Ep. 177- Unpacking the Stigma of Addiction and How It Still Shapes Care Today with Dr. Jonathan Avery
This episode is a conversation with Dr. Jonathan Avery about why addiction has so much stigma and how that has stopped patients and families from getting real help.
Most people still view addiction through a lens of shame and judgment, yet experts like Dr. Jonathan Avery are transforming how we understand and support those struggling. Dr. Avery is Vice Chair for Addiction Psychiatry and Professor of Clinical Psychiatry at Weill Cornell Medicine, known for pioneering efforts to reduce stigma and elevate evidence-based care. His work has transformed lives and inspired a new approach to addiction globally.He also founded the SAFE Program (Support, Advocacy, and Family Education) to provide evidence-based support to families affected by addiction.
Dr. Kibby sits down with Dr. Avery to talk about how his personal experience with family addiction led him to develop groundbreaking programs and research to dismantle stigma, empower families, and open new pathways to recovery. In this episode, we break down:
How addiction affects the brain and why stigma persists despite medical advances
The innovative SAFE program supporting families affected by addiction
Dr. Avery’s insights on challenging societal judgment and fostering compassion
The role of advocacy, policy, and personal understanding in changing the narrative around substance use
His upcoming book "Thriving with Addiction" and what it reveals about resilience and hope
Whether you’re supporting a loved one or seeking deep understanding, this episode is essential listening. This is your chance to hear from one of the most influential voices in addiction psychiatry who shares insights that could change the way you see and support those affected by addiction.
Resources:
The Support, Advocacy, and Family Education Program for individuals and families struggling with substance use disorder
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0:00
Meet Dr. Jonathan Avery: Addiction Psychiatry Pioneer
Hi guys, welcome to A Little Help for Our Friends, a podcast for people with loved ones struggling with mental health.
Hey little helpers, Dr. Kibby here.
Before we dive into this episode, I wanted to tell you how I could help you navigate the mental health or addiction struggles of the people you love.
0:17
Cool of mine is the online coaching platform and community that I built to support you in the moment when you need it the most, like having hard conversations, asserting your needs or setting boundaries.
Even if you're just curious and want to chat about it.
Book a free call with me by going to the link in the show notes or going to kulamine.com KUL AM ind.com and click get started.
0:38
Thank you and enjoy the show.
Welcome back little helpers.
We have a really great guest today.
His name is Doctor Jonathan Avery and tell you a little bit more about him, but he is such a key figure in the world of addiction psychiatry.
0:53
So really understanding addiction, how it works, how we treat it and involving family members and loved ones in the recovery process.
So he is like a big hero of mine.
I've only chatted with him a couple times, but he has already inspired a lot of what I do, supporting family members and loved ones and people with addiction.
1:14
So he is just to tell you about all of his accolades.
He is vice chair for addiction psychiatry and professor of clinical psychiatry at Wild Cornell Medicine.
This is where I did my internship.
That's how I know about him.
And he directs the Addiction Psychiatry Fellowship and founded the Program for Substance Use and Stigma of Addiction.
1:32
So he really, he really pioneers a lot of amazing research and training in combating the stigma of addiction, the silencing and the judgment around people with substance use disorders.
He also founded the SAFE program, the Support Advocacy and Family Education program to provide evidence based support for families affected by addiction.
1:55
That is awesome.
That's a virtual program that basically has all these different addiction experts giving webinars that is free and available to anyone.
Like the one amazing webinar was about just how addiction works in the brain or vaping addiction.
2:13
So I think that's the safe program is super, super cool.
You should definitely check that out.
Doctor Avery also serves as medical director of the NBA's Anti Drug program as the host of Thriving with Addiction podcast.
He is also his, he's coming out with a book called Thriving with Addiction, which will be released later this year, 2026.
2:36
And he's just a a superstar.
He has published extensively on addiction stigma and evidence of his treatments.
He has edited and author 10 books and serves on national editorial boards.
So he has a, he was, he's also just a really nice guy who has both personal and professional deep, deep understanding of addiction.
2:58
And so I, I really was like geeking out in this conversation, just asking him all these different questions about why there's still so much stigma about addiction versus any other diseases.
What can family members do?
What is the best thing for them to do in this really hard situation where someone they love is addicted to something like opioids or drinking?
3:23
But this is a fascinating conversation.
So if you or anyone else struggles with addiction or has struggled with addiction, this is an episode to listen to.
So hope you enjoy.
3:34
Dr. Avery's Journey: Challenging Addiction Stigma in Medicine
Welcome back little helpers.
We have our very special guest, Dr. Jonathan Avery here to talk about stigma and addiction and everything about that.
So I am so excited to have you here.
Welcome to podcast.
3:48
Speaker 2
Thanks for having me and thanks for all the good work you're doing.
It's it's nice to collaborate around these important topics.
3:54
Speaker 1
I know it's nice to connect on similar with people with similar interests because addiction and substance use is really interesting to me.
It's AI first of all.
I don't understand why it's a separate world than mental health.
Do you know why is it there's like mental health and then they're like and addiction?
4:13
Why is that?
4:14
Speaker 2
It's always been the stepchild of mental health and medicine in in general.
You know, I think part of it is, you know, the history of of 12 step tradition plus the sort of thought that it was more of a moral failing than a disease model.
4:32
And I don't think it's really been integrated.
It was integrated fully into medicine and mental health and really until the opiate epidemic almost because that was one condition that really was taking people's lives that needed medications like for OPD.
4:47
So you need to be on medications and, and psychiatric medications and psychiatrist took the lead on that.
And, and so I think 1 consequence of the opiate epidemic was the increased sort of medicalization of, of addiction and, and with that came more recognition that it is a mental health condition and the disease model.
5:06
But if you went to a doctor, even a psychiatrist or a therapist 30 years ago and you said you were drinking too much, they would say go to a, a basically.
And then, you know, over time we've we've tried to address it more.
5:18
Speaker 1
My God, So that that's not that long ago.
That's pretty recent Where it now I understand why stigma is such an important part of like the history of how we understand addiction, because that seems silly.
5:34
Speaker 2
So it's ridiculous.
I mean, when I was, you know, in training in medical school, which was, you know, 15 years ago, I was pretty much told that it was not for doctors and therapists and psychiatrists to go into addiction.
I was one of the reasons I was discouraged from going into substance use.
5:50
It was the thought that, you know, that's not real, true medical care and that's not really addressing the psychiatric conditions.
And and that's we should leave that for, you know, the support groups more than than anything.
Whoa.
6:02
Speaker 1
OK, well, I didn't know any of this.
So tell us about your journey to doing what you do.
And then also like, how did you crossover from your in your training?
It was like, this is not psychiatry.
Yeah, tell me everything.
6:18
What's going on?
6:20
Speaker 2
Well, I was always interested in in medicine.
My dad's a doctor and he was a Hospice physician.
And, you know, his big thing with Hospice, which is taking care of people who have less than six months or less to live, was that people at the end of life often didn't really have a voice or felt they didn't have a voice.
6:38
And, and he thought a lot of his job as a Hospice physician was to give them a voice to help them tell their story, to not be afraid of death and also to involve family members in that process.
He was big early on on on sharing stories, having the person who's who's dying share their story, even writing it down for family members.
6:58
When I was in high school, I would, I would video record back then people in the end of life telling their story.
And they would then have that video to pass on to their grandkids and, and their, their loved ones.
And, and then they studied that type of intervention, sometimes called dignity therapy, ensured that it really helps the patient, helps the families.
7:18
And so I was really inspired by, you know, the kindness that my dad showed and also sort of trying to help people who, who don't, you know, feel like they're empowered to, to feel that power that to tell their story.
Also, growing up, I had family members struggle with substance use and, and loved ones and friends and I, I didn't have a name for it, but I, I recognize that they too were sort of silenced and stigmatized in a way I didn't see with other health conditions.
7:47
And so I thought it was something that was interesting how society treated folks who were struggling with substance use.
I was treated different than other medical conditions.
And so I knew as I was growing up that it was something that I was interested in, in learning more about.
And so I made made my way through college, studied philosophy and then medical school and then medical school.
8:06
I was a little unclear what I wanted to do.
I thought maybe surgery, maybe psychiatry because I was interested from my experiences with my dad.
But then in medical school, I realized, or I was told to not study addiction, that it really wasn't something we're studying.
8:22
And I noticed people in the hospital who were having their voices silenced, I felt, and weren't telling their story.
And we're being marginalized and, and then sort of against advice from everyone thought, you know what?
This is something I, I really feel passionate about and want to dedicate myself to.
And I I decided to be an addiction provider and to study stigma, the stigma of addiction that exists in the places that that should be the safest.
8:46
Speaker 1
That's super cool.
8:48
Unpacking Judgment: Stigma in Family, Legal, and Medical Systems
Can you, can you paint a picture for me what the silencing or stigma looked like even in your your family or in your patients?
Like I feel like many people talk about feeling marginalized or kind of loss in healthcare system, right, of all kinds of conditions.
9:05
But what did it look like with people with addiction?
9:09
Speaker 2
Well, what I had noticed in my family and then similar to the people I was I was seeing as I went through my training is that you feel judgment at so many levels.
You feel it from your family who feel like you should just do better.
9:24
You feel it with your friends and places where you work where you can't sort of endorse, like you talk about a medical condition and at work and go on leave for it.
But there's a feeling that if I was struggling with substance use, I couldn't tell anyone that I had to had to really hide it.
And then I had people growing up that ran into trouble with the legal system and I saw the way that, you know, they were sort of punished and deemed bad people as opposed to people worthy of, of care and, and, and compassion.
9:51
And so I saw it in my own life and, you know, I saw it in spades.
And in the hospital setting, I mean, it's, you know, the percentage of people admitted to a medical hospital at any time, like 1/4 to half of them have active substance use disorders.
It's so much of what we treat.
10:08
And similarly, I noticed that they didn't feel safe to talk about it.
They thought if they endorsed it, they were treated poorly.
They offer and often weren't offered evidence based care.
And you sort of learned like when you rotate in the emergency room, prioritize the people with the real medical conditions, you know, the heart attacks over the people who are in withdrawal or struggling with other things.
10:28
And so the whole system, family systems, legal systems, the medical system seemed to be pushing folks with substance use disorder to the secrets, telling them they were bad, sort of on the face of it, endorsing it's a medical model, but then treating them as if their their moral failings over, over and over.
10:45
Speaker 1
And why do you think that is?
I, when you just said heart attack, I was thinking about, I was thinking of like the role of choice and how the, you know, the, the there is probably a misconception of, oh, you're choosing to drink, you're choosing this.
11:01
Is this something you want to do?
And you can decide not to, but you are and it's causing problems.
But you just said heart attack and I was thinking about people's diet and whether someone exercises or whether someone eats a lot of red meat and that could cause heart attack.
11:17
So why do why do you think that substance use got it such a different stigma around it?
11:25
Speaker 2
I think that's a good analogy.
You know, the often it's people say, you know, oh, heart attack, heart disease, cancer, very different than than addiction, but in fact, they're almost the same.
There's a huge genetic risk for for all those things.
In fact, the risk, the genetic risk of addiction, substance use disorder, something like 50%.
11:44
If your mom and dad have it, you're super at risk of developing a, a substance use disorder.
We know then it's sort of insidiously develops over time, hijacks the reward pathways, hijack so many different parts of the brain and the body to a point that making a a good decision feel is is almost impossible.
12:01
It gets, gets really hard to, to make a, a, a better choice.
The difference is though, in that the end sort of how it presents to doctors or to family members still looks like choice.
And I, I think that's hard for folks, you know, it, you know, with a heart attack looks like dead tissue in, in the brain that the substance use looks like the person who's still drinking, going, buying alcohol or using opiates or, or smoking weed.
12:28
It's a behavior that's continuing, continuing, continuing.
And, and that can be hard to equate with sort of laboratory values of, of, of a heart attack, I think at times.
And, but we see this with mental health sometimes.
I know it's gotten better.
I mean, historically we would say the person's depressed just needs to do better.
12:46
Now, I understand there's all these things happening in the brain, but we can't quite equate the substance use behavior with what's going on the brain in our, our minds just yet.
And and and for what it's worth.
12:58
From Personal Experience to Specialist: Addiction's Genetic & Trauma Risks
Perception of this disease change from being little Jonathan before being Doctor Avery to now Doctor Avery had when you grew up with it, you saw people struggling.
You didn't have a name for it.
And then now not only do you have a name, but you probably couldn't list the different mechanisms and all the different factors that could increase the rest.
13:21
Like what?
What?
Take me through the progression of like what you understood it as as a loved one and now as a specialist in this.
13:31
Speaker 2
When I saw it in in friends and family, I heard people saying it was bad behavior, but for some reason that never clicked with me.
Intuitively, I, I, I thought there's something else going on here.
You know, people I people I love, I know they didn't want to wreck their lives.
13:49
Like it felt like wrong to think that someone wants to grow up and be the best addict on the on the block that it wasn't.
It wasn't adding up to me why we were treating these folks so poorly, thinking that this is how they wanted to be.
And for a lot of folks, I saw them doing the best that they could and and still failing repeatedly like I, I and so I, I was just very confused when I saw people really struggling that we were going to then punish these people.
14:19
That felt wrong to me and not helpful.
And I think the bigger blow was when I saw it happening with people that I thought would know better, like doctors and lawyers.
Like, I think the biggest like disappointment was when I entered sort of the medical training and I saw that doctors didn't have different attitudes than what I was seeing around me.
14:40
Like I sort of had this feeling that when you become a doctor or a lawyer or when people grow up, they, they, they sort of are enlightened.
And to discover that wasn't true was like a double injury for me.
And and really what catapulted me to to want to study this and, and, and help help us all do better around this this topic.
15:03
Speaker 1
Like to hear that your your interest and passion grew as you saw like how this doesn't make any sense.
Like what?
Like all the different logic of wow, these are the kind of people who should be able to stop or, you know, be escape this problem.
15:19
But it's like, no everybody, including doctors who do better.
15:24
Speaker 2
Right.
And part of my experience too, was that the people that I knew who were struggling with substances were some of the best people I knew, like the kindest, most loveliest, who felt the deepest, who I wanted to be around.
Like it.
It didn't align with how other people saw them at times.
15:40
And, and, and that really, you know, and then, so I imagined as I was in this medical setting, like other families bringing their, their special person in to get help and then, and then feeling rejected and, and, and that felt very wrong.
15:56
Speaker 1
Yeah, Remind me of something that my mom said once where she said I was talking about a friend who recently got sober and she was like, does he have a soft heart?
I was like, what are you talking about?
She said.
I feel like people like me and others who struggle with alcohol, we have soft hearts, maybe too soft.
16:16
Does that resonate?
Or is that like, is there like a personality trait that tends to go into?
16:23
Speaker 2
I, I think, I mean it historically, I think people thought there might be, but it really does impact everyone at the end, you know, and it's pretty non discriminatory.
And I mean, there's so many factors that go into why someone develops A substance use disorder.
You know, at times it is sort of self medication and I guess what we're sort of talking about someone with sort of sensitivity to to different things or anxiety and depression, people that that feel more.
16:47
And we know if you've had trauma, if you've had mental health struggles, that does increase your odds quite significantly 2 to three times of of developing an alcohol use disorder, even notwithstanding the genetic loads.
You know, certainly having these adverse life events and, and, and feeling negatively, but also sometimes just environment and, you know, luck conspires against one where you're in this environment where you get exposed to something and you start taking it.
17:13
And before you know it, it, you know, even without mental health issues, even without XY or Z trauma, you end up getting stuck on that.
And then we saw that a lot in the opiate epidemic, you know, people taking meds prescribed by a doctor in good faith, thinking it was the right treatment for, you know, a pain condition or, or something else and ending up with the with the substance use disorder just because of of doctors prescribing, for example.
17:39
How the Opioid Crisis Medicalized Addiction Care
Do you see a different pathways or different stigma perceptions from others with the different kinds of substances?
Like if someone is a drinker versus, you know, hooked on oxy or anything like that, do you see differences in that or is it like you're an addict?
18:01
Speaker 2
No, there are different.
I mean, my work shows to, to we've studied a number of clinicians, family members, lawyers, and the findings are pretty consistent that attitudes are worse towards those with substance use disorder than towards any other medical or psychiatric condition, like profoundly worse.
18:19
And that they tend to be worse for drugs versus alcohol.
So alcohol gets a slight, slight pass.
I mean, it still has that why, you know, so widely accepted in in society when people start using opiates and opiates are almost aligned with nicotine and then some of the other substances attitudes are even worse than than towards drinking.
18:39
But it's really striking how much how much more negative attitudes are towards folks who use substances.
18:47
Speaker 1
Also, do you do you talk?
Do you did you get in in that word any qualitative like what are the of the judgments or?
18:55
Speaker 2
We've used a couple scales.
The main one we've used is the scale called the medical condition regard scale, which, you know, assesses different attitudes, you know, in terms of like, how much do you think they're, they're to blame?
How much time you would spend taking care of them, thinking about them?
19:11
Do they annoy you?
It, it captures sort of depends on how you create the scale, but around 11 different sort of beliefs around a, a person who's struggling with substances.
It's not perfect.
It doesn't capture all the things that go into to stigma, but it gives you a sort of a, a rounded picture of, of how someone might feel to, to any given health condition.
19:32
And so we, we basically in my studies, we present a, a person, we describe them, try to keep it, we try to create sort of people that are, are similar, but the one thing that differs is their health condition, you know, be a diabetes, cancer, depression, or, or a substance use disorder.
19:55
And then we ask people how they feel about these these little vignettes that we present to them based on on the scales.
And, you know, it's if their person is struggling with substances, the attitudes are are much, much negative.
And we've learned that some things do improve attitudes.
For example, if someone does believe in a disease model more than a moral failing of addiction, their attitudes improve.
20:16
For doctors or lawyers that really choose to work with these folks, like addiction psychiatrists or public defenders, their attitudes are better.
For family members who have struggled themselves, sometimes their their attitudes are better than with towards family members who haven't struggled.
20:30
Speaker 1
That's interesting.
Well, people who have more knowledge about it, I guess it makes more sense that they, you know, are more compassionate or they understand the complexities.
20:39
Speaker 2
Exactly.
20:43
Speaker 1
Tell me about, I mean, there's more from my own curiosity.
What did the you were, you're saying that the opioid crisis has shifted perceptions.
What else has it shifted?
I mean, I guess just I feel like I don't hear about it as much now and I don't know if the current administration is as focused on it or if it's getting better, but there seem to be a huge shift when opioids swept the nation.
21:07
Like what what changed?
What happened in your practice or?
21:12
Speaker 2
Well, we always say in the world of addiction, there's all substances of misuse on one hand, opiate use disorder or opiate misuse on the other hand.
And the reason we separate them out one is in terms of how opiates present.
One, as I was saying earlier, doctors way over prescribed opiates in that first wave of the opiate epidemic that we cut down the prescribing and heroin came in.
21:32
And then finally all the synthetic opiates like fentanyl flooded the drug market.
And so sort of the genesis with doctors playing a role plus all this, you know, fentanyl that's that super potent coming in, you know, really raised all these alarm bells and resulted in all these deaths.
21:48
Like you don't die with other substances the way you die when you're exposed to either intentionally or accidentally to to these opiates.
And so that really makes it the red light emergency in medicine.
But what really caused us to take it on more as time went on is that the evidence for how to treat opiate use disorder is strongest with medication.
22:11
So treating it with medications like Suboxone or methadone or Vivitrol.
And because that data is so strong and needs to be prescribed by a doctor, I think medicine increasingly has taken it on as, as the thing that they can address and, and should address no matter what kind of practitioner you are.
22:29
And then with the risk of overdose, harm reduction efforts are, are so important.
And so everyone, you know, should be carrying Narcan kits and doing and testing their substances.
And there's a role for doctors and, and, and healthcare systems to, to play in that.
22:45
So all of that led to sort of a more medicalization, a more active interest and training and, and doctors to, to address it.
I mean, for example, when I started, when I was in residency, almost nothing on opioid use disorder.
And as the, as the crisis increased, suddenly we had mandatory classes in Med schools and every residency mandatory exposure to treatment settings where people were getting opiate use disorder.
23:08
Everyone here gets Narcan kits from the beginning.
And so, you know, more and more of us incorporated into the training and education of clinicians.
23:17
Speaker 1
I was thinking about like maybe then 80s or not, I don't know much about it was just like what you see on TV, but there was all sorts of like Quaaludes and speed and and fed means that were popular according to like Saturday night Fever or whatever movies nums December.
23:35
But you know, that's that seems also like something that would be prescribed for like weight loss or whatever they did and then kind of went haywire and got into the street like speed and stuff like that.
But that didn't have the same shift that opioids do.
23:52
Speaker 2
Not quite into the medicalization of the treatment for substance use disorder.
I mean part of the over prescription of quaaludes and benzodiazepines for that matter.
I mean part of the way those took over was the same playbook in some ways that was used on opiates with directed doctor marketing and encouraging people to over prescribe it when the indication wasn't quite clear.
24:14
But they didn't kill people the way opiates did.
And I think the, the real concern around opiates was just the deaths like we haven't seen something that we prescribed really causing so much harm before, like we saw with the with the opiates and, and really sawing it devastate a a nation drive down the life expectancy of, of Americans.
24:34
And then the way that once we crack down on the over prescribing that fentanyl and and other stuff came in, it was, it was, you know, almost hard to believe how, how it it took over.
I'm.
24:46
Beyond 'Rock Bottom': Loving Support for Families Facing Addiction
I'm wondering, I'm wondering what family members of loved ones should do, if they it OK, going back, going back in my thoughts.
I when I first met you, you told me about craft community reinforcement and family training.
25:03
And so when I did that, I went and got certified because of your advice.
And it was, it was, it's, I still don't understand what family members should do when they're afraid that their loved one, like their child or their sibling is going to die.
25:21
Right 'cause like, the idea is, you know, step back, take care of yourself, set boundaries, like all, all the stuff that I want to talk about.
But what do you do when that person is at risk of death, right?
If like, how can a how can a mother say no to giving money or giving housing or or any other support if they're afraid that their kid is going to leave their house and possibly overdose?
25:51
Speaker 2
Right.
I, I think the advice to family has changed because of the opiate epidemic.
I mean, I used to, especially in certain settings here, the advice to let people hit rock bottom first or get to a state where they were completely motivated for change themselves and to sort of just back Outback off and, and let it happen.
26:10
But you really can't do that with opiate use disorder because the risk of doing that is, is accidental overdose and, and death.
And so we've sort of changed our narrative from, I was always suspicious of this narrative to start.
I'll, I'll say, and we can talk more about that, but changed it from let them hit rock bottom to lovingly support the bottom.
26:30
And, and part of that is approaching them, you know, still taking care of yourself and, and not doing things that, you know, directly encourage use, but at the same time being there to protect them, give Narcan, if necessary, increasingly encouraging people to, you know, give them housing or put them in safer settings.
26:49
And that's not always possible.
And there's a lot of variables that go into each, each family members, each family systems decision making.
But it's like you wouldn't let someone with cancer wait, reach, you know, stage 4 before you intervened.
And, and similar with OPD use disorder.
27:04
You don't want to wait till they're at that final stage before you say, Oh, let me, let me do something.
You want to try to, you know, keep them, keep them alive and, and, and keep them in a spot where, where change is possible.
And, and that's not possible if they're, if they're using in a way that could result in their death.
27:20
What?
27:23
Speaker 1
About let's.
Let's say you have Yeah, do you?
Do you have kids?
27:29
Speaker 2
I have 3 kids, yeah.
27:30
Speaker 1
Three kids Good place How old are?
27:33
Speaker 2
They they're 12/6 and four.
27:35
Speaker 1
OK, OK so my my kids little too.
So imagine you have a 20 year old kid and he or she calls you up and says, you know, dad, dad, give me, I need 500 bucks.
And you know, you know, that kid is struggling with addiction and most likely they're going to use that, that 500 bucks on something like that.
27:58
What do you do?
What would you do?
28:02
Speaker 2
Well, my hope is with my kids, you know, from the very beginning, we're talking about substances.
Like the current recommendation is to start talking about mental health and substance use at the age of 8 or 9 and, and not the edge of the bed conversation where we say, if you use drugs, I'm going to kill you and then disown you.
28:18
But, but really to highlight that it's something important.
It's something we've seen in our family that that's something we have to, we have to be mindful of and, and often almost to Telegraph how you imagine dealing with things if they arise and what treatment is a little bit and, and just as not not in like a lecture type way, but as, as you, you have so many moments with your kids as they grow up where they'll they'll see people struggling with mental health, You'll see people struggling with substances.
28:46
The wonder why so and so when the families struggling with substances, I would use each of those moments as, as a teaching point so that when the crisis hits, it's not like the first time the family unit has has ever handled it.
How I'll handle it if the crisis hits hits when my daughter's 20 and and and misusing substances.
29:05
I'm I'm not sure I I mean I, I and how much to give that $500 versus not how much to support it or not, especially when they're out of the home is going to make me lose whatever little hair I have have left.
For sure.
It's it's not it's not easy.
29:21
My hope is though that I have that connection there and we have the ability to talk about it where we can sort of lovingly set boundaries if needed.
But that there's never a question about the love.
There's never a question that they have a, a safe space to come home or to even acknowledge that uses have it happening and to make sure they have Narcan kits and, and are, are staying safe.
29:42
And you know, if I'll be able to do that in the moment when I'm freaked out and, and, and can't believe it and, and feel only like using my big dad voice to try to scare it out of them.
I'm not sure.
But, but I, I think that's some of the hope.
But I recognize how hard it is.
29:55
Thriving with Addiction: Vigilance, Communication, and Mental Health
Like, I've learned that as kids grow up, like all this advice I'm giving parents, when you're in the middle of it, it's like, oh, oh boy, it's hard.
30:02
Speaker 1
Yeah, I mean, I'm terrified having alcoholism in my family.
And then not just that, actually my some of my extended family members struggle with opioids as well.
The thing that scares me on either side is when you're talking about, oh, it's it's a disease like any other disease, like cancer that is like, oh, OK, so it's not our fault.
30:26
It's not, it's not something that we did wrong, but when you didn't, when it's not something that you did wrong or right, it's totally out of your control.
But if it's something, but on the other hand, if I want to look at like there's something I can do about it as a parent that has its own scariness, right?
30:45
I can do something.
But if I mess up, my kids going to become addicted to something.
So how?
How can parents or family members in general see their role in that?
31:00
Speaker 2
It's the name of my upcoming book and podcast is called Thriving with Addiction.
And the spirit of that is that there's it's an addiction is not going anywhere.
It's in all of us, it's in all of our families.
And there's no sort of like overcoming it, but it's sort of like recognizing it in, in each of us, our potential for it and really developing sort of fitness, as much mental fitness and, and fortitude and health as, as we can with it.
31:29
Just like you would if you had a heart disease.
You would then be very attentive to diet.
You would take the right medication to lower your cholesterol and your, your blood pressure.
You know, you would check your, your pulse more frequently.
You visit the doctor more often.
And so if you're at risk for, for substance use and mental health, you, you want more check insurance around it.
31:49
You want to, you know, check in with how much you're drinking and, and using.
You want open family conversations about it.
You want to make sure you're addressing, you know, mental health issues as, as they pop up and, and maybe doing so more, more aggressively, you know, maybe if you have less genetics risk you, you know, and you have, you know, a week or two where you're drinking more than you want, you don't pay as much attention to it, but it, you should pay attention to it if you have these, these risk factors or have gotten in trouble before.
32:16
And so the hope is that the family unit can be attuned to that and each individual can be attuned to these these risks and, and keep their their finger on the pulse of it.
32:27
Speaker 1
Besides for knowing that addictions in the family, what other huge risk factors or flags are there before someone develops an addiction?
Like like I'm thinking about, let's say hypothetically our kids are in their 20s, they're drinking and going nuts in college.
32:45
And then like, how can you tell at that point who's going to have a problem with it and who's not?
Or is it just a matter of time or?
32:55
Speaker 2
This unfortunately, we, we were hopeful one day you'll be able to come to a doctor or an addiction doctor and they'll, they'll give you this print out of like all your risk factors, what the genes are.
And they'll say, look, your odds of developing A substance use disorder with drinking is, is, you know, one and two or something like that.
33:12
That would, that would be nice.
Like the best we can do really is say, look, if you have a family history, if you struggled with, with mental, mental health issues, if you had trauma, those are really the, the biggest predictors that we have right now.
It feels inadequate.
33:28
And, you know, one person can have all those things and, and not have developed a substance use to sort of even with exposure, another can.
So we're missing a lot of the contributing factors even still.
And so really the best proxy is if you've had a loved one who's been been struggling with addiction in terms of understanding your risk.
33:46
And then the unfairness of it is that.
Yeah, a lot of people go to college and drink or get some exposure to nicotine.
And you know, about one in four of people who do that will end up with an alcohol use disorder.
Three out of four will get off Scott free because they didn't have some of these risk factors or just got lucky.
34:03
But but one in four will have it.
And and when you develop a substance use disorder in those early years, that's always the thing that feels so confusing.
Like I was drinking as much as XY and Z.
Why is it impacting my function?
And and me and the way and why am I having this outsized reaction and this mental obsession to to drinking more?
34:21
It feels sort of not fair and and random almost.
34:25
Speaker 1
Yeah, Yeah.
What about So when when I was on internship at Cornell, I I did the rotation in the ER and it was so interesting.
I just hadn't, I hadn't thought about this until I worked there where I saw that there were some kids usually in their 20s or 30s had, you know, they were just partying more.
34:51
Maybe they, they were smoking weed or they were drinking and they had a manic episode or they had had psychosis.
Do you think, do you think that they were, they had like a genetic vulnerability to that, like they were already at risk?
35:11
Or do you think they're really some people who, you know, that kind of drug use or, you know, partying too hard could actually create or trigger those kind of episodes?
I still don't actually know, like, were those people always going to have like a risk of bipolar disorder or something?
35:29
Or is it just like anyone if they do enough drugs that they could get there?
35:35
Speaker 2
We do think, you know, in terms of how a mental health issue develops, we often think of sort of multiple hits that can result in it occurring.
There's certainly the genetics behind it, there's early life experiences, there's trauma, but one of those modifiable risk factors developing mental illnesses is substance use.
35:54
And, and sometimes it's tough to, to separate out from the mental health because sometimes the mental health thing emerges and, and part of the reason people use is, is to self medicate that.
But sometimes the substance use does uncover sort of a risk for a substance use.
36:10
And and where that's been most striking has been with with marijuana over time where, you know, in the 70s it was very rare that marijuana use would result in psychosis.
There used to be this thing like called hemp psychosis and the older addiction psychiatrist talk about if someone came in with weed induced psychosis, like the whole hospital would come down and say, wow, this is the strangest thing I've I've ever seen.
36:30
But you know, weed has increasingly been more and more potent these days.
You know, it's so much more potent than it was in the 70s and 80's, the ways to use it all the time.
And so increasingly we're having more and more people that present with marijuana induced psychosis or manic or depressive symptoms from from these high potency marijuana products.
36:50
And we never saw that historically.
And so we think that yes, it probably uncovered something, but it could also even more than that, just create, create something given the the potency of it.
And, and that's scary.
And then certainly more potent things like meth and cocaine can can also do the same as well.
37:09
Speaker 1
Yeah, yeah, that's interesting.
There's been a couple of parents who they're dealing with their kids having, you know, a whole host of, of mental health issues and going in and out of the hospital.
And there were, and two of them in my, in my mind that they were like, they were fine until they started smoking weed and so smoke and we 'cause their mental health issues.
37:32
Umm.
And I was like, I can't say if that's true or not.
Like I don't like what is cause but I was like, I don't actually know if that's true or not.
And I can't say either way.
37:44
Speaker 2
Yeah, it's hard.
It's hard to separate it out and to say it's true.
Once it's developed, though, it's very clear you want to avoid it.
So regardless of that's what I always say when people present like, all right, whatever God is here, it's it's a complex thing, the brain and, and neither you nor I are going to be able to disentangle it.
38:02
But it's pretty clear your outcomes for mental health issues, once you develop them are much better if you minimize or, or really cut off substance use.
And, you know, the main thing that really impacts people's mental health, you know, is, is alcohol, probably that's still the thing people drink the most.
38:17
And, you know, we're increasingly learning like even 1 binge episode a week and binge binge is less than people think.
Like, you know, 3 to 5 drinks for a man, 2 to 4 drinks for women can really result in a anxiety episode, a depressive episode.
And so, you know, if you're at risk for mental health or have had mental health struggles, minimizing substances is, is is really key in terms of mental fitness going forward.
38:41
Speaker 1
Good to know.
OK, good to show.
Yeah.
Because I think these parents are worried that their kids were continuing to smoke weed.
And they're like, oh, it's the way I relax and.
38:51
Speaker 2
It's hard to talk to anybody about weed these days.
I mean, weed has this perceived safety.
It's, it's legal now.
It's everywhere.
I mean, you and I are in New York.
It's the smell of New York.
Everyone's doing it.
And again, just like with, you know, one in four of the college drinkers who are drinking too much is going to have a problem.
39:06
The rest are going to be Scott free.
A lot of people that smoke weed are going to be able to smoke it some everyday and not get into problems with it.
But there are some folks who it will be a problem and especially you've been struggling with mental health.
It's sort of like the easiest, simplest thing to do to to make sure you you do your best with it is to is to not smoke.
39:26
Speaker 1
Interesting.
39:28
The Best Ways Families Can Support Addiction Recovery
What are some of the best things that you've seen loved ones or family members do to support someone with addiction?
And what are the worst things that you've seen?
39:39
Speaker 2
Well, I mean, my, my image before I became an addiction psychiatrist was of what family members did when a loved 1 was struggling was that sort of quote UN quote Jack Zonian intervention where people are like around the they're in a circle and they're each reading a letter saying they're never going to talk to the person again unless they, they change their, their behavior.
39:56
And I've learned that it actually seems like it might be one of the worst, most ineffective ways to, to tackle it.
And I think the best way sort of what we've been talking about, which is to just.
Do your best to get out of the fighting and the shaming and just get into this and the yelling and the finger wagging to a point where you're just lovingly, you know, supporting the person while also not, you know, not creating an environment where they're using or I hate the term enabling, but sometimes that's the simplest word to say.
40:27
By enabling the use, but, but really are, are setting boundaries, but, but also you're there for them because they're your significant other, they're your son, they're your father.
And, and you know, but doing in a way that's, that protects, you know, who you are and, and, and also that is there to provide some support.
40:50
That's hard.
That's, that's asking a lot.
And sometimes it is, is for severe substance use or there's a lot going on or there's violence or trauma.
You know, sometimes it's best to, to disengage, but I've noticed that people do best when they keep that connection.
When, when the connection is lost for the person who's struggling, then they're often just lost.
41:09
You know, it's, it's really often the connection to family that's keeping people going.
And when that's severed, it can be very hard to put yourself in a position to to change.
41:20
Speaker 1
I agree on one hand, but at the same time, I'm like, you know, looking back at my experiences, there were times that it was so painful.
Like you're, you're basically watching someone you love killed himself slowly or, you know, maybe unintentionally, but it's just like, I'm going to have to watch that.
41:38
It's so painful.
They're not going to listen to me begging for them to stop.
And then there's that other piece of how painful it is to feel like you matter less of them than their drug choice.
And so, I mean, are there times that it makes sense for someone to cut off contact or are you saying that that's really not advisable?
42:04
Speaker 2
There, there there might be times when cutting off contact is is indicated, but it's a it's a vicious disease that makes it seem, you know, I think everyone I've seen who it seems like they're choosing the substance over their loved one.
That's that's not the case when I really talked to them, They just are in a spot where their brain and body is just not able to do do better.
42:26
They really want to do better for their loved ones.
They want to be better, but they just can't at that moment.
And it's painful for family.
It's painful for the person who's who's struggling, who really recognizes that this is not the the best version of themselves.
42:41
And in general, when I get to know people who are struggling that way, they really want to do better.
They just can't.
42:50
Speaker 1
So.
42:51
Speaker 2
Sad, it's hard.
It's a hard condition.
And, and that's part of why the stigma exists even among doctors and, and, and all these other lawyers and is because we like quick fixes, you know, we, we, we like to think we can solve this quickly and move beyond it.
43:10
But I'm very suspicious.
Even when people are in recovery, you have to stay, stay vigilant for that substance use and, and be mindful of it as a, as a family.
There's no other spot in my mind.
There's there's only being in there with it.
43:25
Speaker 1
How, how would you suggest that family members deal with that recovery period and that watching out?
Because I think that's that we were talking about this before, but it was it's hard to, you know, if someone gets sober, yay celebrations.
43:43
We're so happy, we're so happy to have you back.
But then you're always on the lookout.
You're always like, wait a minute, what's in their glass at dinner or they they've been out all night.
What are they doing?
Like how, how would you handle that?
43:59
That wanting to watch out and wanting to monitor after even when they get sober.
44:07
Speaker 2
It's really hard to rebuild trust in any relationship if there's you know, and, and certainly around substances.
It's hard.
I mean, it's, there's no easy answer.
It takes time.
I would say that the main thing is when you're in recovery is to not, is to figure out a way to lovingly keep it in the, in the conversation where it doesn't feel like a police state or like ideally the person who has struggled and the loved one is, is communicating about it in an ongoing way.
44:37
I think that's the way to thrive in recovery is, is to not pretend like it's something that happened in the past, but it's something that is an ever present risk.
And so the loved one should be asking about it.
Person in recovery should be thinking about it, talking about it.
It's when there's sort of those egg shells around it, when it's like something that you can't bring up and no one knows.
44:56
That's where everyone starts to get get in trouble.
And so even if it means like going to a couples therapist or a family therapist to figure out how to get that communication going, I think that's super worthwhile because I think we all want it to be in the past too.
And we can collude with the person.
45:11
We can be like, you know, they struggled then I'm sure they're past it now and just not want to bring it up.
And, but figure out how to bring it up in an ongoing way that can, that doesn't have to feel problematic, but can feel loving and, and like you would bring up anything like have you taken your heart meds or, you know, should we eat salmon instead of the red meat or, or whatever it is, you know?
45:32
Speaker 1
Yeah, that when you just like couples there be reminded me of similar process of couples have to deal with like affairs or any kind of betrayal where it's like, you know, how do you not check their phones all the time or how do you you know, how do you balance like giving like trusting them, but also your own trauma of well, I was trusting and then something terrible happened but without me knowing.
45:57
So that's tough.
46:00
Speaker 2
None of it's easy.
No, it's it's not easy.
46:04
From Pro Athletes to Youth: New Frontiers in Addiction
Tell me about what you do with the MBA.
My stuff had in your bio.
I was like, what?
What are you doing?
46:10
Speaker 2
Yeah, so I mean at Cornell, I, I run our addiction psychiatry fellowship.
I do this anti stigma work and, and, and try to combat in multiple domains, but I do have this, this cool side gig, which is medical director of the NBA anti drug program, which is base.
46:28
It's more an education piece than anything.
It's just letting you know the players know about the risk of substance use and, and they're monitored as part of, you know, fair play agreements around making sure they don't use.
And then we're here to help them if they, if they need any, any help along the way.
46:43
And it's super rewarding.
You know, I, I was a high school basketball player back in the day and, and, and, and love the sport.
And so it's, it's fun to be around the guys.
They're, they're so impressive.
I, I, I always admire how these kids, which are, they're kids, they're in their, you know, early 20s a lot of them.
47:00
And they're navigating such pressure and money and, and stresses and they're, they're great guys.
So it's, it's a real fun, fun thing for me to do.
That's cool.
47:08
Speaker 1
Is is the risk like any kind of drugs that enhance their like are they at risk for think it's steroids but that that's not really.
47:18
Speaker 2
We're super monitored for that stuff.
I mean, that's something that you know, they're they're like immediately suspended a few tests for, you know, HGH or these performance enhancing drugs, testosterone, all those things.
So like it like all, all the sports leagues and I, I work with a number of athletes across sports sports league.
47:35
They're they're very strict, all of them on the performance enhancing drugs these days.
That wasn't always the case historically.
And there's, you know, notable stories of especially baseball players using using stuff, but that's one piece.
And then the other piece is if if they struggle with sort of drugs of abuse, you know, like alcohol or weed or other substances, although for those they have pretty strict testing.
47:58
And yeah, they're in this, they're in this fishbowl.
They're they're tightly monitored.
And then they're all super conscious about their health.
And mostly guys live incredibly healthy.
You know, they're mindful of their sleep, what they eat, the training.
I mean, the stakes are so high for them.
They need to be at at peak physical form for these years to to maximize their their years in the league.
48:16
I think the average NBA player has like plays for three seasons or something like that.
So you really have to to maximize your your fitness during those those times are.
48:26
Speaker 1
They even at risk for substance use.
I mean, like, yeah, as you're saying that I'm like, if I know I have to train for several hours the next day, I'm not going to party at night.
But I guess 10 year old boys, you know this.
48:39
Speaker 2
Well, I think as times going on, you know, our athletes are incredibly, I mean, they be, they learn how to eat right, how to sleep.
They people are learning that in high school these days.
I think it's, I mean, even compared to NBA pros like 20-30 years ago, everyone is super health conscious.
They know the science.
48:56
They don't want to do anything to jeopardize their their careers.
And so, you know, a lot of guys are are really careful.
49:05
Speaker 1
You saw something that said that millennials are the highest drinking generation of of forever.
Is that true?
Are we, are we the I don't know if you're a millennial or not, I don't know.
But do we drink the most out of everyone?
49:20
Speaker 2
I think what right now we're, I mean, we're, I mean us in the older generation are, are, are, are definitely drinkers.
The what's striking is the young kids these days are, are really not drinking.
They're even not vaping anymore.
They're not having sex.
49:35
But unfortunately they're all on their phone.
They're all on their phone in the room on social media, which is is probably worse, but they're putting us to shame in terms of their their drinking behavior for sure.
They're a lot less are drinking than than our generation and the older generations.
49:52
Speaker 1
Speaking of phones and social media, I don't know if I told you that I worked one of my first jobs in psychiatry was in the gambling disorders clinic up at New York Presbyterian, New York, NY, Columbia and and Yeah, and the whole world of behavioral addictions.
50:14
Back then it was like gambling and some video games.
But now we have those phones.
Is are are you thinking about like phone addiction as like a, like a, an addiction to be treated or is what are we going to do for that Gen. alpha Gen.
50:33
Z?
50:34
Speaker 2
It's an addiction, there's no doubt in my mind.
I mean, it's, it's, you know, are the main behavioral addictions are, is still gambling and sports betting is huge these days and gaming and sex addiction and but the phones are really, you know, destroying our, our youth and I think contributing to this epidemic of, of youth mental health issues.
50:52
I mean, they're designed to be addictive.
I mean, that's, that's, that's the whole design.
And you know, you get, it's like a with all these things, with the likes and it's, it's almost like slot machine reinforcement.
I mean, you get these, this, these things that light up and your brain lights up in, in as a consequence and they're very hard to pull away from.
51:14
And so I, I think, you know, ideally, you know, Jonathan Haidt and all these other guys talking about the anxious generation and getting kids off the screen and delaying phones.
You know, it's, it's, it's so important, I think.
And now AII think runs its risk of all these, you know, other addictions where, you know, you, it's so easy to get emotional and cognitive comfort from these devices that, you know, now you're getting that in addition to the, to the sort of addictive reinforcement and, and kids may never leave the room.
51:42
They've got these teddy bears that are AI informed and they're on their phone getting likes and they, you know, there's there's no reason to see the world.
And that's, that's super scary.
51:52
SAFE Program, Thriving with Addiction: Support & Future Insights
I hope you do something about it.
And in a few years we could look back just like we do with smoking and we could be like, Can you believe that people used to be on their phones on the plane I can use to be on their iPads like that would be that would be nice.
52:07
Speaker 2
But it's hard.
52:08
Speaker 1
Right.
It's hard because it's everywhere and it's just, you know, then you don't want to be out of contact anyway.
There's a whole whole thing we could talk about with phones, but tell us what you're working on now.
Tell us what you want people to know about.
You have so much cool stuff going on.
52:23
Speaker 2
Yeah.
I mean, here at Cornell, I think one resource to know about is we have the SAFE program, which is a family support program.
We provide sort of monthly education seminars and as well as, you know, free consults for family members if they want to sort of understand how to navigate the world of addiction for their loved ones.
52:41
And so that's a a resource we're we're very proud of here.
And in addition to all the anti stigma work I do that sort of dominates a lot of my academic and, and support life here at at Cornell.
And then sort of in some ways an extension of that.
We, we have this new podcast called Thriving with addiction.
52:57
You'll be a guest on as well where we, you know, just to explore stories around substance use disorders and, and learn the latest evidence around it.
I think part of why addiction gets so stigmatized is the lack of rounded narratives.
And that's true for doctors.
53:13
They're often seeing people in these acute settings and they they're not getting the recovery stories.
They're not hearing from family members about their experience.
And, and when you have narrowed narratives and the only thing you can think of is the person next next to you, then, then you don't appreciate all how varied the experiences are and how much people can, can still thrive.
53:32
And so that's the point of thriving with addiction podcast.
I have a book also coming out in the same name later this year.
And so that's some of the things we're thinking about how to provide that support for family members just like you.
You're doing so incredibly with your podcast.
It's, it's really a passion of mine.
And then I appreciate you having me here to to talk about some of my thoughts on all of it.
53:52
Speaker 1
Yeah.
Thank you.
So that's so many great resources.
When's the book coming out?
Just so we know.
53:57
Speaker 2
Probably summer or fall of of this year, 2026.
So it's still to be determined.
54:03
Speaker 1
Keep listeners updated and when it comes out you know at that a link to the description.
Also, can anyone listen to the join the safe program or is it only for people in person or at Cornell?
54:18
Speaker 2
Anyone can join.
The educational events are are virtual so you can look up Safe the Safe program at Walt Cornell online.
Just Google it and you can sign up to be on the mailing list and be informed of it.
Also, all the old seminars are recorded there and available for folks to see as well.
54:37
Speaker 1
Great.
And we'll put the link to check that out in the show notes.
So if anyone's curious, you could look for the safe program link.
Dr. Avery, thank you so much for coming on.
I could ask you a million more questions.
The hardest part about this conversation was selecting the feuds that I wanted to hit on.
54:55
But thank you so much for your insight and your expertise.
This is like such an important topic and it's like, it's sadly such a hard conversation to have with loved ones.
Like it's just there's so much in there when you're talking about substance use and addiction that I appreciate your, your, your perspective on it.
55:15
So.
55:16
Speaker 2
Well, I'm here also because I'm inspired by you.
I mean, the way you've shared your story and, and the work you're doing is, is, is so important.
And, and your honesty, I, I think will help all, all of us be honest about this, this difficult topic.
So I, I appreciate what you're doing and I appreciate you having me on today.
55:31
Speaker 1
Thanks so much.
Thank you so much a little help us for listening this man.
I really have like 18 more questions in my head, but I'll just I'll save them for another time.
Please leave a five star rating on Apple podcast, Spotify or YouTube.
55:50
I don't know even know you could rate on YouTube, but we're on YouTube.
And if anyone has questions for you, Doctor Avery, is there any place that they could find you and they could reach out or?
56:01
Speaker 2
Yeah, they can check me out either through my my Cornell page or the Thriving with Addiction page.
There's there's somewhere to contact me through the podcast.
So there's plenty of routes if you Google me to, to get in touch for sure.
And maybe we can leave those in the show notes as well.
56:16
Speaker 1
Sounds great.
Thank you so much, Doctor Avery.
Have a great day and little help next week.
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56:36
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57:08
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57:32
Thank you.