Daniel Knoepflmacher, MD (Host): Hello, and welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, neuroscientific research, and other important topics on the mind.

Today, we will be discussing alcohol use disorder, the most common substance use disorder in the U.S. In 2022, data showed that 29.2 million Americans struggled with an alcohol use disorder. According to the CDC, more than 140,000 Americans die annually as a result of alcohol use, a number that's significantly higher than the annual deaths caused by opioid use. The COVID-19 pandemic presented its own troubling trends. From 2019 to 2020, alcohol consumption among adults increased by 14% with an especially significant 41% spike in use among women.

With the majority of Americans drinking alcohol as a regular part of their adult social activities, the immense impact of this disorder is often overlooked and misunderstood. Today, we'll delve into this common medical condition that threatens the physical and mental health of millions, and explore the many effective treatments that are available to help people achieve meaningful recovery.

We're fortunate to have Dr. Jonathan Avery joining us today to discuss this topic. John is the Vice Chair of Addiction Psychiatry here at Weill Cornell, the Stephen Tobin and Arnold Cooper Associate Professor of Consultation Liaison Psychiatry, and the Program Director of our Addiction Psychiatry Fellowship Program. He's also someone I value as a close colleague and a trusted friend. He's the first person I call whenever I'm facing a challenging addiction-related question in my own practice, and he never fails to have good answers to my questions, and they're always delivered with an enviable combination of calmness and kindness. John, thank you so much for joining me on the podcast today.

Jonathan Avery, MD: Of course. No, it's my pleasure. Thank you so much for having me and for the incredible work you're doing in our department and through this podcast.

Daniel Knoepflmacher, MD: Well, thank you, John. It's always a pleasure to speak with you. And I'm going to begin by asking you the same question I ask everybody when they come onto this podcast, which is what led you to become an addiction psychiatrist? How did you get interested in this area?

Jonathan Avery, MD: I think the main driving force was that no one wanted me to become an addiction psychiatrist. I thought the field would be interesting ever since I was in high school. I saw friends and family struggle with substance use and saw how they benefited from getting care for those illnesses and made it to the other side of it. And it was very inspirational to see the work that they did. My dad was also a hospice physician and detailed to me some of the experiences he saw in his patients with substance use disorder and some of the barriers that got in the way of them receiving the care that they needed to receive at the end of their lives.

And so, I entered college and then medical school thinking, "Hey, this is something that's really interesting. Something that I'd love to explore further." I thought there was a lot of good that I could do, seeing, you know, people struggling with alcohol and opiates, and it seemed to be all over the news and all over our communities. And I started to have very positive experiences working with folks with substance use disorders in medical school. And I was thinking about that, and surgery, and psychiatry. And as I was discussing my interests with my supervisors in medical school, everyone said, "All right, all those sound good except addiction. Don't go into it. Nothing you can really do for those folks. It's not even a medical treatment, it's something they go to AA for. And anyways, they don't get better." And this attitude I found in medicine, I found among family members, among friends. They're like, "Don't go to med school to become an addiction doc. It's not worth it."

And fortunately, that inspired me to do the opposite of that. I thought, "Hey, I've seen the good that can happen for these folks. They're everywhere in medicine. I was seeing these patients in all aspects of medical care." And so, I decided to really dive in, and I pursued a psychiatry residency here at Cornell, then an addiction fellowship, and I haven't looked back. And in fact, my research is on the stigma of addiction, largely driven by some of those experiences that tried to push me away from being an addiction psychiatrist.

Daniel Knoepflmacher, MD: It's funny, I don't think of you as someone who's a big rebel. But I guess underlying that, you looked around and said, "I know something is right about this, even when other people are telling me it's wrong."

Jonathan Avery, MD: That's right. And, you know, my dad always said the reason he liked being a hospice physician was he felt he could give people a voice who otherwise wouldn't have a voice. And these were people dying, less than six months to live, and he really believed in helping them tell their stories and to convey it to their family members. And when I saw that there was a group that seemed to be silenced in medicine that, you know, really needed the assistance to tell their stories and to get their voice out there and to have hopeful stories of recovery, that did inspire me to speak up and advocate when maybe I wouldn't have otherwise. It really did inspire me to be more outspoken and more of a rebel than perhaps is in my nature.

Daniel Knoepflmacher, MD: Well, I know you've inspired many to go into this field, and that's why you always have people who are eager to join your fellowship. But I wanted to see if you could tell us a little bit about this psychiatric subspecialty, addiction psychiatry. How does it differ from addiction medicine and how popular is it?

Jonathan Avery, MD: I hope with time it's more popular. But right now, it's not a very popular specialty in medicine. And in fact, in the United States right now, I think there's somewhere between 1200 and 1500 addiction psychiatrists in the whole country. And that's a small amount when you think of all the deaths, the hundred thousand from opiate use. We talked about the alcohol statistics, we'll talk about them more. We need a much bigger workforce to tackle these problems, yet very few people end up going into addiction. And I think stigma, as I mentioned, plays a role. People are encouraged into other specialties. It's also a long path. You know, by the time I was deciding on addiction, I was 30 and completely bald and in debt. And so, it's hard sometimes to take on that extra year to really specialize in something. But the value is incredible. And in addiction fellowship, you learn how to treat these folks in ways that you really don't learn elsewhere and where a lot of medicine suffers from not having the skills to take care of folks who are struggling with addiction. Different psychotherapies, different medications, there's really a wealth of things we can do to help folks, yet that's often missed in medical education.

Daniel Knoepflmacher, MD: Yeah. And I think that's a big part of your role is educating other doctors and certainly educating our residents about substance use disorders. And among those is the topic that we're discussing today, alcohol, which I want to turn to. And I suggested earlier in my introduction that alcohol use disorder isn't always known by people as the most common substance use disorder in this country, and maybe is misunderstood. And I'm wondering why you think that is.

Jonathan Avery, MD: We love alcohol. Even when I talk to people about alcohol in forums like this, I feel like I'm, you know, raining on people's parade. I'm not going to be invited to parties or something like that. It's such a huge part of our culture and it's sort of the answer to every question. What you do when you're stressed at the end of the day, how do you celebrate, what do you do over the holidays, friends, family. It's such a part of our lives that at times people don't recognize the big role it does play in their lives. And at times, it can be hard to recognize when one is drinking too much or ending up in trouble. And it can be hard to be different than the people around you.

Daniel Knoepflmacher, MD: That idea of drinking too much is, I think, important and also, that it's such a part of the fabric of our social lives. But can you help us just be concrete for a moment and say what amount of drinking is the threshold for when you have an alcohol use disorder? And I imagine the numbers of unhealthy number of drinks is different between men versus women.

Jonathan Avery, MD: Right. We think alcohol use disorder, which is what we're calling alcohol addiction these days, that's sort of the non-stigmatized language, an individual with an alcohol use disorder, that's when someone's drinking over time in a way that impairs their function or they have craving and physical consequences and social consequences of their use. And that's not necessarily tied with a drink number, like sometimes even a few drinks for certain individuals can lead to impairment in function and a problem. And sometimes people can drink more and not run into the same problems that others run into. And so, we think someone has an addiction when it's really starting to get in the way of things that are important to them.

Thankfully, though, we do have numbers that can help guide us in terms of drink to help you recognize when you are getting in trouble. And we sometimes call this the at-risk drinking numbers. And for men and women, they are a little different, as you mentioned. For men, we don't want them drinking more than two drinks a day. That's sort of 14 a week. Women, no more than one drink day, seven drinks a week. And then, we especially want them to avoid binging. That's when men drink more than three to five drinks on a given occasion, and women drink two to four drinks on a given occasion. And we picked these numbers, not because we're finger-waggers again and we don't like to have fun it's that above those numbers, it doubles and triples your odds of developing an alcohol addiction, doubles and triples your odds of the medical consequences of use.

And I think we're appreciating even more and more how the binge drinking can impact your mental health. Like, if you're prone to anxiety, you have three to five drinks on a Friday night, that gets in the way of your sleep and you're in a little bit of withdrawal the next day. And then if you're prone to anxiety, it starts that anxiety process in your brain that can lead to a frank anxiety episode or frank depressive episode. And so, we give people these numbers to help them cut down and help us understand what's risky drinking. And I think they can be a good guide for a lot of us.

Daniel Knoepflmacher, MD: I've found that in my work with people, that they're not always aware of these consequences medically, personally, and often as it relates to their mental health. On a grand level though, I imagine alcohol use, and especially alcohol use disorder in its more severe forms, has a real cost to our society. So, could you give us a sense of what the impact is?

Jonathan Avery, MD: Alcohol use in general, this includes binge drinking to really frank alcohol use disorders. The economic consequences are enormous. It's in the silly number range, like hundreds of billions of dollars each year based on productivity at work, healthcare costs, legal costs. It's one of the biggest modifiable risk factors in crime and domestic violence and mental health costs as well. And so, it's just really destroying, it seems like a little bit of a hyperbolic way to say it, but it really is, it's really costing so many people's lives and livelihood. And it really is a drain on our society in a lot of ways. And when I say that, I laugh almost because it's just such a part of our culture to drink, that to say it, it feels like hostile or something, hostile to something that's so ingrained in how we are. But the reality is that the costs are tremendous.

Daniel Knoepflmacher, MD: And you talked about the different numbers between men and women that, you know, is the at-risk drinking levels. And I also mentioned earlier that there was a bigger increase among women during the pandemic when it came to drinking alcohol. Can you tell us more about this trend and what's going on in terms of differences between men and women when it comes to drinking?

Jonathan Avery, MD: Yeah. Alcohol use and substance use in general historically has been sort of a man's game, a men's game, and it has impacted more men historically. And a lot of the treatments, 10, 20 years ago were set up mainly for men. What's happened over time is that it's become more culturally acceptable for women to drink at the same levels as men and use substances at the same levels.

And one consequence of that is that women seem to get into trouble with the same amount of substances sooner than their male counterparts, just based on their body makeup and how they metabolize substances. And so now, we have women getting more exposure to substances, having more sort of physical vulnerabilities to it. And we started pre-pandemic to see women presenting for care almost as frequently as men. Then, COVID came and presented a unique range of conflicts and stressors for women that we all know about, including childcare and finances, and everything that COVID-19 brought our way, and the number of women drinking skyrocketed. And suddenly, we saw more women presenting to addiction care than men, more women adolescents presenting to addiction care and concerningly getting into trouble at very young ages. I had to talk to our liver transplant service about women and drinking just because they were seeing so many women in their 30s presenting for liver transplant, something they hadn't seen historically. And so, we really saw the toll that COVID-19 and these changing societal attitudes played on women.

Daniel Knoepflmacher, MD: And what about other groups? I mean, historically underserved groups, minoritized groups, what do we know about alcohol use as it pertains to your background?

Jonathan Avery, MD: It's a similar narrative as I just described for women that these groups that have been marginalized, that often have poor access to healthcare and resources, disadvantaged economically. We've seen higher rates of drinking in these groups and this got worse during COVID-19 as well. For alcohol and opiates and other substances, more and more deaths and severe presentations among these disadvantaged groups.

Daniel Knoepflmacher, MD: You alluded to stigma when you were talking before. And I know for those who are listening, it's important to know that John has studied the effects of stigma within our field, within the field of medicine and thinking about how that impacts people who are struggling with substance use disorders. I want to ask you about that as it pertains to alcohol, because as you pointed out, unlike a drug that is declared illegal, this is something which people grow up with. It's part of their family life. It's part of popular culture. And then, it can reach a threshold where they use terms like alcoholic and somebody may feel stigmatized and different than their peers who are also drinking based on this. And I'm just curious if you can sort of explain how stigma applies with something that is so omnipresent as a social activity.

Jonathan Avery, MD: It's so bizarre, the statistics in some ways, because we love to drink, yet we hate the people who get in trouble for drinking too much. It's a strange combination of attitudes there. And my research and the research of others has shown that our attitudes are worse towards folks with alcohol and other substance use disorders than towards any other medical or psychiatric condition. And these attitudes seem to get worse over time. They seem to exist even in places that should be the safest, like in your doctor's office, among lawyers, even among our families. And part of it is that we don't quite accept that alcohol addiction or alcohol use disorder is a disease. And what we are learning is that it really hijacks the brain and reward pathway and the body in a way that makes change very hard, yet all of us, even doctors, tend to think of it as sort of a moral failing. Like we should just drink less. "What's wrong with you? I can drink less. Why can't you drink less? You're hurting your family, your liver, your kids by drinking too much. Why can't you get ahold of this?" Not recognizing that it's not a moral failing, but rather a combination of genes, environment, and severe use that leads to a state that's very hard to change. And I've shown in my research that if you agree that it's a disease model of addiction, that your attitudes are more positive to folks with alcohol, yet we still think of it as a moral failing, right? We distance ourselves from these folks. We put them in jail. We kick them out of school. Among healthcare providers, which I've really focused on, it seems like we don't offer the right treatment and treat them with compassion. And so, this stigma just gets in the way of so much.

Daniel Knoepflmacher, MD: And I know in your work, you've actually shown that this was a brilliant study that you did that actually the attitude towards alcohol use disorder worsened with progression through medical training, so that somebody beginning as a medical student, maybe you had a more charitable view, was more understanding than someone at the end of residency training, for instance. Can you speak a little bit more about that?

Jonathan Avery, MD: Right. And this was a surprising finding in a lot of ways and has been replicated by myself and other groups. It seems that there's something unique about being a doctor and the way a doctor interacts with folks who are struggling with alcohol and other substances that causes you to have worse attitudes over time, while presumably you have increased knowledge and skills to take care of these folks. And we think a large reason for that, especially in training, is that doctors tend to see the most severe forms of the disease, presenting with the psychiatric and medical consequences of drinking. And they're less likely to see people who are in recovery or who recover on their own. Or once they're in recovery, it's just a note in their chart and not their active experience of this patient group. And so, they get biased into thinking that these folks don't get better when in fact we know most people who struggle with alcohol use do end up in recovery one day. The odds are for anyone presenting to the hospital with alcohol use disorder and some of the consequences of it, they'll make it to recovery. But we forget those narratives or aren't exposed to them as doctors. And so, we get a little burned out over time, taking care of the most acute states.

And, you know, the answer to this and this is a project that you and I worked on, is to hopefully round out the narrative of folks in the medical profession so that they get more exposure to people in recovery, they can have more visions and narratives of hope in their head that they can convey to their patient. But there's a lot of work that still needs to be done on this.

Daniel Knoepflmacher, MD: Because if these providers are not understanding and are stigmatizing, then that's a barrier for people to get the treatment they need for alcohol use disorder. And that's just one of many barriers. Can you speak to some of the other barriers that keep people from getting available treatments?

Jonathan Avery, MD: Yeah. I mean, there's so many barriers in society. And, as I said earlier, when people struggle with addiction, we distance ourselves from these folks. We kick them out of school, we fire them from jobs, we put them in jail if it leads to legal consequences. And we're not so good at society about funding easy-to-access treatments of really leaning in and helping folks like we would if they had any other medical condition by sort of rallying around them as a community, as medical providers. And you know, people, because of this, they sense that judgment, and so they don't come forward talk about their own concerns about their health. They don't feel like they can take off work from it. They don't feel like they can confide even in their significant others, and this leads to the addiction building and building. And so, sometimes doctors don't understand, "Hey, why isn't my patient who's struggling with alcohol use or other substances sort of more forthcoming with me at their session?" I always say you would be nuts to be forthcoming about your addiction. If you've experienced stigma and been rejected at so many levels throughout your life, it would be very weird to suddenly go into a doctor's office and be open and honest about it.

And so, part of the antidote to this, I think, is just having more open and honest conversation about addiction, about our use patterns, and when they get us into trouble, making care easier to access without threatening people with loss of job or loss of school or loss of relationships. And that's where I hope we're going in the future, but we're a far cry from there right now.

Daniel Knoepflmacher, MD: So once people get through all of those barriers, there is treatment available. Tell us about some of the most common treatments for alcohol use disorder.

Jonathan Avery, MD: I think we've made a lot of gains in this space in the last 10 to 20 years. Historically, we pretty much just had one treatment, more or less, which was the 12-step treatments, Alcoholic Anonymous, and there's 12-step treatments for a number of other substance use disorders as well, and it's a very good treatment. I mean, it's free, it's peer-based, you work the steps, you get a sponsor, and has saved many lives over the years. But it's not for everyone, and I think we've struggled historically with sort of a diversity of treatment options for folks presenting them with different therapies and groups and different medications, but we have those now. And so, there are 12-step alternatives that people can pursue. There's a really good organization called Smart Recovery that also provides free and peer-based groups. They have a great online present. There's groups that are based on Buddhist or mindfulness principles like refuge recovery. There's moderation management groups for people that just want to moderate. So, there's increasingly a menu of options psychosocially, in addition to outpatient and inpatient rehabs if you're really struggling. And then, there thankfully is a lot of medications these days. There's four that are FDA approved and more in the pipeline and more novel treatments that we're increasingly using in medicine as well.

Daniel Knoepflmacher, MD: So, these are always combined treatments when they're most effective.

Jonathan Avery, MD: I think so. I think we want to combine the groups with certainly addressing mental health issues as well. Getting the reasons why one is using, addressing the anxiety, the depression with meds, and then combining the treatment with medications that can be very effective.

There's one medication in particular that seems to be winning the game these days called naltrexone. It's an easy-to-prescribe medication with very few side effects. The main side effect is weight loss. Actually, it's been repurposed as a weight loss drug. And so, people tend to like it. It's just not prescribed because, you know, doctors sometimes don't realize it's such an effective med, and patients don't know to ask for it. But it's a med that can help you maintain abstinence. You can drink on it and drink less. And part of my work as an addiction psychiatrist is really to educate both patients and providers on these treatments like naltrexone that can be really effective in improving outcomes.

Daniel Knoepflmacher, MD: And you mentioned the different groups and approaches like Alcoholics Anonymous where there's a goal of complete abstinence from alcohol use. You also talked about other programs which may have different approaches including moderation as an alternative approach. So, I'm curious, as an addiction psychiatrist, where do you fall on the question of moderation versus abstinence? And how do you determine what's most effective for your patients?

Jonathan Avery, MD: Up until very recently, I think we've defined recovery as abstinence. And you went to see an addiction psychiatrist or even a medical provider 10, 20 years ago, we were saying, "All right, you've got into trouble with substances. The best and potentially only approach is to be abstinent from substances. But these days we no longer equate recovery with abstinence and we're appreciating how a large subset of people can enter recovery to a healthier place with substances without being completely abstinent. And this moderation movement has been supported by groups that are there to address moderation management.

Also, that medication I mentioned, naltrexone, has played a big role as well because it's sort of the med of moderation, and we've seen how people who drink in risky amounts can be on that medication and suddenly find themselves drinking amounts that are much less risky and to get below those sort of at-risk numbers that you and I talked about at the onset of this podcast. I think that doesn't resonate with everyone, that recovery doesn't mean abstinence. Certain people balk at it. And certainly some folks, when they're struggling with addiction, need to be abstinent, because even small amounts of substances lead to really bad outcomes for them. But again, there are a lot of folks that can recover without being abstinent.

Daniel Knoepflmacher, MD: So, it's really not one-size-fits-all. You have to kind of meet the person where they are.

Jonathan Avery, MD: And that helps with the stigma too, right? Because no one wants to be told what to do and especially what not to do in sort of a finger-waggy-this-is-what's-going-to-happen-to-you way. And I think giving space for different ways that people can recover gives people space to experiment, figure out what works best for them, helps them figure out where they feel the most comfortable. And in that way, people can change the most, I think. When the change is coming from them, when they're running the experiments in their life, I think people can really help understand what's successful that way best.

Daniel Knoepflmacher, MD: And that motivation for change can be part of the treatment process? I mean, I know something we teach our residents, and in fact, you spearhead this is about motivational interviewing. Tell us a little bit about that and how that is part of your practice.

Jonathan Avery, MD: Yeah. Motivational interviewing has really changed the doctor-patient interaction over time. And I think it's one of the reasons I have longevity as a psychiatrist and physician and why I don't get burned out working with patients, because what motivational interviewing teaches you is just to meet the patient wherever they are in their healthcare timeline. It's a role with resistance and it gives you some skills to help get change talk to come from the patient and not from you. Because historically what would happen is someone would come in with problematic alcohol use and we'd say to them, "Why are you drinking in this way? You're hurting your liver, your brain, your family. You're going to die if you keep drinking in this way." And what's the problem with that? What's everyone in the life of someone with alcohol use disorder telling that person already? "What's wrong with you? Why are you drinking and using in this way?" What's everyone with a substance use disorder telling themselves? "What's wrong with me? Why am I drinking using this way?" And so if we double down on this as a physician, we just push it again to the shadows, push it to the stigma and situate people in a place where recovery gets very hard.

And so, what I tell residents and clinicians, is that your goal as a provider in a motivational interviewing way is really to just be the friendliest face the patient has ever seen. And I always say, "Look, if I can be the friendliest face the patient has ever seen as a bald middle-aged man, imagine what you all can do with your youth and your hair. It's endless." And so, you know, that's really the spirit I tried to infuse. And to be honest with you, it's so successful. It's like what I use with my wife and children. Like I'm living an MI way, because we're a little narcissistic as doctors. We think we know everything. We want to dump all we know on people. And that's just not how people learn and change. And so, my 10-year-old says, "I don't want to go to bed tonight. I'm not tired." I say, "All right, you can stay up and go to bed whenever you want." She says, "Oh, but I am tired. I'll go to bed." You know, we have to get out of this tug of war and information dumping and really just meet people where they're at.

Daniel Knoepflmacher, MD: There's so much wisdom in what you've said there, just about the humility of meeting your patients where they are and really thinking kind of empathically about what the experience of somebody struggling with this is and seeing another face that just is rejecting or stigmatizing is going to not allow treatment to work. So, that's incredibly helpful to remember. Motivational interviewing and all these new developments in some of these group treatments are really important. And you identified some of the mainstays medications that are used. What about newer medications? I don't have to tell you, but in the news, at least within the world of psychiatry, there's a lot of talk about psychedelics, which of course I think would be categorized in a different time as an illicit drug, but are now being looked at therapeutically. And then, additionally, even medications, I've been seeing some evidence of this. And frankly, even in my own practice anecdotally with patients where the medications that we call GLP-1 agonist. So, that'd be a medication known as like Wegovy and Mounjaro, which are some of the popular names, Ozempic being the original one for diabetes, that these might be helpful. I want to hear what you have to say about all this. What do you think about the promise of some of these potentially new options?

Jonathan Avery, MD: There's some exciting stuff coming down the line and, you know, I think it's building on not just naltrexone success, but there are a couple other FDA approved meds including Antabuse, which you can take to avoid drinking, and acamprosate, and increasingly some non-FDA-approved meds down the line that we're using. But these new treatments are exciting. The psychedelics, especially, I know you had Dr. Friedman on your podcast to talk about some of the exciting advances in this space. And we think some of those advances may pertain to addiction as well. We've certainly seen benefits in depression and anxiety, PTSD and there's been a number of studies that have shown that it's also helped folks with substance use disorders, alcohol and other addictions. It seems to help with craving and get people to a place of abstinence or moderation.

There's some concern though, you know, psychedelics, they're not quite approved yet. And we have seen an uptick in problematic use of them. Because of some of these positive reports, people are pursuing them and ending up in psychiatric trouble or misusing them in ways that

can be dangerous. And we've been thinking the psychedelics would help for decades now, and it hasn't quite shown sustained promise. And so, I'm a little suspicious, but I'm hopeful that we'll figure out a way to use these medications or the substances in a way that can facilitate change, especially as it relates to substances.

The other meds, the Ozempics, the Wegovys of the world are interesting as well. And we sort of stumbled on this one, because we saw the promise with weight loss, and then we saw in a number of patients who were benefiting from the weight loss properties, we saw them really decrease their substance use. And I've seen it pretty dramatically in some of my patients. And so, there's a lot of promise for that and we're studying it. I'd say both with the psychedelics and for those substances though, the question is if we get something sort of acutely under control, we develop insight, we drink a lot less, we use a lot less, how do we sustain it? Do we sustain it by taking psychedelics forever? Do we sustain it by taking Wegovy or Ozempic forever? And what we've seen, especially with these newer meds, is that there is a rebound when you come off them. And people can suddenly gain weight again and start using substances again. And so if we're going to use these to sort of get acute success, add ketamine to the mix, add transmagnetic stimulation and other neuromodulating things to sort of get an acute change, how do we sustain it? And we probably need to sustain it with some of the old treatments, the groups and therapies and old meds, or figure out how we can give these safely over time, which I don't think we've quite figured out yet.

Daniel Knoepflmacher, MD: It's also new at this point that we don't know what that long-term maintenance looks like. people were using all of those things for years so that doesn't mean that the new thing has to stand alone, that there may be, again, some kind of combination there that's effective.

Jonathan Avery, MD: Change is hard. It's the hardest thing any of us do. And you really got to throw everything at it for something as challenging as addiction, because it does hijack one's brain and one's life in all sorts of ways. And so, the change can't just be a brain change. It also has to be a psychological change, a change in your environment and how you communicate with family and friends and live your life. And that's pretty nuanced at times and requires some ongoing support and attention.

Daniel Knoepflmacher, MD: Well, what advice would you give to somebody who is in this situation where they're maybe thinking they are drinking too much, maybe other people have told them they're drinking too much and they've come to a point, despite all the stigma and the barriers that we discussed earlier, where they want to seek help to address their alcohol use? What do you recommend?

Jonathan Avery, MD: I think what I try to convey the most and I've tried to convey today is that there are options and there are options that can be tailored to be unique to you. And so if you benefit from groups, try a few groups. If you benefit from seeing someone individually or have co-occurring psychiatric disorders, you know, a psychiatrist or therapist, talk to your internal medicine doc and your psychiatrist about different meds that can be effective to help you address it. Just start talking about it in general with people in your life and help understand what your goal is, if you want to moderate, be abstinent. It's very hard to recover on your own in secret. And so, you know, I think the first step is just talking about it with all these different people in your life and they'll give you options. And through that process, you'll figure out what works best for you. And I've seen it all in my patients. I've seen the person that just goes to AA and that's it. They find their community and they're off to the races. I've seen people that have tried inpatient, outpatient rehab, different AA, different therapies and finally get on a medication and it's like, "Aha, that's it for me." And so, you just have to find what that is for you. And it takes a little bit of experimentation. It takes being open and honest about it, but it can be a process that's very rewarding. And I always say, and folks in recovery will say this as well, if you make it to the other side, the wisdom gained, the knowledge gained, the strength that, "Hey, I made this. What else can I tackle in this life?" It's pretty tremendous. And people in recovery are some of the most successful people among us. And it's hard to imagine when you give up substances that you can gain so much of a life on the other side. But it's there to gain, and there's really so much good that can come from it.

Daniel Knoepflmacher, MD: And what advice do you give to psychiatrists, because I know I'm sometimes one of them who are turning to you for advice about how to address alcohol use disorder in their patients. What ways are some basic tips that you could share for those clinicians trying to help people struggling with this?

Jonathan Avery, MD: One general rule is to ask and keep asking. I think sometimes we forget to even suss it out. And I've heard so many stories from a lot of folks, they've been treating someone for years, and they just forgot to check in on if they're drinking too much. And it's really been drinking that's been getting in the way, and not all the different things that they've been thinking about. And so, to ask the questions, and to make it a part of your routine. So, the review of systems and care, I think, is really important.

And then once you identify problematic use, I think it's helpful to familiarize yourself with these menu of treatment options that I just outlined. For some reason, there is some resistance, even among psychiatrists on sort of understanding these different options, yet we do it for so many other conditions when a new medication pops up. I think part of that is thinking that if I identify this, I'm just going to send it to someone else, send this problem to someone else or this disorder. But I think it's up to each individual to treat it because basically there's no addiction psychiatrist, as I mentioned before, and you've already got the relationship with the patient. And so, I do want everyone to be offering the meds and doing the MI-informed therapy and then helping facilitate entrance into outpatient support groups.

Daniel Knoepflmacher, MD: I can vouch for that advice because based on your counsel, you know, I've had people really have success with Naltrexone, Antabuse even. And it's made a real difference, not to mention, of course, the potential group treatments and psychotherapy. So, I'm speaking as someone who has followed that advice and really seen some positive change with medications.

Jonathan Avery, MD: You're such a good example to our residents. We're so lucky that you lead the residency. And as a colleague, we used to share a wall, our offices used to be right next to each other, they're not now, and your willingness to meet patients where they're at, meet residents and faculty where they're at, is really a good model for myself, for so many of us, and I tried to bring the Dr. K spirit into my own sessions, and it's been great learning from each other over the years.

Daniel Knoepflmacher, MD: We could spend another hour complimenting each but I think it is heartfelt. But I guess my last question, and this could be helpful to people who are listening, is to think about a loved one or a colleague or somebody who you've identified as struggling with alcohol use. What can you do to help in those situations?

Jonathan Avery, MD: It's a great question, and one I'm asked often. I'll start with the kids. You know, for kids, the general recommendation these days is to start talking about alcohol use at age nine. And so, we really want families to make it part of the routine to talk about alcohol, marijuana use, other substances. I think they recommend now talking about anxiety and depression starting at age eight. And then, we're recommending starting to talk about substances at age nine and really setting the stage as a family, that this is something that we can talk about. That's not something that's a secret. That's a health condition that we're all at risk for, and really setting the tone as a family that this is something that is important to talk about. And we know the stats. One-third to two-thirds of us have substance use disorders in our family. There's no avoiding it. And so, we need to make it a part of our general conversation. And that principle, I think, applies to communities and medical settings as well. We should have forums to talk about addiction at school. You know, it should be sort of routine part of healthcare and the legal system and wherever we're living and congregating with other folks. It has to be a part of our dialogue because it affects so many.

When you see a significant other or a family member or a friend who's struggling for addiction later in life, I think the main thing to do is to not avoid it and to have those conversations, even if they seem hard, and to do it in that sort of MI spirit and not a finger-wagging approach and just, asking them if they're okay, making sure they're aware of resources, to know that you're there. I think their fear, the person who's struggling's fear, is they'll be rejected for their use and they need to hide it. And if they can feel that you're generally concerned and accepting of them, come what may, I think that does create an opportunity where they can let you in to get help. And increasingly, because sometimes families need supports around this, there are supports for families that exist. There's AA-derived supports called Al-Anon. There's a lot of other family supports that exist in different forums. There's good books out there. And so there's a lot you can do to get support, including your own therapy and psychiatric support as well. And I would seek that out.

Daniel Knoepflmacher, MD: Well, John, there's more questions in my head, but I know we have to stop. It's always great to talk to you and you just have such a knack for making a very complex topic like this easy to understand and compassionate in how you talk about it. I think it's because of your wisdom and your generous spirit that so many of us turn to you with the hardest questions and people turn to you to get help with the hardest conditions.

I recommend to our listeners to Google John really to learn more about a lot of the important work he's done to help reduce stigma related to substance use disorders, and in New York City, save lives by distributing thousands of naloxone rescue kits, which is maybe a topic for another podcast with you. And really, you've been on many podcasts before because you're out there talking about this. And I think that's message that you really are conveying that if we can all become more comfortable talking about this, understanding it as a medical condition, it will really make a difference. So John, a pleasure to speak with you. And thank you so much for joining me today.

Jonathan Avery, MD: Thank you so much for having me. It was great.

Daniel Knoepflmacher, MD: And thank you to all who listened to this episode of On The Mind. The official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on all major audio streaming platforms, including Spotify, Apple Podcasts, and iHeartRadio. If you like what you heard today, tell your friends, give us a rating, and subscribe so you can stay up-to-date with all of our latest topics and fantastic guests. We'll be back soon with another episode.

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