that area that it's really not appropriate for me to do it anymore. Right? That's how the system works right now. So I think from the patient's point of view, you need to be as informed as you can be. You need to use common sense. But I think also at the same time, you need to find a doctor you can trust. And you need to be as informed as you can be you need to use common sense but i think also at the same time you need to you need to find a doctor you can trust and and you need to know how to do that that's a skill unto itself like how to evaluate how do you do that experts and professionals so you want you know so you want to know like what is their training what is their sort of are they board certified in this special are they practicing outside of their areas of specialty? Are the opinions that they give me, do they comport with the mainstream?

If I read something like the National Cancer Institute says X, does my doctor agree with that? Or are they telling me something that sounds way different than what other experts are saying? And that's a lot of work. I agree. I mean, but there's no substitute for that. And I also I always tell my patients and anyone who asks if you're not comfortable with with the first opinion, get a second opinion, get a third opinion. You know, you sometimes you have to if you if there's a critical medical decision that you're trying to make, it's worth, you know, expending the time, you know, if you if you

don't feel comfortable with that first opinion, but you have to check yourself as well. Don't just search for the opinion you want, you know, that's because if you search far enough, you'll find an expert to tell you anything, you know what I mean? So it is tricky. And I think that's, to me, that's one of the worst things about the alternative medicine phenomenon is that it's eroding the standard of care within the system. And now quacks are infiltrating the system and they are diluting the quality, the respectability of expertise itself. And that's a fatal flaw. The system cannot survive that way because then it'll totally break down.

survive that way because then it'll totally break down because if you can't have a certain minimum level of trust in the system itself, then it's a free-for-all, right? It's anarchy. At that point, there's no standard of care. You mentioned earlier that the things that you're reading in your field in neurology are leading people away from opioids. They're sort of the, the studies that are coming out are saying that there might not be the best thing you'd said earlier that it even might create a pain that, that, you know, it might create pain in patients. Are there better options nowadays? Like we taught, you know, clearly this was a breakthrough medication.

Oxycontin was a breakthrough medication in the nineties and it was used all the way up for, for, for quite some time. Are there some new medications that are coming out that change how we deal with pain? No. And I wish there were. Okay. Great show. Awesome. All right. Pack up your shit. I was hoping there would be something. Were you referring specifically like nerve pain, like Lyrica and gabapentin and things like that? There are things. So there's, so there's medications for neuropathic pain. So those are, that's pain produced from, by the nervous system itself. It's not feeling tissue damage. It's just producing pathological pain. That's not protective. So there's, there's medications for that, but we've

basically been using the same mechanisms to treat neuropathic pain for the last 20 years. There's nociceptive pain, which is when the nervous system is functioning appropriately, sensing tissue damage and experiencing that as pain. And we have the same set of options we had for 50 years, right? For that, we have non-steroidal anti-inflammatories. We have medications like Tylenol. We have opiates. There are new individual drugs, you know, but they're basically binding to the same receptors they've been binding to for 50 years. We desperately need new classes of medication for pain.

Now, I should say there are drugs in the pipeline, meaning that there's like basic science showing new potential targets, right? That's what we're looking for. Not just a new drug doing the same old thing, but a new target, meaning the new receptor to bind to that influences the pain system in a new way because we understand something about it that we didn't understand before. Yes, there's basic science that's showing new potential targets, but only about 1% of new potential targets actually lead to an FDA approved drug that's actually used by

doctors 10, 20 years down the line. And then when we're talking 10, 20 years. So it is my hope that in 10 years or 15 or 20 years, we will have drugs, FDA approved drugs that are treating pain in new ways. But nothing's come out recently. There's also new technologies like nerve stimulation, magnetic stimulation, which are a non-pharmacological way of modulating pain. But that's in its infancy.

And even though there are things on the market for that, like a TENS unit, for example, like the transcutaneous electrical nerve stimulation, the data on it is really dodgy. You know, in other words, the effect- I use one all the time. Yeah, it's like, okay, maybe there's a little effect here, but the data is really weak.

It probably has some small benefit, but it's not a home run. It's probably not as good as one of those copper bracelets that they sell. Those are crushing it. Those things are amazing. Exactly. So, you know, it's just,

we are dependent on what evolution has given us, right? Where there's only so many different moving parts in the pain system. And so we can only manipulate what's there. So, you know, I would love for there to be a time when we just hook up electrical device to your brain and dial down your pain reception. That'd be great.

Maybe we'll be there in a hundred years. I don't know. Who knows how long it will take. That's what we're researching. But right now we still need the few classes of drugs that we have. There's no game changer that's hit any time recently or that will hit any time soon. I want to ask you about recreational drugs in the sense that you see pharmacological drugs, and there's a number of examples. Opioids are obviously one of them. Ketamine is another one.

But there's many, many examples that end up becoming recreational drugs because the side effects, they're intended for one thing. The side effect is euphoria or some other pleasantry. Were we to de-stigmatize the idea of drugs as being recreationally valuable? Clearly, we know there's a supply side to this equation on the recreational side. Would that open up, in your thoughts, a new market for safe recreational drugs that could help stem the tide so people don't turn to drugs that have, you know, like, why would I go use an opioid, for example, if Purdue Pharma made a recreational drug that was every bit as good and safer? Like, is there a reason to think along those lines as a way to solve this problem or to reconceptualize this

problem? Not really. There's at least no, in my opinion, there's no strong case to be made for that. And again, it's a complex dynamic ecosystem. And if we change something like that, I don't think anybody can predict how it's all going to fall out. And there's reasons to think that it might not work out as intended. If you think about what is the most dangerous in terms of morbidity and mortality, right? What drug, what recreational drug causes the most harm? Alcohol. It's the legal one. It's alcohol. Now that also, you know, there's pharmacological reasons for that as well. It's not just because it's cultural and legal, but there is that. And you think, say, you know, what's safer than OxyContin? It is a pharmaceutical grade, you know, very well regulated drug, right? It's not like a street drug. It's not like something that somebody cooked up in their basement where there's contaminants and who knows what the dose is. And you know what I mean? If you take an Oxycontin that says 20 milligrams of whatever, that's exactly what you're getting. But people are still killing themselves with those drugs. So I think that there's a, with opiates specifically, I think there's just an inherent, you know, problem with that class of drugs. It's just massively inherent problem with that class of drugs.

It's just massively addictive. And there's just no way around that. I don't think you could safely recreationally use opiates. Yeah, I guess I may have misstated the question. I'm sorry if I did. I guess what I meant to say is if we destigmatize recreational drugs as a category and then pharmaceutical companies were incented to create, not opiates, recreational drugs that were just designed for their pleasantry. And they wouldn't be opiate.

Could you not have... You're talking about marijuana, right? So we're in the middle of a huge experiment now doing exactly that with marijuana. It's being rapidly decriminalized. And there's definitely a good case to be made for that. Because's being rapidly decriminalized. And there's definitely good case to be made for that because it's a catch-22. You criminalize it. People still use it. You're just now funding a criminal organization around it. And you lose your quality control, whatever. So there's lots of reasons to decriminalize it. But what's going to happen

when we do that? Is it going to really lead us to a better society or less abuse? Or are people going to use that instead of harder drugs? Or is it going to be a gateway drug to harder drugs? Or are we just going to have a society where a huge percentage of people are stoned all the time and are not as functional as they otherwise would be? We'll see. You know, I mean, that's a huge experiment any i doubt i don't believe anyone who says they can predict what's going to happen and i know that the enthusiasts will give you this utopian interpretation of how it's going to all work out wonderfully and they'll cherry pick their evidence to support that claim but i don't buy it i'm not i'm not making the

opposite argument that it's all going to be horrible either i'm saying we don't buy it. I'm not making the opposite argument that it's all going to be horrible either. I'm saying we don't know. We just don't know how it's all going to work out because it's, again, there's cultural influences, there's economic influences, there's pharmacological influences, and how is that all going to settle out? We'll see. We don't know. Let's face it. So, Dr. Novella, you recently came out with a book, The Skeptic's Guide to the Universe, How to Know What's Really Real in a World Increasingly Full of Fake. Tell us about the book. Yeah, so we've been, something we've been talking about for a long time. It's obviously named after our podcast. We've been doing this, you know, the podcast for 14 years. We've been engaged in skepticism for 23 years, activist skepticism. We were obviously just non-activist skeptics prior to

that. And this is the culmination of everything I think that we've learned over the last couple of decades. We wanted to create a book that would be two things, really. One would be a primer for the newly minted skeptic or somebody who is skeptically curious or just you say, hey, what's this whole critical thinking thing about? You know, or somebody says, I have my cousin, you know, needs an introduction to scientific skepticism. So we wanted this to be that the intro into scientific skepticism, but also to be complete enough that it would be a reference for somebody who's already a skeptic.

So it's like you want to here's all the logical fallacies that you need to know. We started out by making a list. Like, let's make a list of 50 things every skeptic should absolutely know. And that sort of became the core of the book. And then it's built into this sort of journey of critical thinking and love of science and philosophy. So, you know, I'm quite proud of the result. I think it came out exactly as we intended and it's been received, reviewed very, very well. So, yeah, I mean, it's been selling well. So I highly, highly recommend it. It is for anyone who's interested in critical thinking.

I think it's a good introduction, good reference. Well, uh, I gotta ask you, you know, I don't know that I've ever heard the origin story of your podcast. Um, I was, I was an early listener, but I'm not sure I've ever heard the origin story. What started you on this, on this road to podcasting and creating, I think probably the most famous skeptics podcast out there. So, yeah, we have told versions of this story or parts of the story before on our show, but I'll give it to you here. So essentially, we've been running the New England Skeptical

Society for, at that point, about 10 years and publishing a newsletter and holding local meetup groups and lectures and starting to get out there ourselves talking and writing. But we knew that we weren't quite meeting our potential. And this was also around the time, you know, 2005, when social media was starting to become a thing. And we're like, you know, guys, we really got to do something. We got to do more with our skeptical activism. And we tried multiple things.

We thought of multiple things. But one day, a friend of ours, who is not, you know, in the skeptical movement, said, you know what, guys? There's this new thing out there. This is 2005, right? There's this new thing out there. This is 2005, right? There's this new thing out there called podcasts. And, you know, we would sit around and have,

like while we're playing video games or doing whatever, we'd have these really fun political discussions. He said, we should record those and then publish them as a podcast. And I famously said, that's a great idea. We're going to do that, but we're going to do it about skepticism, not politics. And you're not involved. Oh, damn. Well, he wasn't, he wasn't a skeptic, you know? So, um, just because that's the, that's what we decided to do. He wouldn't be involved, you know. But we already had a, you know, we already had our organization. So that became, the Skeptic's Guide to the Universe became the podcast of the New England Skeptical Society.

Just like something else for us to do as skeptical activists. But it completely took on a life of its own. And then we sort of split it off as its own thing because it became orders of magnitude bigger than, you know, the organization. And so here we are 14 years later. Are there people close to you in your life that are not at this point skeptics? Oh my God. You don't know the half of it. Really? Oh my God. I genuinely find that astonishing. I'm not even, I'm not faking for a fact. Like I genuinely find that astonishing. I'm not even, I'm not faking for a fact.

Like I, that is astonishing. You would think. You have people close to you. Wow. You would think that long exposure to the Novella brothers, you know, alone. How does it even happen? Would rub off on you. But so, hey, there's a person very close to us

who we don't mention by name who believes the world is flat. No. Shut the- No. What? I'm telling you.

You, hold on a second. In all sincerity. Dr. Novella, Dr. Novella, you're a round earther. I can't believe it. I just can't believe it. This is a sit-a-view though. Like I'm floored by that. Oh my gosh.

Do they use GPS? do they use gps do they use gps to get around sure because that's amazing yeah the ironies are just endless but yeah i mean people are who they are and i certainly i'm not not to say that we haven't had an influence on the people around us of course we had but you can't change who people fundamentally are no matter. And this becomes a lesson that we talk about in the book and elsewhere. It's like, you know, you got to pick your battles, got to play the long game, and you have to be realistic.

But if you expect everyone in your life to be as skeptical as you, you're going to be disappointed and you're going to be lonely. And, you know, we all have to live in this world with other people who don't necessarily share our worldview and our values, and that's fine. And we get along fine with all these people, but, and we're not afraid to be who we are. We are unapologetically skeptical, but we just don't make it personal.

You know what I mean? Yeah. Perry, Perry was on the show for the first couple of years. He was instrumental. His wife was a Jehovah's Witness. Oh, I remember that. I remember hearing about that. Yeah, yeah.

Think about that. Let that one work on you for a while. He was a Jehovah's Witness. Wow. And whatever, it worked. It's fine. You could, you know, it is what it is. Wow.

So if someone, I don't know how they would be listening to our show and never have heard of your show, but let's just presume there's a person out there who hasn't. How would they find your show? If you just search on The Skeptic's Guide to the Universe, you will find all of our properties. Now, our website is theskepticsguide.org, and you can get to everything through there. Dr. Novella, this was an amazing conversation.

Thank you so much for joining us today. Thanks so much. Yeah, it's been a lot of fun. Thanks, guys. So we want to thank our patrons of course we want to thank all our new patrons and all our old patrons

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on this week's show notes. This is episode 473. Tom, we got a message from, I don't know that I want to read it because there's some personal information in it, but it's a message about abortion. And this person said their sister has a rare genetic condition where her chances of any of her pregnancies result in a baby are one in three. And when she was first trying to have children, she had three times gotten through the first three months of pregnancy, only to find out at the doctor's office that the fetus no longer had a heartbeat.

And she was each time given the option to go home and wait for the miscarriage or just have the fetus removed. The third time that she was wheeled back into surgery, she had a bitchy old nurse come look her in a chart and then snidely make the comment about her keeping her legs closed and walked out. And this person says, you know, maybe some of the numbers might be skewed. If we talk about this, this isn't an abortion. The thing is dead. It's dead already. The fucking fetus is dead. It's three months in fetus. Didn't make it. Sorry. It's a sad day for everybody involved. Nobody's fucking happy. There's no party poppers. Nobody's fucking, they're not having a fucking gender reveal party for the three month

for the three month old stillborn fetus right nobody's happy right but yet we're still like oh you know what we ought to fucking shame these people no well that's because that's because there's a a mentality that ties any kind of an abortion or any kind of procedure that is the same procedure as abortion with this moralistic bullshit around promiscuity. Right, right. That's what that keep your leg closed. That's all it is.

It's being moralistic about promiscuity. Yeah. It's fucking bullshit. It's the fucking 21st century, you old bitch. Yeah. It's okay for people to have sex. Yeah.

You know, what the fuck? If you don't want to have sex, don't have it. Yeah. That's the emotion. It's super easy. You can decide that. You can be an't have it. Yeah. That's the emotion. We all get to decide. It's super easy. You get to decide that. You can be an angry insult lady.

Right. You know, I want to say I saw a video this last week. Maybe it was last week, two weeks ago, something like that. And it was a video of these people, these fucking wretches who sit around. I don't even know. I think it's the last abortion clinic in one of those shithole states. And they sit around like vultures waiting for a person to come.

And then they have these people who are volunteers. They wear those orange vests, you know, like the safety vests. And these are volunteers like that are just trying to get the person who wants to get an abortion in the door safely and hidden. They have to put a coat over the person's head. It's a woman

right over her head and then walk her basically walk her cause she can't see. So walk her while these people with bullhorns hold the bullhorns up to the coat and scream at her about how she's going to kill her baby. And it's just the most, it's the most wretched thing I've ever seen. And they crowd up on her. and I'm thinking to myself, I'm like, I know you shouldn't hit those people. I know that's bad. But every part of me wants to hit them. Yeah, I was going to say like- Every part of me wants to do it.

Well, you shouldn't do it because that's what gets played. Not their awfulness, right? Like not their awfulness ahead of time. None of that gets put in the media. What gets put out there is some asshole clocked this fucker. That's what gets put out there is some asshole clock this fucker that's what gets put out there it's always going to be the worst spin for you because you use violence right it's always going to be yeah it's not that i disagree with punching one of those because i'm like part of me is like i want to hit one of those people so hard that that fucking goddamn

bill like that fucking horn gets stuffed in a place that they can never remove it. Unless they get an abortion. You're right. You have to wheel them in because I've stuffed it so deep in you, they're going to need a vacuum to get it out. But I'm just, you watching it, it just makes me see. I'm so mad at it. And I know there's people who do this work. That's their job is to go stand there around these people

to make sure they don't get accosted when they go in. It's unbelievable. Tom, we got a tweet. Would you want to read this? I do. This is from Bishop Thomas Tobin. He says, a reminder that Catholics should not support

or attend LGBTQ Pride Month events held in June. They promote a culture and encourage activities that are contrary to Catholic faith and morals. They are especially harmful for children. Shut the fuck up. The irony meter just goes whoop, whoop, whoop. Bishop Thomas Tobin. Unreal.

Like, how tone deaf to yourself do you have to be? No shit, right? So in reply, Charlie Hines TV says, just because there's a restraining order banning you from getting close to children doesn't mean all Catholics need to stay away. That's amazing. It's really harmful to children when you are a priest that rapes them.

Jesus Christ. We got a message from Chris Matheson, the author of the two books, Story of God and The Trouble with God. He came on the show a couple of times. He's a really funny guy. We had him on talking about Trump. Love that guy. And he's God. He came on the show a couple of times. Really funny guy. We had him on talking about Trump. Love that guy. And he's great.

He's just a great guy. There's a really funny video that we're going to post on this week's show notes. It's God's Art Museum. And it's basically him talking about old timey paintings. And it's hilarious. As God. It's hilarious.

It's so good. It's very funny. So check it out. It's on this week's show notes. Very funny guy. Hopefully Bill and good. It's very funny. So check it out. It's on this week's show notes. Very funny guy. Hopefully, Bill and Ted 3 comes out next August. He says he's going to have a new book, Mocking Buddhism, at that time. He's going to come on the show, hopefully, next August.

So that'll be great. But Chris Matheson, huge fan of Chris. Awesome guy. And we're looking forward to having him on again. But check this video out. Very funny. We got an image. This is about, what is it?

Arthur, is that what it's called? Yeah, Arthur. So, Arthur's, the gay aardvark wedding. I want to post this on this week's show notes. The person only left their email address, so I don't want to read who they are because I don't know who they are. But the person who sent this, thank you very much. So funny. We're going to post it on this week's show notes. Check it out. So Kyle sent us a message and said, hey, I want to make you guys

a rosary. So we were discussing the sad Trump coin and the rosaries and they said they want to make us a rosary, a special rosary. If you send us a message,

we will tell you where to send it. It's Glory Hole Studios. We'll give you the email address. Yeah, we'll send you the email or not the email, the actual snail mail address. And I do remember you, Kyle. So if you want to send us a rosary, we'll put it on Gary. Gary's already got fucking fuck me beads on from Louisiana. So might as well

have a rosary too. The rosary is fuck me beads for little kids. Is that what that is? Is that what that is? They walk in like, show me your tits. Yes, it is. Show me your tits, 10-year-old. Here's some fuck me beads. Laurel. Laurel sent in this image. We're going to post it on this week's show notes. It's a,

we asked someone to draw, you know, a bald eagle rubbing its testicles on a flag. And now we have a coin. There's a coin, an actual silver eagle coin

of that. We'll post it on this week's show notes. Laurel, hilarious. Asked and answered. Asked and answered. Thank you so much. Bravo.

We got another image from Aaron. It's a Garbage Pail image, Garbage Pail Kids. If you remember back in the day, Garbage Pail Kids. I had Garbage Pail Kids. My dad used to get so mad when he would give me an allowance and like,

he'd give me like a dollar or whatever. I'd go and buy Garbage Pail Kids. And he would get so mad that I wasted my money on him. It was a waste. It's a total waste. Stop giving him my allowance. It's a total waste. I mean,

he's right. Oh, I know. It's not like he was wrong. Oh, I know. Yeah. It was a total waste. Would you ever do that with your kids?

No, I don't care what they buy. It's their money. It's their money. Their money. I mean, like short of illicit shit. Kids buying Oxy. Yeah.

Right? Yeah. I mean, if he shares, cool. Right. Exactly. No, I don't give a shit like it's like kids buying oxy yeah right yeah I mean if he shares cool exactly no I don't give a shit daddy's back hurts give daddy an oxy

no I don't oh that's so funny well anyway there's a garbage pale kid of Donald Trump it's not Donald Trump but I don't want to ruin the joke so check it out

it's on this week's show notes so I want to thank Dr. Steven Novella for joining us talking to us about the opioid crisis and we we really enjoyed having him on. He is one of the hosts of The Skeptic's Guide. You can find out all about that podcast at theskepticsguide.org, where you can also buy their book, become a patron of theirs, check out their podcasts.

They're great guys though. Anna Gall, they're Cara Santamaria who has also been on our show. She's terrific as well. Is part of that, is part of that podcast group. So if you want to check out their show, if you haven't already,

I'm sure you have, but if you haven't already, you can check out their show at that link. There'll be a link on this week's show notes. We want to thank Dr. Novella for joining us this time. If you have any stories

that you want to talk to us about, we're still collecting those. The opioid, if you have a question or a comment about what Dr. Novella brought up this time, you can send that as well, dissonance.podcast at gmail.com. We're going to collect all these

and then we're going to basically redact all the information that needs to be redacted like fucking bar here. We're going to be fucking bar. We're going to redact. Short're shorting it to next to nothing. Yeah, I'm going to turn it into a four-page report. But we're going to redact all the pertinent information because a bunch of people did send us messages, but they were like, hey,

don't read my name. Don't say anything about me. Can you remove some of the details of my story? So we are going to do that. And then we're going to read some of the things and also summarize some of the things that were sent to us and then chat about them as an extra for people. So you still have about a week to get those in. You can send them to dissonance.podcast.gmail.com. We'll also be pulling from some of the places where it's posted like Facebook and Twitter. So you could post there if you like.

But we'd love to hear from you. So far, the feedback's been very good. If you have different feedback, let us know. We really enjoyed doing the episode and we love to hear how you liked it. So please send us a message if you did or didn't, or if you have a story. But that's going to wrap it up for this week. We are going to leave you like we always do with the Skeptic's Creed.

Credulity is not a virtue. It's fortune cookie cutter, mommy issue, hypno Babylon bullshit. Fortune cookie cutter, mommy issue, hypno-Babylon bullshit. Couched in scientician, double bubble, toil and trouble, pseudo-quasi-alternative, acupunctuating, pressurized, stereogram, pyramidal, free energy, healing, water, downward spiral, brain dead, pan, sales pitch, late night info-docutainment. Leo Pisces, cancer cures, detox, reflex, and towers tarot cars psychic healing crystal balls bigfoot yeti aliens churches mosques and synagogues temples dragons giant worms atlantis dolphins truthers birthers witches wizards vaccine nuts shaman healers, evangelists, conspiracy, double-speak stigmata, nonsense.

Expose your sides. Thrust your hands. Bloody. Evidential. Conclusive. Doubt even this. The opinions and information provided on this podcast are intended for entertainment purposes only. All opinions are solely that of Glory Hole Studios, LLC. Cognitive dissonance makes no representations as to accuracy, completeness, currentness, suitability, or validity of any

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