So even if you could put all of us into whatever it is we use, fMRI, or whatever type of scan that we might use to pick up on the areas of the brain that undergo excitation, why is it that for one individual, alcohol becomes the thing, whereas for another person, it becomes an opioid?

And by the way, are there clusters where for certain people chemicals really are the problem, whether it be opioids, alcohol, cocaine, and yet for others, it's more behaviors?

And I'll share with you just as an example of why this is a question that is on my mind so often.

So I've shared this story publicly before, but when I was actually in medical school, I suffered a really, really debilitating back injury.

And to make a very long story short, through some errors in the part of the medical system, I ended up on a really, really high, at the time, very high doses of oxycodone and oxycontin, and predictably went through the escalation of those doses until at one point I was up to 300 milligrams a day of oxycontin, so I'm sure you can put that in the context of the patients that you see, and I'm sure you've seen patients higher, but that's a pretty staggering dose.

It's a dose that if you or I split it right now, we would be dead, so just for context to people.

So after several, oh, I don't know, probably six months of being on such a, again, enough oxy to kill a horse, I just decided I wanted off.

And it was a very strange wake-up moment where I realized I wasn't even taking it because I was in pain anymore, I was taking it because I wanted to escape how depressed I was that I was debilitated.

So I just decided to stop, cold turkey.

And I, at the time, was dating an anesthesiology resident, and she was like, you are effing crazy, you're going to die, we need to put you on nortriptyline and 10 other drugs to taper you off.

And I said, no, I'm doing this cold turkey, which I did, and I proceeded to spend the next two weeks in hell.

But this is the point of the story, it's nothing that I said so far.

The point of the story is I'm no more inclined to struggle with an opioid than any other person for reasons I don't understand.

In other words, after that experience, I was quite afraid of opioids and I assumed I was addicted.

But maybe 10 years later, when I had a really bad tooth condition and nothing was touching the pain, I finally succumbed and took Percocet.

And then after two days, when the tooth was addressed, I stopped taking the Percocet and there was no issue.

And I came to conclude, I concluded from that experience that this was not a willpower thing that allowed me to quit.

This was just a luck thing.

There's something physiologically about me that was not becoming addicted to that substance.

And that's why I was able to stop cold turkey.

In other words, I wasn't morally superior to the opioid addict, I was lucky.

And my question is why?

What explains this difference?

Because there are clearly areas like work where I'm not so lucky and where the addiction is indeed real and where the struggle is daily.

Okay, so a lot there to unpack.

Why don't we just start with your interpretation of your experience, which is, yes, I got physiologically dependent on opioids in medical school, but ultimately I'm not a person who's going to be addicted to opioids.

Well, I thought I was, but it didn't appear to be the case based on subsequent use patterns, yes, yes.

Right, you ultimately decided, you ultimately decided, oh, I'm actually, this is not an inevitable problem for me, but I recognize that, especially given what you went through, that it could be an inevitable problem for somebody else, right?

Okay, so let's start with risk factors for addiction.

So risk factors for addiction can broadly be placed into three separate buckets, which I call nature, nurture, and neighborhood.

The inherited or inborn risk for addiction based on family and twin studies is about 50 to 60%.

So this is, for example, based on studies showing that if you have a biological parent or grandparent addicted to alcohol, you are at increased risk of getting addicted to alcohol than the general population, even if raised outside of that alcohol-using home, right?

So these are really nicely carefully done studies.

So high heritability is determined by twin concordance, basically.

Yeah, and family studies, right?

Looking back in family trees, looking at kids who were adopted into non-alcohol-using homes who developed alcohol use disorder at higher rates because they had a biological parent or grandparent.

So those are those studies.

And for a long time, you know, people have talked about the quote-unquote addictive personality.

Oh, I have an addictive personality.

Whatever I do, I take it to the extreme.

I'm gonna get addicted.

You know, that's a kind of colloquial use, but it gets to the heart of this idea that yes, people come into the world with different vulnerability to this tendency to take to the extreme the pursuit of certain types of highly reinforcing substance behaviors once discovered in the environment, okay?

It's also probably true that we each have different, what are called drugs of choice.

So even with people who are, you know, polysubstance users, which by the way, is more common than not today, people use a lot of different substances and behaviors.

They'll still tell you, but you know, my preference is opioids, or the thing I really wanna do is smoke a cigarette, or alcohol is my go-to.

And interestingly, there's very little science on the concept of drug of choice, because I looked pretty hard for that, and I couldn't find very much.

But it is a really important one, because what it means is that here we have the phenomenon of access intersecting with drug of choice to increase the risk for certain individuals.

Let me explain what I mean.

One of the, so we've got the, let me back up.

So we've got the nature, right, in the inherited risk.

By the way, that probably goes along with co-occurring mental health disorders.

People with mental health disorders are at increased risk of developing addictive disorders, and addiction is probably a complex polygenic phenomenon.

Then we have risk factors based on nurture.

So this is the way that we are raised, early childhood development, parents that model maladaptive, addictive behaviors, or that explicitly or implicitly condone substance use or other addictive behaviors.

Those kids are more likely to develop addiction in adulthood, especially if there's trauma, if there's negative attachment.

Whereas kids who are raised in a home where patients are modeling healthy, adaptive coping strategies, where they have a good attachment to their kids, where there's not sexual, physical, or emotional abuse, those kids are protected, right, or relatively protected.

Nobody's completely protected.

You can have the perfect childhood and still end up addicted.

And then we have what I call neighborhood risk factors, and these get to the key of access.

So one of the biggest risk factors for addiction is simple access to that drug.

If you live in a neighborhood where drugs are sold in the street corner, you're more likely to try them and more likely to get addicted.

If you go and get medical care at a place where people liberally prescribe opioids, benzodiazepines, stimulants, your brain will be exposed to those drugs, will change in response to those drugs, and you are at increased risk of getting addicted to those drugs.

Now, in your case, the risk of access was ultimately what got you initially hooked, but probably other innate protective factors that you have allowed you to not end up with a serious addiction, probably in terms of genetic protective elements, maybe having to do with the way that you were raised.

I don't know you, so it's hard for me to judge.

But essentially, that's kind of how we think about it.

But what's interesting, and I guess this is the part that's most curious to me, is I am, I mean, if I'm being brutally honest and take an honest stock of my life, there are clearly things where I behave in very addictive ways today.

So, and let's just acknowledge that the neighborhood for those things is high, right?

Like, I mean, online shopping, like my wife describes me as an e-shopaholic, and she can tell my stress level by the number of Amazon packages that come to the door.

So when I'm under low stress, will go a week without a package.

When I'm under high stress, three packages a day.

To be clear, it's not breaking the bank.

I'm buying stupid, irrelevant trinkets, but it's this dumb little escape I have where, oh my God, I need a key chain.

I wonder what kind of key chains they have on Amazon.

Oh, look, I gotta, you know, so it's, and I fully acknowledge that there are real, that that is a true addiction.

Now I'm fortunate in that the consequences of that addiction are minimal, but I'd like to believe I'm at least wise to the fact that there's just a general good luck that is permitting Amazon to be my pusher as opposed to someone selling illicit drugs.

And I wonder why, that's the thing.

I wonder why, because this to me speaks to, like, we're all addicts potentially. Why are some people unlucky in that the addiction is, it turns out to either kill them or destroy the quality of their life and their relationships?

Right, so let me answer that in a couple of different ways.

First of all, thank you for sharing the online shopping addiction.

As you know, in my book, Dopamine Nation, I talk about how I got addicted to romance novels.

Now, granted, it was a minor addiction and I was able to, once I recognized it, you know, change those behaviors without having to get professional help, which, again, brings us back to this concept of drug of choice and how it intersects with access.

Because what's so challenging about the world today is that not only do we have more access to more potent forms of traditional drugs, including alcohol, but all the other drugs that have been around for millennia, but we also have brand new drugs that didn't exist before.

All of the online digital media, online shopping, pornography, the drugification of the romance novel, et cetera, et cetera.

You described this, Anna, sorry to interrupt, in a way that I loved so much.

I wrote it down.

We are cacti living in a rainforest.

I mean, it's just such a beautiful way to describe the bizarre existence of the human in this condition relative to 10,000 years ago and for millennia.

Yes, and I'd love to take credit for that metaphor, but I can't.

That's Dr. Finnecane from Johns Hopkins, but it's a fantastic metaphor.

That's right.

We weren't evolved for the world that we live in now.

So again, just to go back to my own example, I thought that I hadn't inherited this so-called addiction gene because alcohol was never reinforcing for me.

Caffeine doesn't wake me up.

These are the legal and easily accessible drugs that people who do find those drugs reinforcing are going to be vulnerable to because they're legal and accessible.

Why do nicotine and alcohol kill more people every year than any other drug?

Because they're legal and they're accessible.

So I think that's a really important first thing to say.

Now that we have drugs like online shopping and romance novels, people like you and me who maybe thought, well, I didn't inherit this addiction gene.

Maybe it's not true at all.

Maybe we just hadn't yet met our drug of choice.

And now that we have new drugs proliferating, we are discovering we are just as vulnerable as the next person, given the key that fits into our neurobiological lock.

I am gonna get to the heart of your question in a second, but I just wanna make one more point before I do.

When I think about this from an evolutionary perspective, it makes a lot of sense that mother nature would want there to be inter-individual variability in terms of drug of choice, right?

So if we're living together in a tribe, in a world of scarcity and ever-present danger, which is the world that humans have existed in for most of the time that we've been around, it's very good if we're not all going for the same exact berry bush, right?

It's very good if you like the red berries and I like the blueberries and somebody else wants to hunt meat and somebody else wants to look for people.

That way, we as a tribe can be pretty well guaranteed that together we're going to be able to get all of the scarce resources that we need to survive.

So I think when you think about it from an evolutionary perspective, that's important.

But I really think the heart of your question is not so much why is it that some people get addicted and others don't because we've just explored the fact that really we're all vulnerable, especially in the modern ecosystem, but why is it that some people can self-correct, that as we progress on this road of compulsive overconsumption, why is it that some people can see it and make an adjustment?

Which by the way, I just want to make sure, I know you know this, but I want to make sure the listener understands.

When I tell that story about me with the opioids, I'm not claiming to have self-corrected.

I'm simply saying it was not the lock and key for me.

So it was actually quite easy to stop.

And the only suffering I went through was the physiologic withdrawal, which is dramatic, but it's a chemical reaction that after a few weeks was gone.

And now, I mean, even as I sit here now, we have a bottle of Percocet in our, it's in my bathroom, it's 10 feet from me and it's been there for 10 years and I've never looked at it and it wouldn't occur to me to, but if I was in significant pain, I would go and take two of them and not think twice about it and it would be fine.

So just to be clear, I didn't, it wasn't through any self-discipline that I stopped taking it.

That was quite easy once I just decided and made the observation that I shouldn't be taking it.

If I was truly one of willpower, I would never step foot on Amazon again, or if I did, it would only be for something that I needed.

So in that sense, I am a junkie and I don't seem to possess the tools or at least innately to stop it.

Okay, so good clarification.

You really don't think that you have a vulnerability to opioid addiction, but you really do think you're addicted to online shopping.

Is that fair?

That's fair.

Okay, so yeah.

And, but I think you're too hopeless about your online shopping.

I think that that is an addiction that if you decided you wanted to, you could work on and make progress in that regard.

But you would have to, clearly there are not financial consequences for you to buy key chains.

Now, in my book, I do talk about a patient of mine who did get addicted to online shopping on Amazon to the point where his house was full of partially open boxes.

He was in credit card debt, approaching financial ruin.

He didn't even get pleasure from the things he ordered anymore.

It was just the anticipation and then it would come.

And as soon as he opened the box, he would have an immediate come down.

Which by the way, I can relate to that.

I can really, really relate to that.

And it's with great empathy that I read that story because I can imagine how painful that is as the size of the purchases goes up and up.

And again, for whatever reason, and I attribute it solely to luck and good fortune, maybe it's just a tolerance thing.

I haven't had to get to the point of that patient, but that would be awful if you're spending all of that energy on something and you open the package and you're like, yeah, great, okay, what's next?