Anil Makam on evidence, authority, and the space between

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every Friday at 5 p.m. Eastern. I'm joined today in honor to have on my show

Anil Machen, who's a hospital medicine physician scientist at San Francisco

General Hospital, and he writes on Substack for Health Services Policy issues at AAOX2.

Welcome Anil.

Thanks for having me, and I can tell you a little bit about my background for your viewers as well.

So I'm a hospital medicine physician. Also at Health Services Outcomes Epidemiology Researcher.

It's really my clinical intuition that drives all my impulses and my career.

And I've taken to disseminating ideas and appraisal of evidence and where we're at on Twitter,

or Exno, and started a substack with my co-founder called ANO Times 2, where you can

find some of my writings. I think about all things, evidence, medicine, health policy,

and really try to keep my fingers on the pulse of cutting edge evidence as well as the topics I find interesting and relevant.

So where would you like to start?

I mean, I was interested in your article on Eric Topol and Peter Tia and the one coming down on the other.

And we could kind of go over that, but I think there's some meta themes there of how we parse truth and how much of it

is kind of attendant to expertise.

Before the French Revolution, it was easy to decide what was correct in France because they had ruled by divine right.

And so if the Sun King said something, then that was it.

In the Soviet, you know, the term actual political correctness came around because you could be physically correct,

but wind up with your, you know, in the gulags, you had to think about what you said, so it would be politically correct.

And that has, you know, kind of taken on both the sort of satirical and an actual value at certain points.

But then we have kind of the mountain rush more of medicine in a sense, you know, kind of the Peter Tia representing maybe more of the vocal social media, younger crowd in Eric Topol, perhaps more of the elite establishment one.

You know, whom do we, you know, root for in those situations? How do we figure out who's right?

And when, you know, there's these interesting kind of what's the technical term for pissing match like we see between, you know, Megan Kelly, Tucker Carlson.

And Ben Shapiro and whatnot, you know, there's there's rooting and whatnot, but they, you know, the facts aren't necessarily the same kind of peer reviewed and whatnot.

Those are political arguments and that they can be political and people can have multiple different views, but in medicine, how do we figure that all out?

And what do you, how do you kind of weigh the confirmation bias or the authority bias of various of these actors?

Yeah. So start with like the met of you. That interaction between, you know, Eric Topol and Peter Tia was it really struck a nerve and the broader themes that I've seen play out in science, healthcare medicine.

And I think both are art types, so to speak, of two different camps.

And I think in academia and in elite leadership and, you know, what's called health policy or medicine, it's really easy to point at the Peter atias of the world.

And because I think they're easy to critique and I have a lot of the same critiques.

I think a lot of it is a thesis driven by narrative and not by evidence necessarily.

Whether there's truth to some of what they're saying, I think certainly that's possible.

But I think Eric Topol used the phrase of calling Peter Tia a hoxster and a peddler of supplements and clear conflicts of interest that has gotten worse over time in his view.

You know, I wasn't following Peter atias career and really any great death.

But, you know, I share those critiques.

But to me, it was a mirror.

It was not the takedown of Peter atia that drew me into it.

It was a mirror of the opposite problem and I thought was even a larger problem than people selling theses of how to, you know, live better, live longer, you know, the longevity or wellness entrepreneurship model, so to speak.

What I saw was, you know, it's experts who wear the cloak of the science, so to speak.

You know, I'll put that in quotation marks.

The science.

They're authoritative figures.

And these people are throughout there.

They sit at the head of healthcare systems.

They sit on guideline committees.

They're in major institutions, making decisions for our country's health and well being at a political policy level.

And Eric Topol is just a representative of that.

So there's nothing personal here about either one.

I just think both are representatives of different camps.

And I titled that piece.

Yeah.

The wolf and academic clothes, obviously based on an idiom, which is strange.

So they have one commentator thought I was calling another physician a wolf as a target or a common but the idea that there's somebody who's appearing benign.

But actually quite dangerous.

And I think that's what that's what the Eric Topol type type represents.

It's somebody who has all the credentials delivered in the authoritative tone of the science.

And we're and makes this epistemic habit of substituting some peer reviewed publication of questionable quality.

And broadcasting that with scientific authority.

And it's equating published with reliable and peer reviewed with settled.

Where as science is very fluid.

There's a lot of ins a lot of outs.

Sometimes, you know, the story of all is with time.

There's a lot of problems.

There's always caveats with studies, even well done studies.

But then there's just basically, you know, there's studies that have such basic flaws that you should be like, whoa.

Let me think about that before I, you know, put it on my Twitter account or my sub stack with hundreds of thousands or millions of viewers.

With the authority and respect of someone who's an academic elite.

And in my view, I think that expert over reach.

And again, I'm going to call it expert because I'm going to challenge, you know, what I call expertise.

But I think what people view as academic experts or scientific experts.

It's that overreach. I think that distorts reality is where the danger lies.

Whereas somebody who's selling a thesis, that is a, you know, if you follow that thesis and there's harm or waste, I think that is something you opt into.

And it's more confined to the person who believes in that as opposed to changing the direction of science, changing the direction of policy, changing the conversations that media covers.

Changing how the public digest science when they're reading experts quoted in, you know, the New York Times or CNN or whatever news media platform that people get their health news.

And that was what really drew me in and made me just kind of compelled me to write that post.

Yeah, no, it's excellent.

No, I follow sports here and there. And if you're following sports, you'll generally kind of get steered into buying new jerseys.

Now, not the state of New Jersey, but jerseys that are new.

You could buy a state of New Jersey, New Jersey, perhaps as well.

But, you know, and then if you go to some of the, you know, Peter T type sites, they're going to be selling, you know, various concoctions, vitamins and this and that.

And that seems to be kind of the ancillary cost of doing business. I don't, I will follow a lot of people, I, you know, I respect Dr Robert Malone, Peter McCulloch and others went up.

But I was on the Naomi Wolf video cast some time ago, a couple years ago, talking about men's sexual health.

And all of those places, they, they wind up, you know, having a thing to sell that's going to probably not hurt you.

And not necessarily, you know, extend your life per se either.

And so those are very blatant things and you can kind of argue about the hucksterism used that word appropriately.

But what's, I think missing that I think you underline is the other aspect of people are not overtly selling something.

Or an academia that they're diffused, they have degrees, they have pedigree, authority, tenor, tenure, whatever.

And nonetheless, I think there is something there that keeps them doing what they're doing in solidarity with each other and with an narrative, sometimes more than with the actual process of science.

There's a, a mistaking, you know, when, you know, people talk about science settled or they are the science, whatever, you know, I think there's a kind of a differentiation between, as you said, talked about, like certain having someone be peer reviewed.

And the actual, you know, science meets two things, science is the body of knowledge that we, you know, work on that we accept and science is also the process by which we gain that knowledge.

And I think obviously one of those is fluid, the other is more like the library.

So you have a library of books that you draw upon because they've been experiential. And then there's also the writing and the rewriting and so forth of a lot of those things that form that.

And that's an active process and it has, you know, weight and politics to it.

You know, I'm not going to bore you with my whole story, but I wrote a book called overturned Zika on the Zika pandemic and it came to me.

I started before the four COVID came around and I just was puzzling to me.

Three years out that, you know, we didn't hear anything about Zika micracellally at all, but it was a big, big deal in 2015, 2016 and kind of, you know, in a minor way overturned the world and whatnot.

And I really did deep dive into this and, you know, I commend all my viewers, whatever to buy the book is it's interesting a and be able to give me, you know, five bucks, whatever.

You know, but I've sent that book to loads of academics and I get minimal response and it's always, you know, shunning and whatnot.

But in the obvious sense, there's been no Zika micracellally ever since and still there's a whole institutional turn on the Zika micracellally concept.

They've kind of changed, move the goalposts get back to sports to calling this thing CZS, congenital Zika syndrome, which is almost anything you want and nothing at the same time and any minor changes and what they've just taken away from the absolute thing they could easily point to with micracellally is measurable and whatnot.

And there were a whole bunch of problems again, you know, the book or articles, whatever written on the top.

But my major point is that I've tried to present this in a lot of different academic ways and to one specific point, I have some, you know, medical friends, MD, PhDs and whatnot, I know, you know, professionally or through sports and tennis and whatnot.

And, you know, none of them, I say, look, dig into this like, you know, break me over the coals, like burn burn my theory, tell me where I'm wrong.

And nobody can. And I said, okay, fine. So, you know, get me, you know, get me in at, you know, a lecture someplace where I'm an academic, I don't, I'm not, you know, professor of anything.

And nobody can and nobody will and nobody has and so forth. So it's kind of like there's seems to be still kind of a fortress aspect to it where, you know, if money and funding comes a certain direction, that's not the overt thing that, you know, the Peter T is of the world are doing, you know, with subscribers.

And, you know, whatever, you know, things they sell, the ancillary vitamins and nutrients and whatnot, but it is a thing. It is a thing they sell because they have not an active sale, whatever, but they have to protect.

So it's more like, you know, you know, getting back to the French revolution, it's more royal and regal and monarchy and covered by ramparts and man and so forth to protect.

Now, I don't know if you have any, you don't have to comment on the Zika thing, but I'm wondering just whether that thesis rings bill at all.

Yeah, there's, you know, something you said resonates with me is, you know, when someone has an obvious conflict of interest, it's really easy to point to.

You will profit if you buy this thing, whether it's a supplement or a program or a book, and that's really clear to show to tie somebody's ideas to this obvious conflict.

I think with academic elites, you know, inside, outside the academy, they can be in, you know, help policy institutions, nonprofit, think tanks, this isn't confined to academic institutions per se.

You know, there's something called like intellectual conflicts of interest, and it's in some ways it's even more threatening because people's identities are tied to not a problem, but to a hypothesis or a potential answer.

And to me, in many ways, that is as harmful potentially in terms of like biasing how people are viewing the scientific process, which should be fluid, it should be open to testing and you should be passionate about the question, but not the answer.

And that's what I tell my mentees and students is if you're going into into research or scholarship, you should be going into it with the scientific pursuit of knowledge and being surprised and committed to that process, but not committed to the answer.

And a lot of people come to me or I hear is like, I want to do research to show X. And I'm like, well, that's not, you know, like if we knew as X, then like, why do the research and what happens if it's not X?

And I think there's a lot of people's careers are wrapped up into a camp, into a narrative, and when you threaten that narrative, it threatens their identity, and it causes a lot of internal conflict, I think, and how people are interpreting or even producing research.

So I'm a generalist, I care about all diseases, you know, I really just care about human flourishing, I don't care if we have to solve it with drugs, devices, if, you know, if it's a solution that comes from one field versus another field.

But once you start getting into sub-specialties of medicine, people not only care about that disease, they care about solving that disease through the lens that they have painstakingly trained through many years of very challenging, difficult clinical training and research training.

But once if the solution is not within that narrow lens, and I think that's where some of the disconnect comes from the intellectual conflicts, at least, you know, as represented through like academia or even outside of academia.

Yeah, no, it's a funny thing. I don't have the same career path as you are pretty much anybody else in the world, but I did a family practice general medical practice, kind of on the English model of the GP, just like out of patient medicine for about 30 years, in a blue collar town north of Boston, adjacent to Boston, actually.

And so I saw whatever came through the door and it wasn't really what I kind of planned on doing in a sense, but that I went up and joined it and you know things come through and you know, so I'm not really wedded to any particular treatment.

My job was to, I guess, in a sense go shopping, knowledgeable shopping for my patients, you know, the stuff is all out there.

I mean, whatever bits of knowledge they want to get from me, I mean, obviously going to do some things, you know, might glance a boil, they can't go do that themselves.

But the knowledge part, you know, how to treat their problem, whatever, that's that's up to me to, you know, kind of source for them. I'm like, there's so melee, you know, if you want a good bottle of wine, you're going to get somebody who has more knowledge about that, I'm not going to go into the restaurant or pretend I know all that stuff.

And so, you know, our kind of vast wealth of economy and our economy of wealth comes from this, you know, knowledge exchange where we have differential silos of expertise and knowledge and experience and so forth.

And it's up to me, am I kind of a knowledge, you know, I like learning things, you know, I used to try it out for jeopardy a couple of times.

I kind of qualify, but they didn't pick me that kind of thing. Anyway, it's a fun thing for me. That's that's kind of what motivates me that to know things.

And then it's like, you know, the secondary benefit is you can kind of help people along in certain way. I mean, I don't really feel like I'm helping people per se when I'm doing because I'm just saying things I already knew.

But, you know, their knowledge level is different, so you're kind of helping other people get to a place where they can improve their lives if they, you know, choose to follow you.

You can't make people do things. But, you know, the medicine has, you know, I'm not saying, you know, a lot of the terms that come about like evidence based medicine. It sounds great.

You know, why wouldn't you want to do that? That's awesome.

Medicine. Like, what are the options? You know, but a lot of a lot of terms that come, you know, kind of anodine sounding terms get our cloaking.

They are trojan horsing whatever the word would be other things. And then you wind up with, you know, pretty much guideline medicine with that.

We're going to take a short break. We're going to be right back with Dr. Neil Mockum.

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I'm Dr. Randall Bach here to unpack myths, explorations and give you actual insights into the world of medicine and health.

And I'm back with physician Dr. Neil Mocken and I'd like to talk about how we educate what is truth in medicine with so much conflicting information out there.

What is evidence based medicine essentially how do you figure out what is quote unquote truth or best practices in medicine.

This idea like a marketplace of ideas and medicine and academia, I think it's an interesting thing and I have a lot of thoughts on that.

And then there's the commercial side or the market side of how clinicians interact with patients and because you're you're right, you're not directly interacting with this is not a cash based market.

There's a there's a lot of third parties who have vested interest and regulations.

I'll start you know start at the top, you know, what is evidence based medicine. I've written a lot about this thought a lot about this.

So I went into research not because I hate practicing medicine because I love practicing medicine and and this idea of how do we provide excellent care is a theme and a thread that runs throughout most of my research and public writing.

And then I think evidence based medicine is a term that has as you alluded to I think it's got like bastard eyes into this cookie cutter guy study says X guidelines says why and you just follow it.

And that's what we do and honestly that's how many people practice.

And you know, I think there's a there's a benefit if you're just going to have people follow blindly like sheep.

That might be better than wild wild west where everyone's their own expert and just making up stuff.

I've practiced in settings like that where people are just deviating and doing stuff and that's probably harmful.

Well, you know, there probably is some innovation on the edges where people are doing things where the evidence hasn't caught up based on their hypotheses, but certainly these aren't tested and known at the time.

But it's just standardizing care to be like if you have disease acts and you show up with, you know, these like labs or images or whatever, maybe we do, you know, this next step in the algorithm.

You know, I think that raises the floor of medicine where at least you're getting some standard, but I don't think it raises the ceiling and it might lower the ceiling for any given patient.

And when I say practice evidence based medicine is I can see the same person with the same disease and I might treat them 10 different ways.

And why that is is there is a knowledge base and we call that best available evidence and best available evidence as always mean you should just take it to the bank, it depends on the quality, how is it replicated, what are the caveats of that evidence.

But there is a concept of, you know, that library that you kind of spoke to earlier of just like what is known on this corpus, what's the corpus on this topic.

And then there's like, you know, what is your context and that's between the doctor and the patient, what's going on, what's going on in their lives, how important is this problem, what are their values.

You know, what's their prognosis, you're not going to, you're not going to do treatments that are going to take years and decades like cancer screening is to reap any potential benefit if you know your patient has a terminal illness.

But the guidelines don't necessarily tell you that I mean the evidence and guidelines don't necessarily talk about every single scenario. So that's where like the patient, the clinician's context really matters.

And then it's the patient's values like in goals like what do they want to achieve what matters to them.

And it's really that Venn diagram is what I and others call evidence based medicine and the problem there it's slippery.

So it's like the people who aren't able to engage in that thinking have a hard time with it because it might look again, if you have five or 10, 20 different patients, that answer of quote unquote what's evidence based medicine shifts and morphs.

And some people aren't comfortable with that uncertainty or ability to shift their thinking and their treatment plans.

And I think that's the disconnect when people are like well that the science says this so we should always do that.

And I think that's the you know it's it's a it's a very like poor man's version of what evidence based medicine is and it's certainly on average at a population level probably fine, but for any given patient you can certainly do a lot of harm that way.

Now I'm getting to the kind of marketplace aspect and we can talk about the actual marketplace of medicine now are you seeing patients you know is it seems like there's such a remove between what I call the consumer moment.

When you're buying shoes or buying a car buying whatever versus the medical purchase of knowledge or advice whatnot.

What's your own kind of clinical experience is it active and so forth and and it has it hasn't gotten better over time worse and what are the prospects of kind of if you think it's a value to have kind of the patient being able to pick and choose things obviously not the quite the same thing is going into picking you know bathing suits or shoes whatever because it involves your health but there's got to be some better way.

Having these things done then what I call kind of the paternal model of having you know your child even if you're 40 50 years old whatever you go to the parent and you ask about certain things and the answers no or yes whatever.

I don't know if you want to weave in some of your own experiences there and what I was you know I was going to interpret your marketplace in two ways what is the marketplace of ideas.

And then two is the marketplace of getting care and I think we've done a lot better in the former you know before it used to be how expertise was distilled is there's a group of people you have to know the secret handshake you have to you know be political it's not just like who is like has the best expertise it's like who's politically savvy science is like every other aspect of humanity it's you know people advance for more than you know they're.

They're knowledge and their expertise in the field and I think that was a gated process where this was this came on down high and just told to you and you know this was from guideline committees and policy makers and there wasn't a lot of venue you had to know the right people to get an editorial published in the Wall Street Journal or the New York Times or you to get an article published in the highest esteemed journals in the field.

There's a lot of gatekeeping so people don't like your ideas they don't accept your ideas and there's really no market just to share that so in the marketplace of pushing ideas and what and how to vet kind of what we know and why we know it and people's takes that has dramatically increased in the air of the internet and the era of social media.

And I think the public square so to speak is where I find most of my knowledge now and find most of my trustworthy knowledge a lot more than the editorials written by chosen you know one or two experts in the field I'd rather have consensus from a couple hundred people that I trust on their take that I've created over you know many years of doing this.

And having that vibrant discussion and you get perspectives from all over the place not even just within academia you get perspectives from people different methodologies and you know even like just you know lay persons perspective on their experience.

So I think that marketplace has tremendously changed it's not yet accepted in academia but I think it's a vibrant way of democratizing knowledge and expertise.

And I should say I don't think everybody is their own expert like you can't just go and be your own doctor at home or your own scientist of a topic I mean if you certainly you could do it I'm not I don't believe in credentialism but there's a skill on a process to it and those people who have that have home that skill there is a marketplace for that.

And I'll pause there but I'm happy to talk about what's the marketplace of actually getting care which I think was the second part of your question.

Yeah well let's pause on that because you you prompted a thought of mine conversely which is about getting people opinion getting people's opinions outside of you know strict medicine or clinical medicine per se or even academic medicine.

Now the other thing I've written on I have a book coming out shortly on addiction narcotic addiction and you know the science currently is diametrically opposed to the science of you know a generation ago maybe maybe now almost two generations ago.

We're in it's it's anathema to think that narcotic addiction is not a disease and I I'm kind of on the outside of that I'm an outlier because I think addictions addiction that's why they call it addiction and disease is something completely different and the analogy you know starting in the seventies.

Was that to with the analogy was to type one diabetes and so narcotics needed replacement narcotic the way ins you know diabetics need replacement insulin and this is caused a huge growth frankly in the number of narcotic addicts and it's a whole separate topic I've written on that and I've got some pieces on on brownstone and my substitute and this book upcoming and so forth but I was actually kind of a crucial part of my own career because I wound up.

Suspended by the board of registration medicine 2014 and the first.

Basically the allegations were that it did not see addiction as a disease you know and even if it is disease you know it's still kind of weird that if you're an alcoholic.

Disease if you have alcoholism disease we sober you up we don't give you replacement vodka and you have narcotic disease which we can prescribe as physicians we were not bartenders we can't prescribe alcohol.

But we can prescribe this other thing therefore we have to keep giving it so it's it's even if you stipulate that they're both diseases in our treatment paradigm is completely opposite and only the one that we have a.

Cinecure on a right to you know we have the so we have the monopoly on writing narcotics that benefits us as a profession what not anyway but the point about that is that within that realm of whatever the sciences addictionology.

You can't pretty much get anything out there that doesn't align with the fact that diction is a disease and whereas there are a lot of people who are not scientists.

I I like the podcaster and author Andrew Klaven he had a great piece on Matthew Perry and the time is death and talking about just kind of this thing about addiction being addiction is a horrible horrible thing I consider trauma not exactly the same as you know blunt trauma that you might see in the ear.

Call it a trauma one type or another where things happen like you can break your hip you may never be the same you might it might kill you but it's not a disease to break your hip.

You know it's not a disease to get narcotic it might kill you might never be the same but it's not anyway without belaboring that but there are a lot of people who you know ethically and morally have a view about certain things that we just consider a certain way in medicine and don't stop thinking or thinking any other way because we're very much embedded in thinking that thing that we think.

To kind of act like doctor Zeus there but I think you know that that's that's a place where as we get away from pathology from actual visible forensic pathology you know a glioblast we're not we don't really have arguments about glioblastomas because it's a tissue diagnosis you can see it you have it you don't I trust I don't have one I presume you don't have one and whatnot you know whether you have some behavioral court like ADHD or whatever any of these things so we're then it becomes kind of an emotion.

And the number start to change over time based on whatever society's going through so the number of people who think they're neurodivergent now I think it's up to 40% of the youth in the UK are neurodivergent so when you know a lot of these things that that literally can't be true I mean it's you know it's like you know it keeps changing it's probably not true you know gravity doesn't change that much probably is.

And so you know I'm just you know leave it out there for you again without a real question I apologize but you know have we kind of close the tent too tightly and just get a little bit of an echo chamber within it of our views without considering the other kind of parameters whether they're you know moral.

You know ethical religious societal you know I think I think the covid example is a huge one or economic even where you know we you know there's kind of that thing if we save one child it's all worth it well you know if you do that you take it to the logical extreme of block downs and social distance you know you could prevent every illness whatever but we we die in the worst punishment of solitary confinement individually.

So you know you're in San Francisco you know maybe we can talk about the code experience there or your other experiences you know surrounding that I think you were a reasonable judge of kind of the vaccine appropriateness for certain groups and whatnot how much should we start listening to or have we not listen to other fields in figuring out what is the right what's the public part of public health say.

Yeah so you're kind of talking about like should we have an open tent so to speak and a broad view of illnesses that haven't yet been well defined you know you brought up addiction I see a lot of addiction in the hospital work at I work in a safety in San Francisco you can imagine you know what among our most common diagnoses are people who are drawing from alcohol and withdrawing from opiates often fentanyl and I you know I think addiction's hard it's not going to be this like sickle sickle.

So where you have one gene mutation and boom we found the cause of addiction I think it's going to it's a lot more complex and it's going to be closer to like diabetes where we still don't know like why people get type 2 diabetes you know I think people can look at.

You know through genetics and you know all these new fangled biomedical techniques of being like these pathways are affected and in accumulation of like 20 different things your body can develop diabetes and I think addiction's probably even more complex.

You know this is probably where we've differed the most you know I think addiction is a disease but it's not a well-defined disease and we replace you know alcohol withdrawal not with alcohol but although when I was training if you practice at a veterans affair hospital beer was on the formulary and we used to I think doctors used to prescribe alcohol for alcohol throw which makes natural sense it's the same thing we do for opiate withdrawal we prescribe them opiates and other medications.

You know as well but you know the mainstay is to replace those receptors that are no longer bound to the to the fentanyl that people are taking or the alcohol people are drinking but we give people benzodiazepines or phenobarbital regularly and it has you know similar interrupt just briefly yeah just quick interruption I get that part but that's more of a detox formulation I'm talking about maintenance we have.

Yeah for details we don't have maintenance vodka so I think you know it's the same that I think we don't have good treatments because we don't understand the disease which is separate that isn't a disease which I think there's certainly like a social political context around addiction I don't think it's like exclusively a biomedical thing I think you know your experience to trauma growing up your life circumstances may put you at more risk and you might have more exposure

but I think you know I wonder 50 years from now especially with the advent of new scientific discoveries and you know I think sciences and technologies on this exponential curve of what we potentially might understand and maybe addiction will be like what we understood now about how people get ulcers where people used to thought ulcers were just stress.

You were just stressed out and you just got an ulcer and people called them stress ulcers and then what we learned is to and this was like a complete shock and again as you're talking about how do you break through a field's preconception of what the disease or the model is nobody was thinking it was caused by a bacteria that's like the main cause there's other causes like you can have a cancer that causes an ulcer you can a side of a common side effect of like over the counter pain medicine

of like Advila leave you know that one of the biggest most worrisome side effect are bad stomach ulcers but H. Pylori is the bacteria we found is the major cause of ulcers and we didn't know that for a long time or we just thought it was stress and I think that's where addiction will be and my hope is we'll figure out pathways and better treatments and I think our treatments are honestly pretty lousy for addiction they're not great.

So with that we're going to take a short break stick with us for our third segment with Dr. Neal Makam. This is Dr. Rady Bach, America out of the pulse always be ahead.

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Welcome back I'm Dr. Rady Bach here to unpack meds explore innovations and give you actual insights into the world of medicine and health.

And we were last speaking before the break about addiction and addiction as a disease or not.

I'm talking more about the paradigm we're in you know I think actually people will do better if if things are called what they are.

So for instance obesity you know you can call it a disease and I think that takes away agency and responsibility of how you got there.

And when we you know try to kind of put things into this umbrella that their diseases.

I think we also give the sensibility that it's not something that you had anything to do it.

Now I agree with the glioblastoma probably you know God forbid either one of us get it but whoever does get it had nothing to do with it.

I think that's stochastic you know the role of the dice whatever you live long enough you get stuff whatever and that's that's.

So maybe there are some different kind of groupings about who's going to get the alcoholism who's going to get the narcotic addiction whether it's social genetic you know whatever I'm not I'm leaving that aside I'm talking more about the.

The pathway towards betterment and I think that the pathway towards betterment of disease a fine certain of our issues has been very good for the academy and very good for the clinical practice and so forth but has not.

So I think we have reduced the numbers of those people with those problems in the case in point is methadone maintenance which became a thing in the seventies you know we it's not like there was there was a you know frankly the almost the same proportion of people addicted to narcotics in 1909 as in you know 2009.

But different narcotics it was opium and morphine that people were addicted to in the early 20th century and you know frankly heroin came along as a cure for morphine problems.

Now oddly enough and then methadone came to care for that when I ran some oxygen to cure for that so it's a little bit like a lady of swallow the fly there's always something else to fix the thing that was there but the number of heroin addicts basically went to zero from like 1920 to 1965 or so when I say zero I mean really really close.

And it was only matter of the way we looked at the problem it was punished it wasn't accepted and so forth but nobody said anything about a disease it was considered a failing of sorts and you know I personally would rather somebody.

I know this really can hardly say this but I I'd rather you know be stupid on occasion then have an intellectual disability say you know I did something stupid doesn't mean that's the only thing I'm I can possibly do because I can't.

Make better choices along the way I think this expression called Michael Gerson came over that call the soft bigotry of low expectations.

And this is the way you know the welfare state grew because we think that certain people can't possibly accumulate the knowledge whatever and there are probably the subset of people can't.

You know the chronic schizophrenia whatever you know there probably some people can't do those things but a lot of times you know we give people things and give people maintenance narcotic and tell them.

You're disabled whatever and you give them a stipend all the things you give them you take away there you you keep them alive but it's it's almost zoo keeping.

You know you keep the animals in the zoo alive but you know in a counterfactual world would they be happier being you know copies or gazelles out in the wild someplace even though it's higher risk of getting eaten by lions and whatnot.

And conversing the lions get all the meat they need in the zoo but would they have more fun running around and catching those gazelles.

And so there's kind of the the telos that we have as you know individuals and on our own personal journeys and whatnot which can be you know I don't know the nice word for zoo kept is but you know zoo kept you know we're we're we're cloistered and we're contained and I think that was the essence of the COVID issue where we we were given like a zookeepers sensibility about how we're all going to do well.

Yeah now you know a lot to unpack there I certainly agree I think agency motivation how not to stigmatize people by like a fatalism so to speak by saying you have this disease as an it's inherently like unfixable and some like predetermined illness that you're fated to.

And I think addictions a good example of that because you know the treatments we have can be very effective say you know we brought a method out we know it can be life saving for the right person but not everybody's not like a drug.

Like we'll have other cures or other treatments where you prescribe it and you expect you know similar benefits across the people that you prescribe it to in addiction it's you know the people all most of the evidence is from people who are motivated want to get sober show up to a clinic and roll in a clinical trial and you can see those people on this drug do better.

On methadone they're not methadone but the people I often see are in the hospital not because they want to get sober because something happened to them they got sick they lost access to opiates whatever whatever maybe in that other what's wrong you help them to get to a point of sobriety but they may not and oftentimes are not at the you know at the contemplate they're at a pre contemplative state of getting sober they're not ready to do the work.

That is going to take and they might not have the supports that you know they're a lot of challenging life circumstances and when I when people are prescribed these medicines it doesn't we're not seeing the same benefits you're seeing from the trials because I don't think they're they're they have the internal motivation and agency and ability to stay sober for many reasons outside of their control but

and they're you know there's some good work done at a parallel safety net in New York which sees people the worst addiction they're getting hospitalized for addiction disorders in which you're on and the same treatments that are effective for that highly motivated with group that has agency they don't see it when you're seeing like experts in addiction care not people like me but people who like to vote their lives to treating people with addiction these are like the the do getters of society and angels

and they will spend time at the bedside like much longer than me and do like motivational interviewing and they understand the ins and outs of addiction care even when you see those people maybe one in a hundred are still engaged with care six months later and again these are people in the hospital they're not because they're coming because they're motivated to get sober but because of some reason that happened and now they they're overdosed or they're withdrawing from opiates for some other reason

and I think there's overlap with that idea just because even if I'm going to call it a disease that doesn't mean I don't think that we should minimize that behavioral component and agency and then you know I think it's going to be hard to be sober if you are homeless and you're living in a on the streets where everyone's shooting up around you or you know often this is my biggest gripe insurance is go around addiction as many of my patients who want to get sober

they're like I can't stay sober because I'm staying in these we call them SROs are essentially like hotels that are committed to people who don't have a place to live long term but it's better than for many people is better than living on the street but the problem is people in these apart in this like hotel complex a lot of them are addicted to drugs and have addiction use disorders and are you know are using fentanyl actively and the streets around them and it's really hard to say sober I can't imagine that I can't do that.

Imagine if you are motivated to say sober and you're living circumstances or such and it's all around you like how you can have all the agency and motivation in the world but those are really hard circumstances that are just working against you.

Yeah now I agree to a point I do like to kind of put the template of changing countries or changing timeframes and so you could either one if you go to Russia they don't do method on maintenance there they don't have people on the street they're not a wealthier country than we are but and I'm not recommending moving but they consider it you know

this is research my method on article and I'm not going to speak for the entire country with entire medical established but they consider it somewhat laughable that we are giving people the drug they were addicted to how is that going to make people better how are you helping people you know if I gave Tiger Woods you know with having issues whatever and I gave him a you know a call girl you know three times a week

because he can't control himself sexually I don't think that's respectful to Tiger Woods or his wife at the time whatever anything like that it's like dude this is something that society has not always done or it's time to whatever you know you have to do better you made a promise to your wife at the very least et cetera and you know people do outgrow these things you know narcotic disease you know in the times where people were stricter with this you know people outgrow that they're not doing the same you know level there's a bucket of drugs

there's a botanaly in phase you know people have when they're doing wild stuff and taking all kinds of drugs whatever that tends to to burn out and there's all kinds of other things that people do over time that change and you know it would you know drug abuse would be uniquely the only disease that's you know can be treated by going you know by taking communion or being baptized whatever or you know finding God I mean frankly the whole structure of AA is that it's a religion you know without a denomination without a

name per se but it's basically religious precepts and and people you know for better for worse we're you know I think you are an individual who is you know clearly you know hugely bright and sensible research capable and so forth but you know that's not necessarily the default position of humanity you know I think we are tribal animals or pack animals and you know there are going to be a few people who can do that stuff who can figure out the lay of the land and you know maybe we're the the

sages of the guides or whatever and so forth is probably I'm not sure either one of us is the leader of the pack per se but there's going to be some leaders and then going to be some people who are you know as they say in Star Trek wearing the red shirts you know kind of you know secondary character what not never not everyone's ready for that and you know so when people have AA as a scaffolding you know to kind of give meaning and companionship and it's very low buried entry it's not like the same is joining my tennis club or joining getting into you know medical school or

what not you know they they feel better you know what isolation is the real disease you know I've spoken with

Bruce Alexander who invented rat park kind of you know rat park it's like cause we could this is worth looking

up and I've got an interview you might you know get an hour to waste whatever but rat park you know goes in

this concept of you know the rats when they were you know in the maze whatever they have all the cocaine

or heroin where they keep you know ticking that thing and getting more and more they they they

rug themselves to death but he said the stipulation was wrong because it was a barren place they put

these rats in kind of a maze where when they gave them rat park which had you know greenery

other rats they had different sexes you know both sexes there they had spin wheels they basically made

it like you know downtown London for rats they had the the canister of drugs and they didn't do them

they had alcohol and cocaine and heroin and you know they tried that stuff but they didn't do it

because it kept them from being you know ratty whatever it is with their friends you know of being a

good tribal rat and you know it part of the pack and whatnot and I think most of our lives you know

we have this experiential phase whatnot but I think a lot of the real disease part of drug abuse

and I'm sorry to you know rant on this I apologize but is the secondary part you're talking about

the homelessness and all the kind of you know misery and whatnot if the not everyone has to be out

in the street again if you look at the other countries they don't have the homeless problem we did

we didn't have the homeless homeless problem we did till there was a certain law lots it's

boysy versus somebody from a few decades ago look that one up but it changed the way we could take

people off the street we also emptied out the institutions you know the psychiatric institutions

whatnot where people who had severe schizophrenia you know severe mental retardation alcohol

intellectual disability they were with themselves essentially they didn't do nothing they were

maybe you know doing the equivalent of making license plates or quilts or whatever or stamps or

writing out envelopes or whatever they were doing something I have a friend who's got a severely

autistic kid about the kids independent he has a job and it's not your job it's not my job he's

collecting recycling stuff basically does the same exact thing every day he knows exactly which

followers and which think whatever and that's what he does but it's I you know we have a

a place in the time where we have taken certain precepts of kind of libertarianism mixed in with

some liberty and we call it liberty and it's not necessarily the right mix for everybody

yeah I mean I don't want to delve more into the addiction issue but I think

what you taking it back to even just the broader concept can we be too narrow and I think we

certainly can be too narrow we can be too narrow within a scientific discipline we can too too

narrow with just a medical lens and I think you brought up the pandemic as a you know I don't

think there's a better example of that because it's seared in everyone's brains kind of what that

you know I don't think anybody wants to go back to that and you know we have only a few minutes left

but you know this idea of making decisions based on a partial risk-benefit calculation from

the medical world is you know I think that was a mistake and we didn't consider the long-term

consequences of you know prolonged closure of schools or you know what people might call when

I call closure school but remote learning on Zoom for children which you know I have an elementary

school child I can't even imagine replicating that experience in 2020 or in San Francisco

is 18 months and I can imagine replicating that experience for my for my child I would have no

idea how they would have learned for more than like maybe 10 minutes a day well thank you so much

that's really fabulous I think we're going to have to end it as you say I'm in your debt people

can find you on x at pretty much your name if I'm not mistaken I'm right Neil Mocko and they're

upon they can find your sub-tack which they will find illuminating so thank you so much for

coming on great thanks so much Randy that's all for today remember every myth has a solution and

every truth has the power to transform your health find us on America outlawed pulse radio every

Friday at 5 p.m. Eastern or on demand wherever you get your podcasts stay curious stay informed

and we'll see you next week America outlawed pulse always be the way

you