- [Dr. Borenstein] Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

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- This is something that is definitely a problem on a large scale and we've seen more and more evidence of that over the last few years, especially with the pandemic.

But not to say that it wasn't a challenge before.

- That's today on "Healthy Minds".

This program is brought to you in part by the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

(gentle music) Welcome to "Healthy Minds".

I'm Dr. Jeff Borenstein.

What should you do if you are experiencing addiction?

Today, I speak with leading expert, Dr. Nii Addy, about the treatment for chemical dependency.

Nii, thank you for joining me today and thank you for the work that you've done and continue to do on this important topic.

- Thanks so much for having me.

It's great to be here.

- I wanna jump right in and talk about addiction, chemical dependency, starting off with the scope of the issue.

How prevalent is this?

How large of a problem is this?

- Yeah, this is something that is definitely a problem on a large scale and we've seen more and more evidence of that over the last few years, especially with the pandemic.

But not to say that it wasn't a challenge before.

So often, when we're thinking about chemical dependence, really talking about excessive use.

And we know from the data that there are many individuals who use substances, but only a subset of those will actually develop what we typically refer to as substance use disorders.

So it is still unfortunately prevalent in a lot of different spheres, in a lot of different scopes, a lot of different populations, and we really want to make sure that we have an understanding of why this occurs and how we can help people actually move through that to get to a better place.

- What would tell you as a clinician, a family member or a person themselves, what would tell that person that this is a problem for them at this point in time?

- Yeah, an excellent question and something that I think about quite a bit, even myself being a scientist who does some of the studying, but then also working closely with our clinical colleagues in psychiatry.

A lot of times, what we do tell people is that when you notice a change in behavior that is very disruptive to someone's everyday life.

So if they're no longer engaged in their normal activities, their normal responsibilities, and it really becomes disruptive, then that, of course, is a time of concern when you want to try and make that known to the person and make sure they are actually able to get help.

- So really, if it's affecting the person's functioning, that's a clear cut sign that help is needed for that individual, whether it be at work, socially at home or with friends or in school in younger people.

- Exactly.

And very similar to what we often say in terms of other mental health challenges as well, whether that be things like depression or anxiety, where people are wondering, is this something that is just a minor concern or something that's bigger that's really disruptive to that person's life?

- Bringing up depression and anxiety, I know a lot of your work has revolved around sort of the intersection of addiction, depression, anxiety.

I'd like you to speak a little bit about that.

- Yeah, so for us, that's been something that's been really important.

Something we've paid attention to more and more.

But to be honest, the way that we first thought about it was just in terms of the brain biology itself.

So a lot of the work in the lab that we had been doing was thinking about aspects of relapse.

So what's happening in the brain that makes it easy for people to slip into relapse and maybe not get to a place of less use or abstinence if that is the goal?

As we were looking at some of these patterns in the brain, we noticed that the places that we were looking at, specifically within the dopamine system, and also thinking about another neurotransmitter, acetylcholine, those same processes seem to be highly implicated in depression and anxiety.

So it led us to think about, well, perhaps, these are systems that are important in both.

As we looked into things a little bit more, we also were aware of the literature showing that those who are navigating through substance use disorders have much more of a likelihood to also be navigating through things like depression and anxiety.

- So an important take home message for people is that you can't treat one without the other.

If a person is having depression along with chemical dependency, you need to treat the whole person.

You need to treat both of them and vice versa.

- Exactly, very, very well said.

- So as you've been looking at these really commonalities in terms of the the brain, where does that lead us clinically in terms of treatment?

- Excellent question as well.

So clinically, we've also been thinking about how can we try and alleviate some of these symptoms simultaneously?

So one of the things that we've been doing is to try and look at specific targets within the brain that can do exactly that.

So for instance, if someone is going through a period of abstinence and has heightened anxiety, ideally, we want to be able to decrease the craving and the relapse that occurs, but then also decrease the anxiety-like symptoms as well.

So one of the terms that we often use is a term anxiolytic, which basically means that we're decreasing the anxiety profile.

And so we've been fortunate to actually look at specific agents that block channels in the brain that are also important and used in anti-hypertensives.

So this gives us a way to be able to say, maybe we can use a pre-approved FDA-approved medication that's already on the market to actually decrease relapse and decrease some of the anxiety that's associated with periods of abstinence and even decrease have antidepressant-like effects.

So this can be very relevant for people who are trying to navigate that and are having these symptoms simultaneously.

- And the types of medicines that you're referring to aren't medicines that are typically psychologically nor physically addicting.

- Yes, a very important point as well.

- In addition to medications, there's also psychosocial interventions.

And I'd like you to speak about that as well.

- Excellent, well, thank you so much.

And I'm smiling because that's something that's really a passion for me as well.

One of the terms that you used already in this conversation was just holistically and as a whole person.

So we often do try to think about that.

And as you know, and as I'd like to share with your viewers as well, we often, of course, are thinking about the biology because that's what we study in the lab.

But we're also thinking about how that biology intersects with all other aspects of our interactions within the world.

So how it intersects with how we interact with other human beings and all those psychological components.

We also think about things like spiritual components, even though, obviously, we can't study that in the laboratory as easily.

But again, it's so important for us to be able to think about how these things intersect.

And so when we think about the biology, we're also thinking about, if we have a medication that is acting at a certain place in the brain, how's that going to affect a person when they're in a certain situation?

So as I talked about craving or relapse, we're often thinking about the context where that relapse occurs.

So then you want to marry those two things together to have something that can decrease some of those brain responses, but we also have to think about the psychological and the social factors and what state the person might be in, what environment they might be in, and how those medications will be helpful or perhaps not helpful in certain situations.

- One of the challenges is that as the availability of marijuana, legally, has increased concern about its use increasing and leading to chemical dependency, and I'd like you to speak about marijuana use, especially in younger people.

- Yes, that's something that we have definitely seen a lot more of and this actually touches on one of the other research areas that we look at as well, which is nicotine use and vaping, in particular.

And so there is a lot of co-use as we have seen from the evidence of both nicotine and marijuana and some of these devices.

And it's a very challenging conversation because it's very mixed in a lot of ways.

So early on, people were having debates about whether this was helpful, whether it was harmful.

There are a lot of association studies that suggest that long-term marijuana use can lead to detrimental effects down the road in terms of potential psychosis.

It's not clear whether that's causal, causing those types of things or not, but this is something that has been a very important topic of conversation, especially as you mentioned, as we see increased rates of use among young people.

So it's something that we're continuing to pay attention to.

Within my lab, we don't focus on marijuana in particular, but I have a lot of close colleagues who are.

And as you mentioned at the beginning, when we think about the scope of these challenges, there are a lot of several common themes and processes in the brain that happen when people use different substances.

One thing I should add that is of concern to us is also when that is happening at a young age when the brain is still developing.

And that marijuana use and drug use, in particular, can impact and change some of those processes that, again, can have long-term consequences for young people as they become adults.

- Very important person.

And when we refer to young people, really the brain is still developing through the mid-twenties.

So it is an age that might be a greater vulnerability to some of the effects of substance misuse.

- Exactly.

- Let me ask you a little bit more about cigarette use.

- Yeah, so to put things in context as well, as many people may already know, over the last several decades within this country, we had actually done a pretty good job in terms of decreasing combustible cigarette use.

With all the health consequences that we know that are associated with that use, we also know that nicotine is a primary addictive component in cigarettes and it's often very difficult for people to stop using once they've started.

So even while that decrease in use was happening, of course, we've seen an explosion in terms of the e-cigarette market in terms of the types of products, in terms of how easily they can be concealed.

And so that has something that has just grown astronomically over the last few years in middle schools and high schools.

And so we've really seen a dramatic increase in that use, even as cigarette use has continued to come down.

So one of the challenges for many of us who are in this work, particularly, when we talk again about young people, is knowing that that is a critical period in development for all of us as human beings.

And for people who are going to start to experiment during that phase, it's much more likely they'll eventually transition to a state of substance use and substance use disorder in adulthood.

So that is something that has been of concern for us in the field, thinking about this early exposure to nicotine, how that may impact later nicotine use or combustible cigarette use.

Also thinking about how that might transition to other substances as well.

And there's a lot of evidence showing, again, that that's a critical period.

If people do not use early on in their lives, it's much less likely they'll actually develop addiction or dependence if they started using later in life.

So it's something that we're paying attention to.

And in our work, we're specifically looking at how flavors which are in these products, over 10,000 options at this point, can actually impact the use of those products as well and make it easier for young people or for people, in particular, to start using those products.

So something we're actively researching.

- Some of the concern is that the flavors are geared directly to market, even though they're not officially marketed to young people.

They're really geared to bring them in as customers.

- Exactly.

And you see that with the evidence of all the candy flavors that are on the market, of course.

I mean, we can all probably think back to our earlier years and what we liked about lollipops and all these different types of flavors that now are associated and paired with nicotine in these products.

So there is definitely an area of concern, as you mentioned.

- What should parents do?

What should teachers do to discourage young people from trying this and potentially becoming addicted?

- A very important question as well.

And I'll share some stories about what we've tried to do within some of the schools as well when we are actually talking to parents about these issues.

So sometimes, we'll talk with the parents.

We often will talk with the students as well.

And the biggest point that we make there is really to make sure that the students and young people that you all are informed.

So we know at the end of the day that if we just say, "Don't do this, don't do that", that's not going to be as helpful.

But we want to make sure that people know what the risks are.

So we talk about aspects of what happens in the brain when it's exposed to nicotine.

We talk about addiction.

And we want to make sure that people know, and young people know, in particular, what the consequences are.

So I think that's always a helpful starting place for parents to have those conversations and to also just be acknowledging of the challenges that can come as well.

So specifically with nicotine, we know this from young people, we know this in adults as well.

Oftentimes, nicotine can have effects that help people calm down.

They can have some antidepressant effects if people are in stressful situations.

If someone is an adult who's trying to quit, if they had a stressful event, lost a loved one or lost their job, they're much more likely to use.

So I think in conversations with our young people, we have to acknowledge that as well.

We can't pretend that these things are happening in a vacuum.

We have to acknowledge that there are reasons why people might want to start using, what they may see as a benefit, but really have open and honest conversations about the consequences.

And I should also say it's not easy.

I do acknowledge that, but very important.

- And and also to acknowledge that there may be some immediate sense of relief from using tobacco or other drugs.

Over the long haul, it really may not be beneficial.

And there are other approaches to deal with those uncomfortable emotions.

- Exactly, yeah, really well said.

Really well said.

- I wanna ask you about the issue of trauma, addiction, as well as depression and anxiety.

I know this is an area that you've looked at and would like you to speak about.

- When we think about the clinical literature, when we think about the research that's done in humans, we know that trauma and adverse experiences play a very large factor in how likely people are to experience mental health challenges like depression and how likely they are to use substances or to use them to excess.

So it's something that we continue to think about, and I'm just grateful that we've been able to have these conversations with many of our clinical colleagues, to really be honest about some of the traumas that people have gone through, that they have no control over, that makes it much more likely for them to, again, use substances to excess or to navigate through depression and anxiety.

And so there's a lot of work that has tried to look at what are some of the long-term effects of those traumas on the brain.

Not to say that that's the endpoint and that's a hopeless situation, but what can we do to actually address some of those things, again, through psychological interventions.

But then also to know that when we're talking about things like chemical dependence, there may be specific treatments that we have to develop for people who have had very traumatic situations that may be more helpful for them because of what their brains have already gone through.

So again, coming back full circle, we often try and think about this in a very holistic way, even though in our work in particular, we're really focused on the brain biology.

- And we know that brains can change, that the brain evolves over time due to physical things that you do, due to environmental things, both in good ways and in negative ways.

I'd like you to speak a little bit about that.

- Yes, another really important point.

Something that I've often mentioned when I'm speaking, again, to public audiences and saying that the brain can change when we have positive experiences, and it can also change when we have negative experiences.

And those things impact how we then engage in our future experiences or engage with those around us.

And so we're often thinking about both in our research and in our conversations with our clinical colleagues, what are the experiences that people have been through?

How is that changing their brain?

A term that we use in the field a lot is plasticity.

That's a term that seems to have been picked up within the popular commonplace language, everyday language as well.

But it's really something that's important.

So even when we think about not only people's experiences, but when we think about medications, medications also change the brain.

In particular, antidepressants are known to have effects on plasticity in positive ways.

Substances can have effects on plasticity and brain changes in negative ways.

And so again, we really think about what experiences have people been through and how will that impact how they respond to specific interventions?

And in our case, how would that impact their brain biology?

If we're targeting specific areas in the brain, specific regions and specific processing in their brain that may be helpful in terms of decreasing relapse behavior and antidepressant and anti-anxiety types of medications.

- One of the areas that we as a field have started to look at, and it's an important area, is what we refer to as the social determinants of health and mental health.

And I'd like you to speak about that.

- Well, thank you so much for bringing that up.

I think it's a really important area.

There are so many people who have been doing this work for years who are now having more acknowledgement of their work and how important it is.

Several different people come to mind.

One person I'll just mentioned is Dr. David Williams at Harvard University, who has been involved in a lot of this work over the years.

Again, just looking at how things like where you grew up, your zip code, has a direct impact on your health.

And there are several reasons for that as well.

There are race factors that are involved in that.

There are access factors, socioeconomic factors.

And so a field that has been, again, something that has been an area of focus for so many people, but now that we're starting to pay attention to, and it ties back to some of the topics that you raised in your earlier questions as well.

Thinking about those life experiences and how they impact not only people's health, their access to different aspects of healthcare, but also how they respond to some of the medications or psychological interventions.

So when you think about social determinants, everything that we have gone through over the last few years in terms of the effects of racism, people are now acknowledging all the mental health consequences that come as a result of racism.

David Williams, again himself, Dr. Williams did some really interesting work, looking at the mental health effects in specific communities where there had been individuals, Black and Brown individuals, who had been killed at the hands of police if they were unarmed.

And what he found was that that had detrimental mental health effects on communities of color in that state where that occurred.

It didn't have effects on those who weren't from those backgrounds.

So again, that's just one example, showing how something that's happened in society can have differential effects in different populations.

And we have to be aware of that as we are trying to help people and navigate through some of these mental health challenges.

And there's so many other examples, but just to highlight one concrete one as well.

- Right, it brings us back to the issue of trauma doesn't necessarily have to happen directly to the person to be traumatized.

- Exactly.

- A person can be traumatized by something that happens to someone else and still has that kind of an effect on them.

- Yeah.

- What do you recommend to people who have experienced discrimination, who've had the type of experience you just spoke about?

How do they deal with that?

What's the way to get through that?

- Yeah, the first step is something that you've done, even in asking a question.

And what we always remind people is just to acknowledge that the challenging situation, the trauma, the racism, whatever the case may be, that it's actually happened.

And it is something that's significant and difficult to navigate through.

I think in so many ways, in so many aspects of our society, it's been too easy to ignore those things, either as a coping mechanism or either as a way of not wanting to acknowledge the pain that has happened and just trying to move through it.

So the first step has always been really important to acknowledge it and to be able to acknowledge it to those who are empathetic and willing to listen and willing to hear.

Even from a psychological standpoint, there's so much evidence about the power of listening and how that can help people navigate through those challenges.

Of course, as a second step, we have to be able to make ourselves and avail ourselves to the many different ways that we can actually address those things.

So I also encourage people to think about whether that's meeting with a social worker or meeting with a psychologist.

Psychotherapy is another option.

Whether there are other things that have happened that are also intersecting or impacting how people are responding to some of these challenging racial or racism related traumas and challenges.

And to be able to say to have time to explore those different things.

It's not always straightforward.

It's not always clear.

Sometimes, unfortunately, there's trial and error, but it's always good to be able to have access to some of those resources and we may come back to those specific resources in this conversation as well.

- Yeah, why don't we tell us a little bit about those resources.

I think it's important to bring that up.

- Yes, thank you for acknowledging that as well.

One of the resources, just very broadly, in terms of mental health challenges, a great organization is the National Alliance on Mental Illness.

That organization is so key because it seeks, it's a grassroots organization that's been around for decades that seeks to provide support for both individuals who are navigating through mental health challenges, but also for family members and loved ones who are helping those who may be navigating some of those mental health challenges as well.

So there's lots of support groups that NAMI has, both for the individuals and for the family members, because we all know that it can be challenging to try and help a loved one walk through some of those mental health challenges.

So that is a very important resource.

There are also crisis text lines that have been set up nationally.

There's also a new national hotline for suicide prevention that people should know about as well.

And so there are many resources that are available, but NAMI is one I always like to mention because it's across the country and there are local NAMI chapters as well that people can plug into.

- Very good point with referring to NAMI.

And obviously, the hotline is 988, that's the new 911.

But for mental health emergencies, crises, and really just the way to get help, easy to get to.

So very important to talk about that.

I want to ask you about the role of faith in treating addiction, anxiety, depression, other mental health issues.

Talk about faith.

- So faith definitely plays a role in so many people's life journey and also in people's mental health journeys as well.

So there's, again, a lot of evidence just showing the power of being in community and the power of being in a faith community and how that can help people navigate through mental health challenges, especially with things like addiction, depression, and anxiety.

At the same time, on the other side, I've had conversations with people who, like me, have focused on the biology, but have been dismissive of the faith aspects.

Again, despite all the evidence for how powerfully that can be as well.

So for me, it's just a passion area to be able to acknowledge that we can integrate all these things and really think about ourselves as whole beings, all aspects of our life and how we can use all these different tools to actually move to a better place of wholeness and healing.

- I think it is so important.

Often a person that an individual may trust the most with deep feelings might be their faith leader and that may be what helps guide them to treatment.

So it's important - Exactly.

- that the two work hand in hand.

Nii, if somebody's watching right now and they realize they're having a problem with substance misuse.

What should they do?

- Yeah, the very important piece.

And so anyone who's watching and thinking about that, I think if you are asking yourself that question, I know I've said this already before, but you've taken the most important first step.

To acknowledge that, "Okay, this is actually a challenge and it's disruptive to some aspects of my life."

So that's the first starting place.

I would say the second is to think of a trusted individual that you can actually follow up with and talk to about that.

And you want to make sure that that's someone who's actually going to listen to your story.

Again, this is something that comes up in NAMI quite a bit, and to hear why you've gotten into this place.

Not to have a place, not to have someone who's going to judge you for that decision or some of those decisions that you've made, but really to listen to how you got there and someone who is able to support you in that and say, "Okay, I'm here to help you find the support you need."

And then at that point, it really becomes a step of talking to different providers.

If you have a primary provider, hopefully, that's a good starting place.

That isn't always the case.

Not all of our first providers have access to some of this information about substance misuse, but that is becoming better.

So I would still suggest starting there.

If that person doesn't have that access, you may still be able to ask them if they know of places they can refer you to as a next step in that journey.

But again, would really encourage anyone listening who has made that important acknowledgement to take that next step to talk to somebody about that.

- And a key point for chemical dependency is that really with treatment, with help, people are able to get better.

And that's something that people should keep in mind.

- Yes, definitely.

- Nii, I want to thank you for the work that you've done, that you continue to do.

Thank you for joining me here today.

And I look forward to speaking with you again soon.

- It's been my pleasure, Jeff.

Thank you so much for the work that you're doing with "Healthy Minds" and for continuing to make these conversations open and available to society.

Such an important piece.

My pleasure to be able to contribute as well.

- Thank you.

Today, we spoke about medication treatment, psychosocial treatment, issues of trauma, social determinants of health, use of faith in the process of treatment.

There's so many aspects.

The key point is to seek help.

Because with help, there is hope.

(gentle music) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by the American Psychiatric Association Foundation and the John and Polly Sparks Foundation.

(gentle music continues)