We're Out of Time - Dr. Mark Gold: Can GLP-1s Help Treat Addiction? The Science Behind Cravings & Recovery

Episode Date: June 23, 2026

Could medications originally developed for diabetes and weight loss help transform addiction treatment? In this episode of We’re Out of Time, host Richard Taite sits down with addiction medicine pioneer Dr. Mark Gold, widely regarded as one of the founding figures of modern addiction medicine. For more than five decades, Dr. Gold has helped shape the scientific understanding of addiction, cravings, dopamine, withdrawal, and recovery, with groundbreaking research that has influenced treatment approaches around the world.Together, they explore the growing interest in GLP-1 medications, and why many researchers believe they could represent a major breakthrough in treating substance use disorders. Dr. Gold explains the science behind cravings, the gut-brain connection, food addiction, alcohol use disorder, cannabis use disorder, and how GLP-1s may help reduce compulsive behaviors.Richard also shares observations from Carrara Treatment Wellness & Spa after integrating GLP-1 medications into treatment for over three years, including an early finding that approximately 80% of participating patients have not relapsed. Dr. Gold helps place those observations into scientific context while emphasizing the need for continued research.The conversation also tackles one of the biggest questions surrounding GLP-1s: Should people stay on them long term? Dr. Gold offers a candid perspective on what researchers know, what they don’t know, and where the science is headed next.If you’re interested in addiction recovery, neuroscience, GLP-1 medications, cravings, and the future of addiction treatment, this episode offers a fascinating look at one of the most promising developments in the field today.If you’re interested in addiction recovery, neuroscience, GLP-1 medications, cravings, and the future of addiction treatment, this episode offers a fascinating look at one of the most promising developments in the field today.#glp1 #addictionrecovery #glp1 #neuroscience #recovery #drmarkgold

The GOP-1s have a chance to have a revolutionary impact in addiction medicine because of their relationship to food, their relationship to addiction, and the fact that they not only are gut messengers, but their brain messengers. If someone has a problem with substance use disorder, please call one call placement. That's 8888-8-3-1-1581. And if we can't help you, we'll make a referral to someone who can. please, we're out of time. One Call placement is affiliated with Carreira Treatment, Wellness, and Spa, and One Method

Treatment Centers. Today's guest is one of the true pioneers of addiction medicine, Dr. Mark Gold. He's a world-renowned physician, researcher, and educator whose work has helped shape the modern understanding of addiction for more than five decades. He is one of the most cited addiction scientists in the world and has all. authored more than 1,000 scientific publications on addiction, cravings, and the neuroscience of recovery. Now, he's helping lead one of the most fascinating conversations happening in medicine today, the potential role of GLP1 medications in addiction treatment.

At Carrero, we've been integrating GLP1 therapies into treatment for more than two and a half years and have seen growing interest in their potential to reduce cravings and support recovery. He'll be doing a training with our clinical staff so we can keep getting better as a clinical team because we're always interested in getting better. We'll also talk about the important work he's doing through the Gold Standard podcast, where he continues to educate clinicians, researchers, and the public on the latest developments in addiction science. Dr. Mark Gold. Welcome. It's an honor and a privilege to have you here truly.

Thank you. It's my pleasure to be here. Your entire career has been based around studying addiction. What is the most exciting thing about the GLP1 conversation right now? Well, it's a great point, Richard. I mean, I've been working in the field in earnest since about 1973. And I started by looking at amphetamines and memory and looking at pleasure. I didn't intend to be an addiction researcher. It just turned out that way.

My research led me in that direction because there was really no other way at the time to study pleasure. We had at that time a focus on simple neurotransmitters, noraphenephyne, serotonin, acerone, acetyone. Letal coline, less on dopamine. I brought dopamine out pretty much in the 80s, early 80s. But right now with the GLP-1s, as you bring up, we are in a new age because historically, we know that the gut is connected to emotions. We know that because people who have inflammatory bowel disease or other bowel diseases

often have concurrent psychiatric problems, people who have. eating disorders have concurrent substance abuse problems and psychiatric problems. So we know it's connected. And even 2,500 years ago, Hippocrates said all diseases begin in the gut. I mean, the father of modern medicine in Greece said all diseases being in the gut. So for the first time, we have kind of gut brain proof. And so the GLP ones have a chance to have a revolutionary. impact in addiction medicine because of their relationship to food, their relationship to addiction,

and the fact that they not only are gut messengers, but their brain messengers. I have to let you know that we opened two and a half years ago after my five-year non-compete, after selling my last place. 31 people came from my last place to do this with us. So we're not, and they're the best practitioners in the industry, okay, from rated the best treatment center in the country in 2025. So I took those people and brought them here from my last place. So we're more like 20 years old when you think about it.

My people are so good that my doctor, Kenneth said, I want to put you on the gLP ones. I said, why? I'm not fat. He goes, well, you could lose five pounds, ten pounds, but that's not why I'm doing it for you. The reason I'm doing it for you is because you smoke so many cigars. I've never seen you without a cigar in your mouth. Okay? And he says, it's going to cut you down. I said, I don't want to be cut down. He said, of course you do you have children just do this for me cut to i struggle to smoke two cigars a day so when that happened to me we were just opening the centers and i went to him and i said this works on addiction i want to use it here don't give it to anybody with an eating disorder

But other than that, I want this used if you feel it's appropriate. But I want to put this into our program. It works so good, okay, that I would say that everyone who's been on it, not everyone, but I'd say about 80% of the people who have been on it have not relapsed. I don't have the data in front of me, but I know my business pretty well. and I'd say about 80%. Now, when have you ever heard a number like that, doctor? Well, we have, it's a really interesting question. You have the medication, like you have to, let's say, let's look substance by substance.

If you compared it to Naltrexone, you'd say, what are the differences? Well, actually, there's no random assignment, a randomized trial, right, to this point, comparing the two. But we do know that your 80% number works for naltrexone if you take it. Now, the reason that people take gLP ones rather than naltrexum, which has an adherence problem relative to gLP ones, is probably because of the weight loss. They get reinforcement from peers and others because they look better. But I'd say that 80% number, if you look at TMS and depression, 80%. But let's get back to your notion, why would this be? Why would that doctor in your treatment program say that? Well, it all actually started with the notion that drugs and food

compete in the brain for the same reinforcement sites. That was a paper of mine, and you can kind of Google this Yale historic conference on food and addiction. And so we said, well, like you know, Richard, If people are on they don't eat. If people are addicted, they don't eat. And so drugs on, food off. And so that must mean that there's kind of co-regulation. We had no idea what the messenger would be. And so my group in that project, we were actually studying at Princeton,

and sugar self-administration and high fructose corn syrup, manufactured food self-administration in laboratory animals, and showing that it was just like drugs of abuse. And you may remember at the time they misquoted our lab saying that that sugar was just as addicting as which it wasn't, but the mechanisms in the brain were the same. Our group then went the opposite way and we said, well, gee, you could give addiction,

anti-addiction medications to overweight people, and that would cause them to lose weight. And so an example of that would be the medication contrave, which was naltrexone and grupropion, which is a medication for smoking or alcohol to put together. But the real advance was in the GLPs, which you see clinically, because they looked out it the other way. They said, let's take a weight loss med and give it to addiction. You take GOP ones at home without treatment and therapy and medical supervision and everything that we do here, all the modalities. You ain't getting 80%.

Okay. And if you stop drinking and using drugs, you're going to be nuts because you didn't fix anything. you're just not taking the medicine that you needed in order to live. So I just wanted to point that out. One more thing that it hit me, right? I mean, you can, I assume that you agree with this, right? But the second thing was you said about the sugar and the and I got to tell you, addict needs a nap and a sandwich, okay?

sugar is a problem because you got to go out and score you know you got to make that decision to do it most of the time you put sugar in your mouth you don't even know you're putting sugar in your mouth okay and you got to eat every six hours right so it's a lot harder for me and you know after seven days i was on sugar after seven days it was the hardest seven days of my life But after seven days, you don't think about it anymore. That's my experience. That's anecdotal. No, no.

It's like each of these projects of mine, like take decades. It's not, so I worked on the sugar as a drug. In fact, have an Oxford University textbook on the subject with lots and lots of different labs working. It's a big project. But it's very important. And it shows you why it's hard to get off junk food. do you you you wrote a textbook that they use at oxford i just got goosebumps hopefully they i have i have if you write a thousand scientific articles hopefully somebody reads

them and you know on the the books like the yale historic conference on food and addiction the all of the collaborators that worked on that from around the world put a textbook together for Oxford University Press called Food and Addiction. And then it's subsequently been updated by mentees. Just like you have mentees, people who are, you trained and mentor along the way. Like my mentees are running the food and addiction lab at Michigan and Princeton and Mount Sinai. And, you know, they're carrying the work now. I'm just grateful that they include me.

from time to time. I recently got a Lifetime Achievement Award from CADCA, Community Anti-Drub Coalitions, and previously got an award from the National Association of Addiction Treatment professionals. So when you're in a lab or you're doing science and you're writing papers, you don't always see the impact of what you do. But when I interact with people at the ground level in cities at CADCA and they say, you don't always see the impact of what you do. But when I interact with people at CADCA, say, you know, your work has made it easier for us to do our work because we know that drugs are addicting because of the things you did in the 70s and 80s. That kind of means a lot to me. Same for treatment professionals. You know, they pick, I write about once a week for psychology

today, and I get notes from treatment professionals all the time that they're using this article on GLPs and basically it's all free so they downloaded, handed out to patients. So for me, at my stage of my career, what can be better than having impact? No, nothing except for having children. Let's let's move. Right? Obviously. It's true.

Let's move on. Why are cravings often one of the biggest obstacles to long-term recovery? Well, you'd answer that one as a clinical expert. I'll answer it as a research expert. As a research expert, we know that you can have cravings that do not reach conscious level. So if you have a craving and it doesn't reach conscious level, you may not be able to identify what's going on other than you're being drawn like magnetism to bad environment. to people who are holding drugs and so forth. And it reminded me of an old story that was told to me by a doctor

who came into a treatment program in Florida that we had at the University of Florida. And he was supposed to show up for treatment. And he didn't show up for a day. Everybody wondered, but his plane landed in Gainesville. He didn't show up for another half day. And when he did show up, he was positive. And we said, well, what happened? And he said, don't blame me.

You're the ones with the driving cabs. I said, like, what do you mean? And he said, I walked in one cab and I looked for a friendly cabby. I found one. And I sat in the back. And of course, he then said, you want to, you know, it is like, so he could literally smell the cold. And but not. And then that would trigger craving.

So craving, when you think about craving, some of the reason that people like the GLP is they reduce craving. And you may have noticed that for your cigarette, your cigar smoking. It happens without you thinking about it. It's something that you could augment with CBT and going to therapy and having a sponsor and doing all the right things, like just knowing that you shouldn't be with these people, places and things. But craving can be elicited and it can take a life of its own, take on a life of its own without conscious intervention. That's the biggest problem in craving. So that's something that would never have come out of my mouth, okay, because you're a researcher, and it was absolutely beautiful.

So the question was, why are cravings often one of the biggest obstacles to long-term recovery? And there's a couple reasons for it. Number one, on my level, okay, it calls you. So you could be sober, and it's just calling you. And it calls you until you get the support you need, right? And once you get the support you need and the treatment you need, it calls you less and less until you're not being called. Then it will come back if you don't do anything about it.

You can't go from 40 hours a week of treatment to a therapist once a week. That doesn't work. Okay? You got to go therapy three times a week. space it out with the day so you have time to process okay you got to know where you're supposed to be work kids whatever okay and if you're into a a you should go to a if not you should go to a group therapy thing now if you do those things at a certain point i just wrote a book co-wrote a book with dr constant sharp called transcendence okay and what that means is is after a certain period

of time, if you do the work, okay, you can transcend this whole thing to where it's simply not who you are anymore. Okay. Now, it doesn't happen for everybody. It might happen for five percent of us. Okay. But it's the goal. It's the goal. So that's my thinking on this. No, no, I think that's a good way to put it. I mean, I put it in, like how brains work and say, well, the craving can be separated from action. Right. So the other way, the other kind of thing that happens with craving, and you make a great point about this, when you're in a residential treatment, you're probably getting 10 hours of

treatment a day. When you're an outpatient treatment, you may be getting, you know, 50 minutes. The dose of treatment is so different that. that, you know, it took a long time to develop all these bad habits. So if you look at cravings, craving just the state of craving, untreated, changes the way people think. And there's even a recent study showing that people who are in a state of craving make bad choices consistently bad.

They needed a study for that, doctor? See, I still can have a sense of humor. But, you know, you need to study for everything. But yes, you can just say it's a proven fact that it doesn't matter what the consequences are. And we know that you say they don't need to study for that too. I mean, how many times you get hit over the head before you realize you're hurting yourself? But they even have a new study that shows. that people who have substance use disorders don't learn from mistakes.

How much money they spend on that? How much money they spend on that? There's a whole field of research now on how the brain, you know, the brain changes throughout development. So we could talk about this. But if you happen to have a child, the brain goes through a new growth, expert. And that's been really, it's very, very recent research, but it's very interesting. So in a way, people who've never had children are different from people who have, even in brain functioning.

That's beautiful. That's beautiful. All right. Can a medication reduce cravings without replacing the personal work required for recovery? This is what we were just talking about. So, medications have a role, but treatment is still going to be necessary in my point of view. You couldn't put naltrexone in the water and get anything other than less drinking. So I do think you could get less. And maybe that you've thought of that question because of the GLP's. One of the new findings, of course, is that if you take GLP's, there's, less harm from substance use.

That doesn't mean there's no harm. You know, it just appears you just, you reduce the exposure, the total amount of dose. That's what I was thinking that it's not, also the duration should be a little less, but the amount should be a lot less. The amounts less. And there's a really big study, VA study. I don't know if it was 30,000 people this year or 50,000 people, just showing health care utilization was down.

So I do think, Richard, that you could say, well, gee, and you know, this comes to mind because of bipolar illness. When early days of lithium, they said, let's find a place which has lithium in the water, naturally. And there's a West Texas area that has enough lithium in the water that people have substantial lithium levels. So they found like they didn't have bipolar illness at the same rate as equal like matched place in Texas. So if you had GLP's or Naltrexone, you would have less craving, less use. It's an interesting question because we don't still know whether there's other areas that will be compromised. I mean, I don't know you well enough. Maybe it'll affect you emotionally

not to smoke that much. Or maybe I have no idea or cognitively. I have no idea. But it is pretty clear that the medicines that we have are improving and they're surprising people because craving just doesn't reflect desire, but how decisions are made and biases the brain. And so therefore, if you're thinking about it, if you have less craving for a cigar, you make choices that don't involve cigars. It really increased the quality of my life. Okay. I'm not a hostage to smoking. Okay.

I'm not smoking out of habit. I'm smoking when I really want to enjoy a cigar. And so literally I took an elegant. practice, made it full of scumbaggery, and now I'm back to the elegant use of this cigar. So I loved it. We have like, so people who've had substance use disorders change their brain. And then what happens after that, we have to figure out. But it's, it's, it's, I've looked at it myself like, um,

You may remember in substance prevention, we used to tell people, delay, delay, delay. Like get a kid to 21, and their brain would be formed. And so, but now with more sophisticated brain imaging, we know that the brain is developing from birth all through the 20s and maybe even into the early 30s. I did not know that. I thought it's, I thought your frontal cortex. developing at around 25, 26. This is new information.

Yeah, I'll send you the reference, but there's a really, there's a new study with sequentially doing prospectively looking at brain imaging. And, you know, it is true that men develop later than women. That's true. It is true that the brain really is pruning something,

meaning it's not using them so you lose them and accentuating other things. So one of the things that happens, you spend a lot of time looking for drugs, thinking about drugs, using drugs, your brain is thinking, well, why play the violin? That's hysterical. That's hysterical. You know, so like skills start to fall to the wayside that you might have had. In a similar way, in my own family, I learned this early on, my father's identical twin. He's now long deceased, but so I can tell his story, that means he has exact same genes of a twin.

So his one twin became a CEO and very successful got a master's degree at Oxford, an undergraduate degree. in chemistry at Cincinnati. And my father played basketball. And so I said like, it literally played basketball in college, played basketball in World War II in the Army, and then didn't really work very much compared to my uncle, but they're identical.

Absolutely 100% identical. So the first thought is they can't be identical. So we checked them and the genes are the same. is now you can do that like 23 in me or something. And so I said like, how did that happen? He said, well, the only thing we can think of is we were exactly the same till seven. And then my brother broke his leg. And he had a really severe break and fracture.

And they set it. And so he had to stay home. And then he never really healed enough to play basketball with me. And his mother, my grandmother said, you should study. So she made one study and the other one stayed in the streets in Brooklyn playing street basketball. And there you go. So the brain, like, just use it or lose it all along. But now it turns out that the major brain reorganization points are 932.

66 and then 83. I'm not looking forward to 83 because... Repeat that. Go over that again, doctor. I missed... Why did you mention all those numbers? I must have spaced. Those are the peak brain reorganization periods. So the brain reorganize the way a person should think about it is the brain has lots and lots of capacity and prunes it, focuses it, and you can develop it. Now, I can't be LeBron James, but by the same token, it's pretty clear that I'm good in physics and math because someone spent the time to teach me physics and math, so it's almost intuitive for me, by 9, by 32, 66.

So those are the brain growth periods that have been studied, maximum growth. Then at nine, there's a new kind of growth till 32, which I call specialization. And if you're spending nine through 32 thinking about drugs, using drugs in and out of drug treatment, you're going to give up something. Yeah, I clearly gave up something. I lost 25 years. So I did the same.

Let's touch back on the brain and GLP-1s. How exactly do GLP-1 medications appear to affect the brain's reward system? That's the bottom line. So the bottom line is you have these gut hormones in cretan-based therapies. So when you look at them, they started out like Wachovie, OZempic, GLP receptor agonists for diabetes and then as weight loss. And then people found by accident that people who were being treated with them drank less, gambled less, smoked less cannabis.

And so then the next question was, well, if that's the case, why? And that's the one you bring up, which is the gut and the brain, communicate by way of the vagus nerve. And we know the vagus nerve can directly impact mood, anxiety, and other factors, because there's even such a thing as vagus nerve stimulation, which is being used for people with severe depression. But anyway, so this GOP-1s, most people don't realize this, they started with the study of the GILA monster.

The study of what? Gila monster. You know that little like, because they don't eat for such a prolonged period of time. I forget how long it is, but they only eat a couple of times a year. The desert. And so some brilliant scientists at the National Institute of aging wanted to know, like in the 90s, why it was that how could they do that? How could they just eat three or four times a year and not be hungry or,

all the time because he was hungry just thinking about it. And it turned out they actively suppressed their appetite with this GLP1, which they called Exenden 4. But nevertheless, after a while, we knew it was GLP1s. We could find the receptors in the gut. We knew that by stimulating those, people would eat less and reverse their type 2 diabetes and diabetes, but then we found the same very receptors are all over the brain. So when you teach people about addictions, we teach them about motivation and reward and the

so-called dopamine system that includes a nucleus accumbens in ventrotechmental area, hippocampus, and so scientists were able to show the exact same GLP receptors that are involved in the gut, are involved in the brain as modulators as a way to dampen the activity. So GLP's net net dampen the activity of the dopamine system, almost like making you an old man. So like young people have a really active dopamine system. They get drugs, they get big bang of dopamine. If you give me anything, I hardly have any dopamine left.

So, I mean, I can get a little increase. So the GLPs keep a lid on it. So let me ask you a question because this just came up for me. The first time I did OZempic, I got nauseous. It made me nauseous for three straight days. I put it away. I wasn't interested. Then Kenny gave me the zepp out.

And I take a microdose of it. Okay? And it works fine because I was afraid to get nauseous again. But there's these new third generation. GLP is coming out. And I know nothing about them, but I heard they're even better than the Zepound. Is there anything you can tell us about that?

No, but I'll say you already had the what's called the twin Cretin, GLP 1 plus GIP. So that's a dual stimulation. And that one is being tried, by the way. Monjaro in cannabis use disorder. The newer ones are still related in my, the way I read it, um, to those compounds are just more efficient at the receptor level. I don't suspect that it would be I mean, it's a pretty dramatic effect. You, you said 80%. We're not going to get to 100% on anything. So, but as far as weight loss goes, the newer ones may have weight loss equal to bariatric surgery.

Okay. All right. That's good. Do you think we're looking at a weight loss drug that just happens to help addiction, or is it entirely different addiction treatment? No. No, I think that it's back to the old theory that food and drugs compete in the brain for the same reinforcement sites. We didn't know why or how. Now we know the big questions for people that are in treatment are going to be,

well, what happens long term? Like, as you just said yourself, just putting in the water supply isn't going to be a treatment. It may cause weight loss, but we doubt it's going to undo the pathological attachment to drugs. We do think that new treatments don't come along that often. Like I was there pretty much ground zero for Narcan. I remember giving that the first time. I was there ground zero for now Trixone. And that's in the 70s.

So here we are in 2020s. We should see how this works. And the way I propose it is you take, in a research setting, you take somebody with a cannabis use disorder, and you would treat them, well, what other treatment can you compare it to? Nothing. So you'd take Richard's treatment for cannabis use disorder,

and you say, and Richard's treatment plus Mangaro for cannabis use disorder, and you compare them. So it has to be randomized. You have to have a placebo. And then you'll say in clinical care, it's better to have two than one. If that study was run, I can promise you it would tell you exactly what we know from the ground.

Same thing happened for early days for alcohol use disorder. We had, like, people don't realize, like, all the treatments that we have until GLPs and the reason that I'm so excited about them is all the treatments were from my age. I had methadone as a treatment. Antibuse. Remember an abuse? Exactly. Like these are really old, even even buprenorphine is an old treatment. I think I wrote the first time about it in the 80s. It's not, but these, the GOPs are going to be revolutionary and but the bottom line is going to be how are we going to integrate them into clinical care and which, like one advantage, let me give you another advantage.

So naltrexone may be good for reducing alcohol use or harm from alcohol, may be good for opiate use disorder. So there's two, but we think the gLPs are going to have an effect across all substance use disorders and maybe even behavioral addictions because they, they, they, They dampen the dopamine reinforce. Right. Let me ask you a question. Is it okay to stay on the GLP ones forever?

So this is, we don't know. Of course, we do know that if you stop for weight loss, you gain your weight back. Now, that's- You know that, doctor? Do we know that? Like if you're, like if you use it to start to get your head start, right? And you do it with a nutrition plan where you're eating whole foods and you're not eating sugar and you're not, right, you're not doing all those processed things. And you're now working out and you've got a self-care program and all that other stuff.

They still gain their weight back or no? Well, it doesn't make sense that they would gain their weight back. But most of the available data says there is a slippage so that maybe you don't gain all of it back. And I agree with you 100% that you should be able to make lifestyle changes. It depends on what you went into it with. So, but intuitively. I know if you don't work out while you're on this thing. okay, it's, you look horrible. You look worse than you did at the beginning.

Yeah, I'm, I agree with you. And I'm just saying from the 50 years of science that I've been involved in, we haven't had a novel, truly novel class of molecules. So I'll give you an example. So in the 80s, my group showed that it was addicting. That seems ridiculous, but it was said to be non-addicting in the 80s until our studies. The 80s during the epidemic, right? It was considered to be, okay, I can't. Yeah. You can ask your psychiatrist at your treatment program.

The DSM-1, which was called the RDC criteria said, is not addicting. Like I wrote about it by saying, like, how could this possibly be? And how could millions of people be asking for help from a drug problem that you say doesn't exist? Like people actually would go to the emergency room in 83 and say, please help me. I'm addicted to COVID. And the doctor would say, you can't be addicted to COVID. Or they go and say, I've had a heart attack due to COVID. And they go, like, that's not possible.

Mark, Mark, Mark, I was up six to eight days on average, at a time, eating a big Mac once a week just to keep myself alive. And it was in 83. Are you telling me that these people, in light of all of that had the temerity to say it's not a day. It's not addicted. Didn't they sing you, Jack City? No, like, so, like,

this is your DSM. Like that, like you look at it and you go like, oh my God. So yes, I, I worked on the online.

Oh, it just hit me. It just hit me. It just hit me. And I hate to interrupt. It's for the billing codes. That's all it was for. Insurance companies didn't want to pay for.

treatment. So the DSM was written that it wasn't a thing because if it's not a thing, they can't issue a code for payment. Well, I'm going to tell you is that it took till the DSM3 revised edition, and I think 1988 for the comprehensive textbook of psychiatry, to say it was addicting. Now, in 85, our group said, It was addicting by virtue of its effect on dopamine systems. Organized medicine said it wasn't addicting because it didn't have an alcohol or opioid withdrawal syndrome. So they had defined a circular definition of addiction. Addiction was withdrawal.

I've written about this, but it ended up hurting a lot of people because, like, you can be addicted to pornography or gambling or you don't need withdrawal. you need pathological attachment and drive and use despite horrific consequences. That's right. The 85 was the dopamine hypothesis. So anyway, all I'm saying, Richard, is we had the dopamine hypothesis for, but it never, that never led to a treatment. We tried increased dopamine, blocked dopamine, juice it up. None of that led to new treatment.

But here, with the GLP's, we have a possibility of a new treatment. and it doesn't discount the dopamine theory, but it says that some damper on dopamine activity is possible through this system. That in 85, when I wrote the dopamine hypothesis paper, we didn't even know it existed. So back to your first question, there are these dampen GLP1 receptors that if you stimulate them, they won't let the dopamine go wild in the presence of alcohol.

all code. Do you know it should be mandatory? Anybody who's doing studies on on stuff like this to actually do the drug once, okay? Because anybody who would do the drug once would have the personal experience of knowing this is addicting. Yeah, you know, it's, that's another different point, but which we make, we, we started, I remember training people in addiction medicine who were impaired health professionals. And so maybe I started doing that again in the 80s. And I did believe that lived experience that they had plus an organized fellowship and then supervision and mentoring was an ideal combination for

an addiction professional. Let me ask you a question. Are there any particular substances, alcohol, nicotine, stimulants, where the evidence with using GLP-1s currently looks more promising? I like alcohol. I think to me that's the most promising, and I'll go back to my early Yale work. So you may have heard that they're these green, vervet monkeys and St. Kitt's, Yale had a monkey. colony and they would run around and try to find fermented sugar cane. And I can maybe send you

pictures of this. I have them in my collection, but I won't do it today. But they have these fermented and they basically seek out fermented sugar cane. So you have sugar is a food. Fermented sugar cane is alcohol. So if you think about alcohol, is related to food through sugar. Therefore, my first bet is going to be GOPs for alcohol. All right. Some people worry we're replacing one drug with another. How do you respond to that criticism? It comes back to the OUD treatments. So when we had like, when we have people dying of replacing Suboxone with or methadone with. or anything with to keep them alive, to engage them in treatment, to give them a second chance

to me is not controversial. Where do therapy, community, purpose, and accountability fit into this conversation? Oh, well, I mean, if we look at like, when we were talking before we got on, I said, I've spent some time thinking about A.A. and one day at a time and this two will pass and the wisdom in community help and people helping people. We went back to craving. One thing that people prescribe people for craving,

go to a group, speak to your sponsor, call your therapist, just separate the emotion of craving and the drive from use and over time that you can expand it to the point that they could be like you. So community, part of what works in AA is seeing people in different times at the same time in recovery. So you see somebody who's been there for 10 years, somebody who's been there for one week. We don't have to tell you that there's a process of recovery. We don't have to tell you that the more engagement, the better the outcomes, because you get to see it.

You see it for yourself. So I think in psychiatry, even for something like depression, antidepressant response rates are much greater when someone has a therapeutic relationship. and antidepressants are given within a therapeutic content. Like, we don't have treatments that you can give someone right now against their will. So if you think about, like, let's say you had strep throat, I could give you an antibiotic, and you don't have to do anything. In psychiatry and addiction, we don't really have anything like that. We need the active participation of the person.

We need them to be involved. And I think the reason for that is bad learning. You have years and years of bad learning. And how do we teach you how to do things in a different way? It takes a lot of time, at least as much time as it took for you to get in this place in the first of it. You know, doctor, I got to tell you, I've never heard it like that. I was loaded from 12 to maybe 35, I guess, and I always get confused. It took me three years in AA just to get 30 days.

But after that, I had it. And so it didn't take the full Monty. but in order to get comfortable in my own skin, it took that long. So I think you're, now that I've talked it out, I think I think you're right about that for sure. Well, you're very lucky too because like some of the people, I don't really go into this in my psychology today articles, but I worked for 25 years for the Board of Medicine's addicted physician group.

And I would read it evaluate physicians and try to get them treatment so they could preserve their license and ability to function once treatment was over. And one thing that I did learn was some of them lose capacity. So it is one of the challenges we have in addiction is when the person gets sober, they may turn around and say, say, I can't believe I can't do that anymore. And so in the Board of Medicine, you could see somebody who's a neurosurgeon who has had these exemplary test scores and ability to learn all kinds of new things that just can't do it anymore. And I do think that the neurological side of drug taking and kind of.

drug injury. Now, I dealt with this in opioids because, like, I wrote an article on nodding. Like, what is nodding? And they make it seem like sleep. It's not sleep. You're unconscious. And the oxygen sensitive cells in the brain, which happened to be all in the hippocampus related to memory, are getting compromised and killed. So it's like you have overdose, overdose reversal, nodding, all these things. So it became obvious to me in working with the neurosurgeons. Many, like a number of them, we help become addiction medicine doctors. But it's something that has been a mistake.

We don't want to stigmatize the illness, but we have to tell people that there's no guarantee that when they decide it's over. they can, they'll be the same as they were, um, cognitively, intellectually, behaviorally, emotionally, before this whole thing started. No, they'll be different because of the, because of the damage. Let me ask you a question five years from now. How do you think addiction treatment may look different because of the GLP one medications? So it's, um, I think if GLP ones or the GLP dual,

action medications are used for cannabis use disorder, we'll have evaluation and treatment for cannabis use disorder, which is one of the fastest growing addictions and trivialized, but no less of a problem than any other addiction. So I think that's a one. Two, I think we may have GLP treatment plus AA, GLP plus residential for alcohol and also will keep naltrexone

and the camper site and like you mentioned and abuse. So we'll have lots of good treatments for that. I think that will be a good thing because you'll see comparable efficacy

where we'll know which is better for which. I think also the bringing of endocrinology and the GOPs into addiction medicine and psychiatry suggests that the whole person approach should reemerge. Like that's the way it was when I started in the 70s. You had evaluation. You had diagnosis and treatment for co-occurring medical problems,

co-occurring psychiatric problems, addiction problems, which were more than one addiction all the time. I just, I'm hopeful that in five years we'll get back to that rather than balkanizing addiction. I'm not sure we really got the answer on this, but is it okay to stay on GLP ones forever, whether it's for addiction, treatment, or weight loss? We didn't get an answer because there's no answer. I mean, we don't know what forever is. We do know that people have, there are certain medications that people are taking now for long periods of time since the introduction of GLP ones. And we're not showing, alarm bells are not going off. I think as you propose, the combination in addiction, as well as in overeating obesity of lifestyle change,

diet and exercise, psychotherapy, group therapy, NGLP ones is likely to be more effective than either alone. You know, doctor, it's not just that it takes the noise around the cigars or whatever, the food away. It's not just the noise. It's when you finally go, I haven't had a cigar in seven hours. I think I'm going to go smoke a cigar. And then you grab a cigar and you're walking out to the backyard.

And then you think to yourself, but I don't really want a damn cigar right now. And then you go back to the humidor and you put it in. Same thing happens with the fridge. You go in, you tab it, you open the fridge. And then you go, am I hungry? No, I'm not hungry. And so it's not just the noise. It's once you make the conscious decision, I'm going to do this or I'm going to smoke a scar.

going to get some food. You're not even interested then. Well, that's pretty, that's pretty much what, what, um, we're saying about the dampening. You're getting, you're getting the ability to control the reinforcement, rather than the reinforcement, the ability to control you. And it makes me feel good because that was my last thing. And I wasn't giving it up. That was my last addiction. And I was like, I ain't given this up. This is like my thing. I ain't doing it. And I just didn't want to. It's like I could if I wanted to make it a must,

but I didn't even want it to be the M in must. I wanted nothing to do with it. So, but it works, man, it works. If you were advising treatment centers today, what should they be paying attention to right now? For me, the co-occurring illnesses are the big missing piece. That would include medical, neurological,

endocrinology, psychiatric, and evaluation and treat the whole person. The second thing, I think in the history, is the lack of attention to overdose history. So we don't have on admission in most places checklist with follow-up questioning on how many times were you overdosed, how many times you've been rescued, how many times you've had trauma, how many times you had loss of consciousness, how many times you had a physical fight argument where you were hit in the head, the kind of

neurological consequences of drug use, memory-related consequences, affect a person's engagement in treatment, and it affects their ability to hear and incorporate what they're hearing and seeing in treatment, much more than we think. And the charts, like the patient's records, just don't help you. So when I, I mean, I'm telling you, when I would see the records for impaired doctors, they would go, like, the person was found in the on-call room. that's not a history. I'd like to know what it was and did they have reversal

and how long did it take for them to get their memory back? But I think those are my two big things. And they're still around the same theme of the whole person. I think treatment programs are really great around this idea that they haven't divided up addictions into all these different groups. they look at addiction as a single entity and that drug use itself could be treated. I find that to be something that's increasingly supported by genetic studies that pretty much show there's not a gene for cannabis and a different gene for this and a different gene for that, as well as for just what's happening in everyday life.

even the biggest change for cannabis is not only they now have cannabis use disorder addictions, but now we got cannabis plus nicotine lozenges, nicotine, chewables, nicotine, co-smoking. So we're back. Every drug of abuse acts in the same basic brain system, so we should recognize that. Those would be my three big things. How many treatment centers or what percentage of treatment centers in the country do you think do all of those things? You know, I don't know, but I would say. I know.

I know for certain. Well, you're the one that you're the expert. Zero. Zero. Zero. Because it's not cost effective and there's no way they can do it in this. climate when 20% of the treatment centers during an opioid epidemic are going to go out of business this year for various reasons. So I've never seen a climate like this before. Having said that,

I believe we do about nine out of ten of those things. That's good. And that's why I'm so grateful. Yeah, but I don't know. I think we do nine out of ten of those things. We may do more. we may be do a touch less but i know we're doing them because i know we're doing them this is going to help a lot of people so you helped a lot of people today doctor i don't know if you know that but you did if i live next door to you i would knock on your door every day and ask you to come out and play right you're your kind um i appreciate treatment providers and know what that it's really hard work and I know my work is much easier and I'm grateful, you know, that I'm on your show and people hear it. I'm always saying, gee, you know, I'd like to be more impactful. My youngest

daughter said, Dad, you should write a column explaining science to young people and the people who aren't super scientists. I've tried to do that. I'm having to do that. I'm having to happy that your group and others can just pick what I know and download it for free. And psychology today appreciates it. Listen, I love the fact that you're going to write that book because your daughter is exactly right. My whole hook is I take difficult concepts and I make them easily explained to the masses, right? right that's my gift that's what your daughter wants to do for a group of people that are young that can come up and maybe be excited to do what you do or what i do i think your daughter's fantastic

last question you've remained incredibly active through your research writing and your podcast got a podcast all right the gold standard podcast what topics in addiction science are you paying the closest attention to right now. So thanks very much. So I did that my podcast because some of the older people that built this career and that were there on ground zero when there was no career. We weren't even allowed to admit somebody with an alcohol problem to Yale New Haven Hospital in 74.

It was church basement. or nothing. So honestly, so I started by saying, I'll interview these people before they're lost. So I interviewed David Smith, who founded the Hayd Ashbury Free Clinic. I interviewed him, and he said, and I know him, we've been friends since Woodstock pretty much. And he had the rock doctors, and the Hayd Ashbury was he coined the phrase, health care is a right. And he treated the whole person. So I interviewed him and I said, gee, I need to interview the head of the guy that founded the National Institute on Drug Abuse, Bob DuPont. So I interviewed him.

And it was like that. It was more that I wanted to put these people in one place. So if someone was a history of addiction had an interest in that, they could go and see what these people said. said in their own words about their career. All right. Have we left anything unsaid that you want to talk about anything, anything at all? No, but if you want to know what I'm thinking about this week, you can always go to Addiction Outlook.

That's my blog on Psychology Today. There's probably 180 of them up there and take any, but once a week I'll do something. And this week, I covered an invention by the Stanford research group that showed that if you were giving ketamine for suicide prevention, you could increase the efficacy of that. Again, Richard, it's almost to that 80%, maybe even was 80% in their study, if you add buprenorphine. So it's a very controversial article because of the opioid question, but by the same token, I found it brilliant because it said to me that some of suitoriality and is independent of depression. And maybe we could find a new treatment for suitorial thinking other than four-point restraints in the emergency room, locked up and sent to the psych ward. etc you said something so interesting just now you said that i'm paraphrasing there are other factors to see reality um other than depression i didn't know that i thought that if you're in enough pain

at some point it becomes too much you get flooded you can can't get out of it and you end it. That's not, is there, is there any other. Yeah, it's really, so that's really what this article was about. And after you read it, you'll write me or just let me know what you think. There's, it's, it's like a Venn diagram. Yes, it's true. There's an overlap with depression. But there's too many cases where people are being treated successfully for depression who's anyway, die by suicide anyway. And so my angle on this was really esoteric. Only a researcher would do this.

So just, you know, you need a sense of humor when I'm talking about it. So there's literally a zebrafish study showing that if you give zebrafish ketamine in their tank and so forth, that you eliminate their hopelessness and giving up in the face of swimming upstream. So in other words, because this is a combination of opioid buprenorphine plus ketamine. Ketamine adds to it. It's not just resilience. It's the ability to keep fighting in the face convincing. in the face of thinking that for sure you are going to fail and there's no way out.

So in a way, it's what you did for yourself, Richard. You got to the point and said, it seems like there's no way out. I'm going to make a way out. But other people get to that point and give up. Doctor, this was again an honor and a privilege truly. Thank you for coming today. And everyone will see you next Tuesday. We're out of time.

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