Alcohol: Examining Alcohol culture, history, and use disorder

[00:00:00] Yeah. I don't actually know what a cold open is, Preston. I just am like, what do you mean by that? Oh, do you wanna tell me what you mean by that? Yeah, so like a cold open is like whenever you watch a show like the Office or something. Mm-hmm. And they start out with just a skit without this whole intro of like, hi, welcome to the office, let's run the office.

Tele television thing is just like, oh look, here's uh, Jim putting Dwight Stapler in Jello. Oh, okay. And that's, it's like a, it's like a tight 32nd scene and then they go into the intro. That's what a cold open is, because it's like you open cold without, so don, we're cold plunging right into the, the bells whistles and everything.

Yeah, exactly. So, so us doing a cold open could just be like, we bring the audience in mid conversation, like we're in the middle of a bit or something. Oh, okay. Okay. Yeah. So it's not the ice. Well, we would have to be funny. I feel I'm rusty at being funny. Now we could be a little bit icy to each other. We could have a fight.

We could actually. I, I, I had a good joke [00:01:00] earlier that I think really got me out of my, like, dry spell of not being funny. So we were in supervision and we had this guy sitting with us and he said that Freud was asked, what are the things that lead to, to good mental health? He was like, if you were to put a paper together, what makes good mental health?

Um, you write it out and Freud's like, I don't need a paper. I just need two words. And he spoke German. So the two words were liba and arbit. If you're familiar, it's liba means love and arbit is a work. And we were, we were talking about someone's, uh, patient who wasn't accepting help. And I was like, oh, that she's arbit the hand that's leaving her.

And then,

and preceptor to laugh pretty hard. So I was like, all right, I'll, I'll see you guys next week. I'm just like picturing you saying it and you're just like leaning in like, Hey guy. You're like, I've been working on this one. Stop it. [00:02:00] Stop it. Um, yeah, and it was, it was the, we had a guest supervisor, it was first time with us today.

Been with the department for like 30 years and I was like, and you were like, nailed it. I was like, welcome to Preston's Continuity Clinic mornings. Did he laugh? He laughed, but it was like one of those like, I'm laughing because I see other people laughing. I'm, I'm like, I'm like empathetically smiling along, but I don't think it hit him the same way.

It hit the rest of the stuff. It's like psychoanalytically. I'm laughing. Yeah, it's okay. So today we are talking about alcohol use disorder and if we didn't have a copyright infringement, I wish we could put that the teen drinking is, or whatever. I got a fake id. Teen drinking is very bad. A fake id. We are not talking about drinking today.

Everybody is club and tipsy. Yeah, yeah. Something like that. So everybody in the club is worried because of the surgeon General thing that in the amount of alcohol that you've been consuming, well not you specifically, [00:03:00] but like who me? You. Royal, you we, yeah. As the country, as we've been drinking a lot. Are you familiar with the surgeon General?

Is that thing that came out? No. No. What came out? So before, um, so this is, I think back in December, the surgeon general had announced like a recommendation. So not necessarily like a publication, but like mm-hmm. A recommendation that there should have to be like carcinogen, um, warning labels on alcohol.

And that is why everyone's suddenly been having the conversation around like, wait, alcohol is poison at any dose and why people have been having a new convo, although it is not the surgeon general, but it's interesting that that happened in December, right before dry January is big mocktail behind it. I don't know.

Maybe, I think it's just RFK, junior. I feel like, um, I'm just so aware of interrupting you now. Don't interrupt. Oh, yeah. So if, um, if you're listening, we got someone wrote in, they were like, don't, don't act that they were like, Margaret interrupts too much. And then someone else was like, I'd like to [00:04:00] hear Margaret talk more.

And then someone was like, Margaret goes mm-hmm. Too much when she's listening. So Margaret's just been kind of, she's, she's punching the wall about like how to interact now. I'm just, well, and we had this conversation where you were like, early on, this is like by episode four or five, where you were like, you need to feel more comfortable interrupting me because I, yeah.

And then I came feedback too. I was like, scenes, well this is before the other feedback. And you were like, this is behind the curtain for our listeners. Like you are like, you need to feel comfortable interrupting me. 'cause sometimes I'll, I'll just continue talking and I want you to feel empowered to do that so that you, we have more of a back and forth.

And I was like, I don't really want to do that. Um. But I'll try and that's a good point. And now I'm even more like, I will, he, I will just silently nod in the back. We'll make my screen black and white. Mm-hmm. And I'll just be in a, like a silent movie while you're in the color vision. Yeah. Well it, and so [00:05:00] conversation is hard.

It's not fair for me to just be on a runaway train and then be like, oh, I'm not responsible for including Margaret in the conversation. She should just interrupt me. So I can also improve there and, and kind of reel you in more. But here's me saying I, I've, I have toes. I'm using my fingers. But these are toes.

No, I want you to step, I want you to step on them and cut me off in conversation when you have something worthwhile to say. And speaking of things worthwhile to say, we have a couple fun topics, um, on alcohol use disorder. So when we come back from this quick break, we're gonna be going over dis discerning between this kind of normal or adaptive alcohol use.

Mm-hmm. And find out on the spectrum where it becomes a disorder. Then we're gonna talk about some of the neuroscience of alcohol, specifically the neurotransmitters and how it affects our addictive pathways. And then Margaret is gonna lead us on medications and therapy approaches. Yeah, we got feedback.

Everyone's comments and reviews have been really helpful. And so one of them was, besides me [00:06:00] interrupting you, which I shall continue to do despite feedback, uh, was wanting kind of more clinical discussions between us. And so in that part we'll talk about medications, but also hopefully maybe try and talk about some cases or situations that come up that are a little bit more nuanced, uh, that can get people something to chew on.

So we'll be right back.

So when we look at the culture of drinking in the us, especially in young adults in medicine, Margaret, how do you think about alcohol as a part of our culture? I think there are so many stories about alcohol that any of us has and picks up and probably uses different ones at different points in our lives.

Um, I think when you're like 18 to 22, there's an alcohol story of like what's normal, um, which sometimes we equate normal and good. I would say it's more normative as in [00:07:00] like it's common. Mm-hmm. Um, I actually fun fact did not drink till I was 21 because I. Have an Irish Catholic background and I'd heard enough stories that I was like, and I was scared of the law, so I was like, I'm gonna wait.

Um, so I think I had a story always that like alcohol was this big bad thing and I was very, I was a square probably in a lot of ways. Mm-hmm. So there's a culture. So I give that as an example of like, there's cultural stories. We have some people have really positive relationships with alcohol. They grow up around like having a glass of wine with dinner with their family.

Mm-hmm. But for you it was forbidden fruit. Yeah. I think it was scary. And then once I got though into my, like, past 21, then drinking was something that was like. Fun. And it would have, we would go out to bars and dance and it wasn't, you know, it was something where it was like, I would have a couple drinks, but I had done the awkward thing of in college, going out to things where you're like in a dorm room with 20 other people and everyone else is [00:08:00] drunk besides you when you're holding a Sprite.

Mm-hmm. And so I, I felt like that forced me to deal with my own social anxiety and like learn to be that. So for, for me it was scary and then it was fine. And now it's like, uh, you, you mentioned in healthcare and now there's this part of like, what does alcohol mean for me as I'm 30 now. Like, do I wanna interact at the same now as I did in my like mid twenties?

And then also, um, how do I think about it for patients and how, and what does, I do think there's a healthcare component of like, people working in high stress jobs and just seeing a lot of things and like coming home after a long day at the hospital and, mm-hmm. Having a drink, but, so those are all my stories and just also some categories of stories people can have.

What about you? Yeah, I, I think I've always seen alcohol as a social vehicle. Like, I think it's just common in human society, the substances with which we use to cope, correlate to our status or, or the type of character that we're trying [00:09:00] to portray. You know, I remember like the cool kids who didn't care would smoke cigarettes or they would go, I remember they would go smoke weed, but they wouldn't have like pipes.

So they would do it out of like an apple, like they would bore the apple and then like stuff, a bunch of weed and then smoke out of it. And so like, I would kind of hang around these kids and try to act cool, like, oh, you know, I. I don't care about these like rigid normative rules, like don't do drugs, you know?

So like for me, um, alcohol was like a, a vehicle to become cool. Like, the fact that I was able to have these stories about going out to a party and drinking wa was like currency for me. It was like, it was like social stature. So I think for a long time I, I saw alcohol as just like a part of this kind of life that I had idealized.

Mm-hmm. And then I also had the stories of it being bad, not in a way that it's like. That a sin or something that should be forbidden, but that like people can get sick from it. So I had [00:10:00] a, an uncle who struggled with alcoholism. Mm-hmm. And it was the kind of thing, like my mom would bring it up like in the car, like, I want, you know, that that's your uncle.

Like he drank way too much. Then he went to the army and then he got kicked out for snorting glue and drinking too much cough syrup. And I was like, whoa, that's a lot. Mm-hmm. Okay mom. And then she'd be like, anyway, so don't drink too much. 'cause you have alcoholism that runs in your family. And then, and then that was like the end of the conversation.

So I was kinda like, okay, here's the thing that's like, that's bad is the story that, that was my chat that was Yes, same. That was the story. I'm like, it's sexy, it's fun, it's cool. And also I have family members that have suffered from it. So like it was mm-hmm. Hard to reconcile those two things. And then I remember for a while people kind of were pushing this narrative that like, oh, as long as you do like a glass of red wine at night in moderation, it's cool and it's actually good for you 'cause of antioxidants.

Yeah. So I think you had something you were gonna say to that. Yeah. So that was kind of, I feel like that research was the most prevalent when people were [00:11:00] really kind of big on the blue zone idea or the idea that, what's the blue zone idea? The blue zone idea is research that was done originally, um, in the field of like gerontology.

And it was basically, there was these populations of people that it looked like certain areas in the world had more like a, a significantly higher number of like over 100 year olds or cent centenarians. Mm-hmm. Over 100 year olds. Um, and so in the gerontology world, they were basically going to look at it and, um, maintenance phase, the podcast did a great episode on the, like, nuance of this.

Basically, they went to look to see if, like, why are these people so old? What's going on here? Are they really this old? Or is this just like a misunderstanding? Dah, dah, dah, dah. Mm-hmm. I won't get into that, but one of the things was like. Red wine, Mediterranean, like the, these people are healthy and they have a glass of wine with dinner and dah, dah, dah, dah.

And then there was research from like a few studies on, in cardiology on the kind [00:12:00] of heart health pop possible benefits from very like mild to moderate, up to like a glass a day of red wine in particular. Like grapes have antioxidants and grapes are in wine. So some of those antioxidants like make it through.

I think it, like, there was some better theory than that. I can't speak to the direct theory mm-hmm. Towards it, but like, I think there was some, this sounds true ish or this like is correlative data. I see. Um, but I think what we know now is one of the things that they hadn't accounted for in that data. Um, I was listening to, I was listening to another, like lecture basically on this a couple weeks ago.

One of the things they didn't account for in the data was that basically there was a graph that it looked like. People who didn't drink at all had slightly more, more like morbidity and mortality risk than people who drank a little bit. And then the curve went back up for mortality and morbidity risk as you like, go into more and more [00:13:00] drinking.

Right. And there's like a dose response there. But now there, there may be a thought that there might be, that may just both be true and there may be a correlation, not a causation as like mm-hmm. Maybe people who don't drink at all have a history of drinking differently and they had to stop for a certain reason.

Mm-hmm. Maybe they don't drink at all because there's other things going on, mental health, physical health wise that preclude it, um, rather than the glass of wine made their health benefits. So it's almost that moderate drinking is a confounder for a healthy lifestyle. I think that's where we are now.

Yeah. And that, that the healthy lifestyle was the true predictor. Mm-hmm. That, that's kind of how I heard it too. Yeah. Was that a glass of red wine? At dinner once a week is correlated with being like a rich snob. And being a rich snob is correlated with living longer. And, and I'm being like a little tongue in cheek here, but if you can find a way to bring it back to socioeconomic status, that's almost [00:14:00] like, like your track home to like, okay, this is probably why as your confounder, there's, um, so I live in San Antonio.

Mm-hmm. Our town is broken up by neighborhoods and like my first day of residency we looked at like average price per home mapped onto neighborhoods and then also like life expectancy, kidney disease, you know, rates of obesity and Yeah. All of the places you'd expect like light up exactly the same. And you could, you could probably do a similar thing with like moderate showed alcohol showed Yeah.

Consumption. And showed, they showed us that similar things showed in St. Louis too, and it was like called the Delmar divide there, where it was like a couple decades and, and all these, yeah, yeah, yeah. And no, it's, it's tough here. So we have this place called Almost Park. Mm-hmm. And. It's, it's actually its own municipality because back in the fifties they're like, oh, if we make ourselves our own city, then all of our own taxes can go into our own police force.

And also we can write special laws like brown people can't live here. Mm-hmm. And then those laws I repeal to like [00:15:00] way later than they should. Yeah. You know? Yeah. And then now, now we look at it and we're like, oh, okay. These all correlate directly with like a lot of outcomes, especially like life expectancy and morbidity, mortality.

Right. Which I feel like this concept is just as important as the, the thing we're talking about today. But like in the, in the current information landscape right now, online in the last five years, but especially now with like, takes five seconds for someone to like throw a claim out there and it takes like five hours for an expert to explain why that's a misinterpretation of data.

Mm-hmm. And so I feel like. Us touching on this now and as we go forward on like, how do we know what we know when we're talking about these studies is super important for our listeners, whether they're in healthcare or, or a consumer of information about their own health. And I feel like correlation mistakes are so common.

Yeah. And it's part of why this alcohol thing has been confusing for people and, and they're [00:16:00] packaged as click bait really. Well, yeah. Like we need to acknowledge that at their core, these studies are looking at groups of old people who lived long and saying maybe something about their habits is the reason why they lived longer.

Right. And, and for a lot of it, it could be a bad habit. So it's like they lived long despite smoking every day. Right. Not that smoking every day is what made them healthy. And 'cause everyone can think of their, that one grandma who lived to 110 smoking a pack a day, but we all pretty well understand that it's not good for you.

Right. And it's easy to make those, um, misinterpretations with alcohol. Yeah. So. I guess the next point that I wanted to get to it, which is we're looking at moderate drinking, no drinking in excessive or pathologic drinking. How do we draw the line between that? I know we have a lot of different metrics that we use to measure, um, misuse of alcohol.

Mm-hmm. How do you kind of measure it in, in your patients or in, or in people that you see? Yeah. Thinking about how much is someone averaging each day and then [00:17:00] thinking about binge sort of episodes, um, for functioning purposes as well, as well as like physiologic health and dependence. So if someone's drinking like every day.

One of the things I found helpful is like the term, like harmful alcohol use as like. Kind of the spectrum someone can be on. Mm-hmm. And so if some, I think about like if they're drinking every day, how much they're drinking every day, if they've ever had like withdrawal or detox, all those things.

Dependence. And then there's multiple types of screens. And then like evaluations you can use either cage or Ds or audit, which are the mm-hmm. Names for those. But the three C's I feel like in my mind is always helpful of the like craving consequences and oh my God, maybe it's not that helpful. I can't think of the third one.

Um, can't stop. Is that it? No, I just made that up. That's control. So it's close. Yeah. Craving [00:18:00] consequences and control. Okay. That's good. I, I haven't heard that. Yeah. And then thinking about like physiologic implications of alcohol, full body. I think especially given how it's been marketed, as we were saying, is just like healthy and maybe good for you.

I think people can, it's so normalized, especially in your twenties, to drink a lot. And because of that, I think it blinds people from asking questions when they might otherwise, if they didn't, if they thought it wasn't that good for them. Um, but how do you evaluate it? Because I know we work in sort of different settings at this point I'm mostly outpatient.

You're inpatient with a little, yeah. I'm trying to think like, what'll make me zero in on someone drinking. So usually I ask them if they drink, I'll, I'll ask how much. Like, I always start with frequency, and then I, I think therapeutically, I, I try to assess like, do they, can they have fun without alcohol?

If they say they just kind of do it socially? And then, and then I'll kind of be like, well, what's the mo, like, what's the most you'll drink [00:19:00] in an evening? And then mm-hmm. Like you said, I think I, I navigate through those three Cs that you're talking about. Mm-hmm. Um, craving consequences and control.

Mm-hmm. And, and I really, I think I zero in on consequences probably the most. Yeah. Because people can tell that their relationship struggles mm-hmm. If they've been drinking too much. So I kind of, I, you know, if, if they're kind, express 'em indifference about it, I ask if other people have commented on it.

Mm-hmm. Or if they have trouble getting up in the bed, getting up out of bed in the morning, things like that. So I think in general, the way I draw the line for a lot of things being pathologic is if it kind of stops you from living your life in the way that you want to. Mm-hmm. And so that's kind of what I start with.

Like, okay, where is this causing, like any amount of disorder for you? Yeah. And, and I think that's just a higher sensitivity. Like obviously if something's craving, causing cravings are hard to control, it's probably gonna cause disorder, but it's mm-hmm. It's hard to suss that out. Like, I could still be [00:20:00] functioning and not have a level of disorder that's detectable by a psychiatrist or my friends.

Even just kinda be like white knuckling cravings throughout the day. But then when you start to get into consequences, then I can can detect it easier. Well, and I feel like it, it so depends on, I, I think there's times, like if you're meeting someone in a, like a detox setting, obviously that's a different conversation you're having than when you're meeting someone outpatient who kind of says offhandedly.

Like, yeah, I have like four beers with my friends like four nights of the week. But that's just like what we do and like doesn't seem open to talking about it. And I feel like when we think about this, like related to our motivational interviewing episode, I feel like the style and how in in depth we go with the, with asking and inquiring about it is so dependent on how much it seems like the patient wants to explore it.

Mm-hmm. [00:21:00] At least I try to outpatient. Sometimes that's less of an option if it's like, it's the emergency department and someone's withdrawing and you like, need to know it for detox treatment. Mm-hmm. Yeah. It's, it's hard because sometimes it's blatantly obvious that this drinking is causing them an issue.

Like you can read from their chart that they have multiple DUIs. Mm-hmm. Or they've been admitted for detox. Like that, that's a, an objective measure of like disorder in this person's life. Yeah. Yeah. And then there's the, the person who's like, oh yeah, once a month I have a glass of wine with dinner. Like, it's kind of the, the picture of drinking in moderation.

Mm-hmm. So I wonder, like, I wonder if I could do a better job of asking about cravings actually. Hmm. Do you find yourself wanting to go get a beer after work or wanting to go do these things? And I think part of, like a normal person can say like, who does it after a hard day? Mm-hmm. But also that if that's becoming kind of a habit, the fact that mm-hmm.

That this is now entering this, this. [00:22:00] Reinforcement pattern. Mm-hmm. Then that would put that person at, at more risk for developing an unhealthy relationship with alcohol. So I think, I think actually might incorporate like kind of my assessment of cravings a little bit more in my interviews. Mm-hmm.

Mm-hmm. Yeah. I think this also gets to the cultural norms and like I wonder sometimes how we collude with this in healthcare where there's such this, especially in residency, there's such this like intensity whether you want it to be there or not. Like just make it through things that are physically hard, like working for 24 hours, like high stress, not having an outlet.

I wonder sometimes if we miss seeing people because we're around people who are in these high stress jobs that need like a pressure valve. And so it's kind of normal in healthcare to rely on alcohol for coping sometimes. Mm-hmm. And so I wonder sometimes if we like kind of miss things because we also are in a culture that's like, yeah, that.

That happens. Like that's who [00:23:00] doesn't want a beer after work? Mm-hmm. Is it it's an accepted and normalized coping skill. Yeah. Like you can practice your box breathing or your controlled breathing, or you can go for a run or you can have a beer. All, all three of those things will take away I, sorry. Yeah.

Or you can have a shower, beer, all three, all four of those things will take away the unpleasant feeling reminder that we are doctors, but we are in training and not your doctors.

Uh, I guess one other thing I just wanna mention that I think in psychiatry we bypass sometimes is just thinking about taking really good care of people that you know, or have talked enough about to be concerned in their agreement to like getting labs and things like that. I'm not gonna talk about inpatient and like emergency department.

We're, we're not gonna talk about like warnick and cor cough today, but I do think talking to people about their, like organ health with alcohol, especially liver health, um. Can be really important as part of [00:24:00] the work we do even in psychiatry, given that we're the people who are often talking about these things with people.

So just knowing, like checking with people on their kind of like health literacy on how alcohol impacts them. Again, not bearing down on them so much that they feel shamed, but I found a lot of people, including myself before, like the end of med school, we know that it's like bad for your liver to drink.

But I think the understanding that the pattern of binge drinking where it's kind of like overwhelms the capacity to metabolize alcohol, that is particularly probably bad across the board in terms of what alcohol impacts, organ and liver in particular. And then also that like there's not a healthy amount of alcohol to drink, which I don't think that has to mean people.

No one should drink. Like me personally, I say to my patients like. There are many things that I do that I, I know are not like perfect for my health, but [00:25:00] I want to be able to have the information of what they're doing. And I think as clinicians, it's our responsibility if patients want to explore that at all, to be informed consumer so they can mm-hmm.

Can know. And I'm thinking about like if someone has like normal LFTs, that's like, that's good. That's reassuring, but it's like alcohol is still impacting your liver if you're drinking in this, particularly in the heavy pattern, not necessarily like a glass of wine a week to an extent that you, I think people super need to worry about it.

But like if they do have this kind of heavy, normalized period, their liver's probably not loving it. They may be someone like the grandma who smoked a pack a day for her entire life and lived to a hundred. They may be that person, but also like, I think sometimes like the understanding can be that it's either like all or nothing, like mm-hmm.

You just drink, drink, drink and nothing happens and then suddenly you get cirrhosis versus understanding the process. And I think as psychiatrist, we shouldn't shy away from [00:26:00] that when we're talking about substance use with our patients so they can have the info. I think the place where I give the most education is to someone who is actually probably in their mid twenties or early thirties and they're like, I only drink on Saturday, but they get like blackout drunk.

And so, you know, seven beers Saturday night may even be worse than one beer each week night throughout the week. And, and if you think about it, this, you're still going through five drinks, five to seven drinks in a week. Yeah. But you're just compressing them all into one evening where you're overwhelming your liver.

Yeah. Yeah. So from that person's perspective, they're like, I only drank four times last month. Yeah. But each of those times. Was in a, a binge, an a toxic amount and, and still meets criteria for disordered drinking. Right, right. Yeah. I mean, I think that's like the harmful drinking spectrum is like people drinking more than this amount per day, or more than like four drinks for women in five drinks for men in two hours.

Which like, I hate to say it because I didn't know this in college, but like a Long [00:27:00] Island iced tea is like 3.5 drinks, like one long Island. Is that, so I, yeah, I, I think that you're totally right and, and the binge culture is so normalized that it's, it's, it's very easy to feel like it's fine. Mm-hmm. Yeah.

And to your point about there being like no quote unquote healthy amount of alcohol to drink, I think whenever I have to have that conversation with someone, I just, I try to go like full philosophy mode. Yes. So I say like, well. You know, life is really about how much time you have left and what you want to do with it.

And psychiatrists love talking about mortality. We do. No, seriously. Like I know, I agree. Whether you have 80 years left or 10 years left, like do you, like, do you want alcohol to be a part of those 80 years? Like yes. It, it could have some risk, but you would also have risk of me dying, like driving to work.

Exactly. The fact that I woke up [00:28:00] and exposed myself to like, there's probably no healthy amount of, um, sulfuric acid to be exposed to yet when it rains, there's like acid rain in the city that I'm in. I'm gonna be exposed to it no matter what. But, but like to me it's worth it going to work, right? 'cause I wanna live a life where I can be like a productive and successful member and then have money that I can spend on my hobbies.

So I'm like, okay, this is a risk I have to take. Like, I try to put it in perspective of like, you are taking all these risks that are gonna have somewhat negative effects on you. And if you try to live in a bubble, it's not gonna be effective. So, right. Yes. There is no healthy or beneficial amount of alcohol to drink.

And also. That's okay. It's, it's up to you to just decide how you want to dial in that risk. You know, the phrase like, pick your fighter. I, in my head, whenever I'm trying to make health decisions for myself, I'm just like, just pick your carcinogen. Like pick, and I say that only a little glibly as someone who has been impacted by someone with, who got, you know, a serious cancer, very young in my family.

Um, that they're like, [00:29:00] it sometimes it, these, the headlines that then pick up this like health information, like with alcohol are so like panic inducing and it makes people, more people click and read all these things. Um mm-hmm. But ultimately what I wish is that people could have accurate information and then not have the fears of like.

Illness and mortality, like shoved down their throats with how it's written about is like, if you ever look at a bottle of alcohol in your grocery store, again, die, you'll get cancer. Stupid, horrible person. Die. Yeah. Like and, and don't you know the purpose of life is to eliminate every carcinogen down to the point where you can live forever.

Because, 'cause you'll never die if you follow our advice. Right? Well, it's like a couple people had asked, I had put in my story, um, on Instagram questions people had for this, and one of them was on talking about kind of this question of like, is there a healthy dose? And I think one of the things I think about as a psychiatrist, when I have someone who's [00:30:00] like, well, I have a, we're working on their, so like let's say they have social anxiety disorder.

We're working on their social anxiety, they're on a good dose of an SSRI for it, and it's helping, um, and we're doing like the right therapy for it to help them slowly have different skills and things like that. And every once in a while they feel really uncomfortable, but it's important that they go to their friends like wedding that's out of town.

They don't know everyone there. Mm-hmm. And they have one to two glasses of wine and they feel like it helps relationships and staying connected are also very important for health and stress management and mortality risk. Um, let, and that's without even talking about quality of life. Mm-hmm. Do I insist as their psychiatrist that they, that all alcohol is poison?

I don't personally. Mm-hmm. And again, that's like a made up situation, but there's so much nuance in like, what is a good long health span and quality of life. Yeah. Like if I think about the things I'm doing that are gonna pose a risk to me [00:31:00] is isolating myself. Better or is having a beer at the pub with my friends, like, I guess I'm trying to think about almost like vectors, like mm-hmm.

Is the positive vector of being close to my family, does that outweigh the single beer that I'm having? Because if I just Right. Keep myself alone in my room and I isolate, and like, ideally you'd be able to socialize without needing to drink and other things. But some cultures it's so intertwined. Like, yeah.

How, how do I tell the finance bro that like, Hey man, like maybe just find a way to hang out with all of your bankers without drinking. And he's kinda like, okay, dude. You know what I mean? Like there, there's a lot of cultures where it's like, it's a part of the, the language to drink and Yeah. And I remember even in med school, it's literally in my religion, like communion is wine.

Yeah. And do I not partake in my religious things because it's a carcinogen? Mm-hmm. You were saying you remember med school? Oh yeah. Like it. [00:32:00] All of our like events where we would bond usually had something to do with alcohol. And it became like a thing, like there were Muslim students that were like, Hey, can we have some events that aren't like mm-hmm.

Revolving around alcohol because it's hard for us to feel like we belong. Like it's hard for us to integrate ourselves into this like community. And I was like, that makes a lot of sense, dude. Yeah. We're we're, all this stuff is based around drinking, like Right. The first bonding event we had at med school was the beer Olympics.

Yeah. And that's the other side of this coin we're talking about. Like don't you, maybe we don't have to go so far into panic mode, but I do think there's the other flip side of the norms in that everything is very, like alcohol. A lot of social events in your adulthood are very alcohol central, including in med school and healthcare.

Mm-hmm. So, um, now we've kind of, I think, debriefed a little bit about the social landscape around alcohol. I think we can start to dive in more clinically. So did you have anything that you wanted to say about medication assisted treatment? I know you left something in the run of show about that. Yeah.

And then, [00:33:00] I mean, I think everyone in addiction and psychiatry thinks this, that it's like you don't say medication assisted treatment in any other condition. Even treating depression, you're not like Zoloft, uh, Zoloft mentioned not sponsor Zoloft, like Zoloft assisted depression treatment. You just say like treatment.

And there's something inherently stigmatizing in that, in saying like, MAT for substance use disorders, so like alcohol, like we're gonna talk about medications and it's like that. And like opioid use, we talk about MAT treatment and those are extremely regulated, especially for opioids. And there, there is a lot of stigma.

Um, and it's implied that you should be able to kick it on your own. Yeah. Yeah. I don't see my friend giving themselves insulin who has type one diabetes and I'm like, there's another medication assistant. What? Yeah. Like you should be able to handle your diabetes independent of our help, but. 'cause you're such a moral [00:34:00] failure 'cause you have no willpower.

We'll give you medication assisted insulin for your diabetes treatment. And the person that says says that like the next weekend, they're like yelling at their kids like T-ball game. They're like, get Yeah. It's like I have so much more willpower than you. I know. Oh my gosh. So yeah, I think that that was kind of the mm-hmm.

That final point, which is even within psychiatry, where we already deal with stigma and have a lot of these ostracized conditions, substance use is its own black sheep. Mm-hmm. And I, I saw that I was, uh, just came off of a month in the, uh, rehab center and there's even just kind of this feeling around people that have relapsed several times.

Like you can feel it in the staff when, you know, someone has checked back in for the fifth time to rehab, but there's kind of this hopelessness around it and also that some judgment, even if it's like subliminal right. And. I was talking with my attendings about it and they're like, yeah, [00:35:00] it's, it's really tough because relapse is the expectation.

Like mm-hmm. It's the exception if you don't relapse, but it's just a part of the cycle that people go through with addiction. And it's really hard because they have trouble helping patients kind of understand the balance between like, here's where the disorder is and what we're trying to treat, and also here's where my responsibility is.

Yeah. Because some people, they push the needle too far and they say, oh, I, you know, the store's not even real. It's all just willpower. Like, okay, that's not the most accurate. But then, but then people will be like, I have no responsibility for anything I do because it's all the disorder. And then, you know, just like people can do with other like somatic conditions and that's also not accurate.

It's something that you have responsibility for. Mm-hmm. And have to find that balance with your care team. I think it's so frustrating. I. You know, it's a very different approach than what we are taught in med school implicitly. The point of being in healthcare is, and I think that [00:36:00] looking at your own helplessness to help someone else brings out really interesting and sometimes harmful reactions.

And us as clinicians, because it's really uncomfortable to be helpless. Um, and it's also very uncomfortable. Like I think a lot of people who end up in medicine, it's like there's so many hoops you have to jump through that you kind of think like, I think it's easy to get a story, like I'm just like a hard worker and I'm all these things and people just need better choices.

And like certainly people in healthcare are hard workers, but I think to look at someone and see them struggling with addiction, you have to really tilt your worldview to be able to say like, sometimes we don't have full choice over what we are doing and. I don't know. I think that's really hard for people to, to like let be true that uncertainty.

Yeah. There was a, this story of a patient, um, who, they came into [00:37:00] the, the unit and they were going through detox and they had been to rehab like three or four times, but you know, this time was different. And they, they were like, please send me to rehab. Just gimme one more chance. Like, I wanna, I wanna stay and I'm gonna turn it around this time.

And, and a lot of people took investment in this patient and they, they like the attending, I think even bought them shoes mm-hmm. Because they didn't have shoes when they were getting discharged. I mean, like rallied together and got them clothes and all this stuff. And then it was like this heroic discharge to get them to the mm-hmm.

The rehab facility. And then they, they showed up and immediately got in a fight with the front desk and left. Mm-hmm. And then three weeks later. Came back to the inpatient unit and realized, and we're back on substances and everything, we're like, you gotta let me in. And all the whole same story. And I think like, I could, like feel the burnout mm-hmm.

How much effort it was to do all these things for this person and then have it just completely fall apart. And I think, like [00:38:00] I really had to take a step back and say like, how do I measure whether or not I'm doing a good job? Because if, if I measured my success based on like this person getting better, I would just be like bashing my head against the wall.

But then I could say like, okay, I did all the things that I should do for this person. Right. And then kind of stop it there. And I think that's, that's where it's like extra frustrating that, that helplessness, because we measure our success as healthcare providers based on our patients getting better.

Right. And psychiatry is such a hard specialty to do that in, I, I had an addiction attending. Talk about this once, and it was like on kind of changing your measurement like you're saying, and it's, it was like not the idea that just on a population level, there are people with the illnesses that we treat, that some of them may die because of their illness and or they, the, [00:39:00] the illness may go on for their whole life, maybe not.

But there'll be long periods of suffering. And if the goal is to get rid of the suffering or totally cure them at this point in history, in psychiatry, you're gonna not like this career very much 'cause you're gonna have no wins. But if you look at it as like, can I give this person a period of six months of sobriety where they get to like go to their daughter's wedding and be there and be present and make good memories with their family, does that get to count as a win?

Mm-hmm. Both for the patient and for you? Um. And I feel like so much of that is so true in addiction and psych. It's like mm-hmm. We have to change how we think about what good work is by us and by the patient. Mm-hmm. And, and you might not know it, but you may plant a seed that doesn't grow. For years, my voice just cracked, but like five years from now, they may have think back on that conversation I had with you, and then that starts to change their behavior.

But you never saw that, and you may never know. Yeah. Yeah. Like it's, it [00:40:00] really strikes me, um, now that I'm in longitudinal clinic, like patients will tell me like, Hey, you told this to me and it's been really sitting with me. Mm-hmm. It's never the things I expect. It's never the thing you expect. You're like, what?

I'm like, I'm like, that sat with you. Like, okay. Like, I think, I think for one I was just like, I was like, yeah, bro. The halflife of, of like adrenaline's like 15 minutes. So like once you get anxious, like your body's just reacting. You have to wait it out. Like months later they were like, bar, I just realized I have to accept that I don't have control over it.

And I was like. That's what I was like, I was just spitting facts about the halflife of adrenaline, but like, hell yeah. Hell yeah. Brother worked. So, and I think that's a good segue into now kind of talking a little bit about the physiology of alcohol. So I wanted to kind of take a step back or step in to talk a little bit about how alcohol affects our brains and why it's so extra hard to kick this as a habit.

So, um, first starting with the psychology of it. Oh, [00:41:00] actually, when we come back after this break, after these messages, Preston's gonna talk a little bit of science. That's cool with you, Margaret, for all you science nerds. We'll be right back. We'll be right back

and we're back. Welcome back. Okay. Okay, Margaret, sit down. I'm gonna tell you about the brain. Or what I found about the brain for what she's, she's actually already been seated, but I knew she was gonna stand up for that. So start clapping. When you think about a addiction, it's in a lot of ways a way to run towards a pleasant feeling and a way to run away from an unpleasant feeling.

So the psychological terms are positive reinforcement. So reinforcement meaning like doing a behavior over again. I want to reinforce that behavior, but positively. So you're impelled towards a nice feeling or negative reinforcement, which is reinforcing the behavior, but taking away something that's good.

[00:42:00] Mm-hmm. There's also positive punishment, which is introducing a bad feeling, and that's gonna be important later when we talk about being punished for being sober and being rewarded for engaging in the, um, misuse of those, the substance. So when we drink alcohol, what happens? You feel good, right? So you get a sense of euphoria and, and our understanding of why that happens is through one of our reward pathways with dopamine.

So the nucle accumbens, the ventral tegmental area, all that stuff that I love to talk about that houses a lot of our dopamine. And when you actually look in rats and give them different substances, you can see about, I don't remember the exact moles, but I looked at relative concentrations of dopamine that was released.

And so on one of the spectrum, you have methamphetamine, which let's say we'll put out a factor of about 15. Mm-hmm. Cigarettes is about a factor of 1.1. Mm-hmm. Alcohol's about one. Okay. So both of them are about a 10th of what methamphetamine cause you to release, but they're kind of [00:43:00] comparable to each other.

Mm-hmm. But alcohol, so if alcohol and cigarettes almost have similar amounts in, in small controlled doses mm-hmm. You can get a more of a euphoric feeling because you can just consume so much more alcohol. Mm-hmm. Mm-hmm. But it's not blasting the dopaminergic receptors the same way methamphetamine is so.

Point being, it feels good to drink. Do you, do you think that there's also part of it where, like, I'm thinking of what alcohol is often paired with that. It's like, not just the alcohol kind of dopaminergic transmission. It's often also like, this is the social thing, this is the like dating thing. This is like, you're having good food with it, you're feeling belonging and connection.

Yeah. So e everything else that your limbic system is gonna get excited about is associated with drinking sex, food, socializing, things like that. Mm-hmm. So those all kind of get to hijack that same reward system and maybe like, almost like classically conditioned with [00:44:00] it. Mm-hmm. You think about drinking and you think about all those other fun things you do.

So that's, that's the reward part of it. So we're impelled to do things, but then when you stop drinking. Oh, and then so for negative reinforcement, sorry. Alcohol can take away unpleasant things. Mm-hmm. So when you're drinking, what do you not feel? Anxiety. Yeah. Fear about it takes away pain. Ability to sing.

Man, I feel like a woman at karaoke. Yeah. All that. All that social anxiety you have at the bar, that goes away too. You inhibition starts away. You may get to take away the parts of yourself that you don't like. Right. The parts that you're hesitant about. Right. So that reinforces the idea that drinking can be helpful if you're in a lot of pain.

Mm-hmm. Both physical or emotional pain. Alcohol can numb that. Mm-hmm. So that's through this kind of next neurotransmitter, which is gaba. That's the one that everyone thinks about as the inhibitory neurotransmitter. So GABA is an ion channel and it brings [00:45:00] chloride into the cell. Chloride is a negatively charged ion, so it makes the neuron more negatively charged, which means it's harder to fire.

So you can think about it. It's just like dampening everything makes everything more negative, everything's harder to fire. And in our brain specifically, we actually have a huge density of GABAergic neurons in our cerebellum. So your cerebellum kind of sits at the occipital part, the base of your skull, and that controls a lot of coordination and something we call miria.

So your ability to kind of like organize and compute things as you're moving around. So if I would take, touch my nose to my finger or my finger to my nose and then touch something else, I have to do a lot of calculations to make sure I know when my finger's gonna stop and when it's gonna like move around with each adjustment, you know?

Mm-hmm. Almost like making small adjustments on the joystick while you're a aerial refueling two planes. So it, it actually, I totally understood that metaphor. Yeah. That's the air force metaphor, but I. Yeah. It's, it's just, it's like trying to dock a spaceship, [00:46:00] you know? Gotcha. And you have to get all these inputs in.

Yeah. Really fast. I, I think about almost like a graphics card that's doing like millions of computations a second to generate the picture. Oh, yeah, yeah, yeah. Can find control, motor control. Yeah. It, it turns out that, um, there are affective syndromes that can happen when the cerebellum is affected. So these calculations are not only important for motor movements, but they also, a lot of them can have effects on our decision to execute something.

Mm-hmm. Or impulsiveness. Mm-hmm. And what's appropriate in conversation? So we find in patients that have strokes in their cerebellum, they can develop a cerebellum. Mm-hmm. They can develop a cerebellar affective syndrome and may speak out of turn or say inappropriate jokes or laugh or lose inhibitions.

Mm-hmm. So there's a lot more social and emotional implications that come through. Yeah. What affects our cerebellum? Back in like the 2010s. When I first learned about it in high school, cerebellum was like literally just balancing coordination. That's, that's how we saw it. You were learning about the cerebellum in high school?

Yeah, it was like my early, my psychology class. [00:47:00] Oh, okay. My teacher was like, think about Sarah Beum and she's a ballerina and Sarah Beum is always trying to bounce around and balance on one foot. I can still like picture it, shout out high school school teachers. I'm like, Sarah Bella, love them. Yeah. Like, oh, Sarah.

Yeah. So back then it was like the brain's modular, you know? Mm-hmm. This single Lego block in the back of your head. Right. That's balancing coordination, nothing else. But now we know, okay, wait, this computes up a lot of different stuff. It coordinates win and win, not to execute an action that applies to talking and other things.

Right. So it kind of makes sense that if you were to drink a lot of alcohol that's gonna affect this thing, you're gonna lose your coordination. Mm-hmm. So we know people stumble around, they slur their speech. Mm-hmm. And then they lose their inhibition. So all that kinda makes sense for how it affects your cerebella.

So alcohol makes you think you're a good dancer, but makes you worse at dancing? It does. You heard it here first. Yeah, I um, do you think of it as different from other things that might impact [00:48:00] GABA in terms of alcohol versus like impacting similar receptors? Also, we can cut this if you don't wanna talk about this and we can No, sure.

So yeah, and, and this, so that's a great segue into like how does alcohol actually affect gaba? So there's GABA A and GABA B receptors. We have a lot of, um, medications, things like benzodiazepines and barbiturates that specifically agonize the gabaa receptor and they affect both the frequency and the channel opening duration.

Yeah. What alcohol does is it affects pre-synaptic release of gaba, so you dump more GABA into every synapse and you also affect post-synaptic augmentation of those receptors. Mm-hmm. And you can displace those agonists. So alcohol kind of floods everything in a lot of different ways. And not to go too into the weeds also because I don't understand this, um, fully, is that we are affecting so much more than just like one single receptor in synapse.

We're also affecting, like, across the way. Mm-hmm. And, and this really large volume of [00:49:00] drug it's going to our body versus, you know, something like Xanax, which is gonna be more specific for that single receptor, which is probably why you don't see all those effects from a benzodiazepine as you do with alcohol, but some similarities.

Mm-hmm. Mm-hmm. Gotcha. There's another thing that I wanted to get into. Mm-hmm. Um, that alcohol effects that also helps with its kind of numbing, um, property, which is not only does it. Make GABA stronger. So it reinforces this inhibiting neurotransmitter. It also attacks some of our exciting neurotransmitters.

So glutamate, the well-known amino acid. It has a moonlighting job actually, and it's a neurotransmitter. This, I'm sorry, you're like, you're wearing a sweater vest with your glasses and glutamate actually, yeah. It's, it's not just in your proteins, guys. As a matter of fact, glutamate is, is exciting things in your brain as we speak.

So, glutamate receptors, by and large, they're excitatory, they let calcium into [00:50:00] cells. Mm-hmm. Calcium is positively charged, so it's gonna make the cell more positive. It's gonna excited. That's the easiest way you can think about it. Mm-hmm. And there's multiple different receptors for glutamate. So there's NMDA receptors, there's AMPA receptors, there's kypa receptors.

Mm-hmm. I don't want you to worry about what any of those do, but just that. There are many different downstream effects. Mm-hmm. Both at the transcription level and at the ion channel level, that glutamate impact, and a lot of them have to do with exciting or turning on functions. Just about all of those are inhibited by alcohol.

Right. So we've got increases are off in it. Yep. It's bolstering off switch, decrease the impact of the on. Yep. And it weakens the on switch. So now when we're thinking about slurring your words, coming down from something, numbing everything, we're coming at it from two angles. Mm. You know? Mm-hmm. I, I would think about it like we're, it's winter right now and I'm basically, I'm turning off the heater and I'm opening the window.

Mm. Okay, gotcha. Yeah. Yeah. [00:51:00] So, so my house is gonna get cold really fast. Right. Then this is what we also think about when we're thinking about why detox is so dangerous and why, with, like, why recovery can be so hard. Exactly. And so that's, that's kind of when the concept of positive punishment now comes in.

Mm-hmm. We have to kind of get into the idea of what happens when you habituate yourself to alcohol. Mm-hmm. Over time. So if I am, if I'm taking a substance that increases my release of gaba mm-hmm. Both at the pre and post synaptic level, what do you think my body's gonna do with my basal amount of gaba?

I'm gonna decrease it. Yeah. It's gonna be like, okay guys, I wanna say you got this bud. We have too much GABA going, I don't know what's happening, but like we're getting way too much. So we're gonna kind of put pump the brakes on a production of gaba. I'm picturing the like, SpongeBob episode where they like burn all the files in his brain and that that's just like what the GABA's like, and then now for glutamate, despite all the glutamate that we're dumping out into the system, [00:52:00] we're not getting enough signal through.

Mm-hmm. Mm-hmm. Now what does your body do? It's like, okay, well screw it. We need to produce more glutamate. Mm-hmm. And so this is, this is my analogy that I came up with today for how to try alcohol withdrawal. So. If, if, if this is my fist listeners, I'm hearing this for the first time. This is, this is my fist.

And I, I want you to think that glutamate pushes my fist closer to my face and gaba pushes my fist farther away from my face. Okay? Mm-hmm. So, so I take, I drink a bunch of alcohol and starts to push me further away. Oh, nice. But then my body's like, wait, we need to ramp it up a little bit. Let's, let's push back towards the middle.

And I'm like, no, I'm gonna drink more. And then it pushes it away. My body's like, okay, we're gonna make more glutamate and it's gonna push towards her. And now, now I'm, I'm pressing really hard, you know, Uhhuh, because the system's tough. 'cause I'm drinking like a pint today. Uhhuh, I'm gonna drink even more, push it further this way.

Okay? I'm do this every day. And my body's like, oh, we're gonna correct. And then I'm like, wait, I should go get [00:53:00] my appendix taken out and hang out in the, out on the floor for four days so I won't drink it all. And bam, all that, all that glutamate is no longer fighting against the alcohol to suppress it.

And then it just. Goes into like disinhibited, excit, toxic mode and that, that's really the best way I think about alcohol draw, which is this kind of imbalance between GABA and glutamine. That's how a lot of people kind of phrase it to me. Doctors come and round on you or you see people in the community, they go, why are you hitting yourself?

Stop giving yourself. Yeah, exactly. I can't not hit myself. Well, we've solved alcoholism with that metaphor. Yeah, we have. I'm, I'm, I'm like sweating. You're like, I was pushing so hard. Um, yeah, I think that is really helpful and that gets at the point of kind of like from a macro level for the body of whenever we're talking about like to make this kind of clinical and concrete whenever we're talking with our patients [00:54:00] about alcohol, that if we start the alcohol conversation at in any way, I think and give any information that's like this, maybe you should consider cutting back.

I think it's our. We always need to be having the conversation around the dangers of detox. Mm-hmm. Because like, it can be so easy when you're short on time and like trying to talk about a bunch of things to, to give someone the bad information like, or like the impacts of alcohol and then they leave, but they don't know about detox since they're coming from drinking like four or five beers a day or more and then they just go cold Turkey.

'cause they're, you inspired them so much with your metaphor. Mm-hmm. Then they can precipitate, withdrawal and withdrawal can be dangerous due to kind of changes in the excitatory that gets translated into Yeah. Sympathetic activation. And I think like my point for that third part of the, um, habit forming mm-hmm.

Um, nature of the substance is that [00:55:00] most people with alcohol use disorders that have withdrawals can start to sense him within 12 hours of stopping drinking. So now you have. Kind of looking back at this, these reinforcements and punishments. Mm-hmm. You have positive reinforcement. This feeling before if you drink it takes away the pain.

And also now if I don't drink, a new unpleasant feeling is gonna be introduced. Mm-hmm. So it's positive punishment. Right? Yeah. So this is an extremely hard substance to get away from it. And I don't think there are many other substances. I think opiates is similar. Mm-hmm. That behave similarly because even something like methamphetamine, the level of positive punishment when you stop smoking meth isn't on the same level as it is with alcohol people.

What makes you say that? Because if you stop, if you stop smoking meth and, and have extreme withdrawals, a lot of people will sleep and eat. That's true for several days at a time. Which, and they can be grumpy, they can be frustrated. I'm say [00:56:00] they can be pretty dysphoric. Yeah. But that's not delirium trending, I guess not to play like.

Substance Olympics. I, I just think that like alcohol punishes you for not using it a lot more than other substances do. One of the things that they would say on our detox unit was opioid withdrawal makes you alcohol. Withdrawal can kill you. Opiate withdrawal makes you wanna die. Wanna die. Yeah. Like, it makes you wanna die.

And so, yeah. No, I think, I think from a danger perspective, yes, you're right. I think from a, I guess one of the reasons I ask that is, is I don't know enough to push back on it to say like, what is it like to live what, without like meth if you're Yeah. Like day to day. Um, just, I'm thinking of the opioids example 'cause I like, I don't know, once you get past those first four days with alcohol, it's still bad.

But I feel like [00:57:00] some of the other with like withdrawals are also awful. Um mm-hmm. Yeah. And I think. Opiates is pretty terrible. So I don't know. There's also been, there's some, I was reading, um, I have like the, like Kaplan and static, uh, comprehensive psychiatry, whatever, behemoth textbooks. And I was reading the alcohol and like substance use chapter, and also with this, the idea long term of recovery that this change doesn't end.

It doesn't, it isn't resolved after you have gotten through the detox period, right? Mm-hmm. It doesn't. Mm-hmm. You're not, like, your brain neurobiologically is not recovered, quote unquote from mm-hmm. In a balance of this kind of GABAergic, glutamatergic like change it made mm-hmm. Up to like a year of abstinence.

So the change last that long. [00:58:00] Um, and so yeah, preparing people thoughtfully for recovery. I think does mean giving them a, a more simplified, probably conversation than we're having right now, but like an understanding, not to scare them away from recovery, but to help them not feel like if they're still struggling two months of without alcohol in and the cravings are really strong and the feeling distant from their life or feeling like they can't enjoy things almost like they're living behind like a glass wall mm-hmm.

Is partial. Like, it can be helpful for people to be, to understand that they're still in recovery. Not in the, like, not just in the way we say psychologically of like that the, the kind of urge to drink might always be there, but neurobiologically their brain has not fully kind of recalibrated, especially if they've been drinking heavily for a long time.

Yeah. It's, it's incredibly tough to manage those expectations. Yeah. But if, if done properly can help them kind of stay the course. [00:59:00] So now that we've kind of gone through all the. Terrible ways that alcohol can get you under its spell. I think you had listed that you'd like to talk a little bit about how we treat it clinically.

Yeah, so the, the, the medication assisted whatever treatment. So clinically speaking, I think there's two agents I tend to use most often. Um, and one I don't use as often. And I definitely also have a preference for naltrexone, I will say. Mm-hmm. Um, so naltrexone is, I think the primary thing that we use the most in terms of people coming off of detox.

I mean, the first thing for detox is like if you're drinking regularly each day or you've experienced withdrawal symptoms. So, you know, handshaking, heart racing, night sweats, chills, tremors, blood pressure changes. So you wouldn't know that probably if you're just a person walking around. Um, first we have to treat that and the way we do it now is with [01:00:00] benzo benzodiazepines.

But the way we used to do it, which I always get a kick out of this, is that they used to have beer, wine at the hospitals to do detox before benzos were invented, which is great. Yeah, you could, there's like an old beer order I saw at the VA the other day. That's awesome. Can you imagine like Q six beer?

It's like, I need a beer stat and also get one for my patient. Yeah,

you are, you are funny today. So, um, for those who, who aren't familiar with the pharmacology, what does naltrexone do again? Yeah, so Naltrexone is a mu opioid antagonist, and so one of the contraindications is if someone's also struggling with opioid use or they're on any opioid for like pain management naltrexone, they're gonna have a bad time.

You're gonna have a second withdrawal in your hands from the opioid. So it's. Contraindicated in that because it will kick [01:01:00] them off the receptor for opioids, but it can help. Yeah. So, so it could precipitate an active withdrawal. Yes. If you have a little bit of heroin in your system. Okay. Yes. Um, but for alcohol use, it can, what we think happens is that it, again, we've been talking about these kind of dopaminergic pathways and reward centers, is it can reduce cravings for alcohol and episodes of heavy drinking, um, through modulating the cravings probably.

So, like not having a strong urges. So there are mu receptors that mediate the release of dopamine. Right. Um, so it's actually interesting. So with some opiates you can get, um, hallucinations. And so that's how I thought about it. Like, okay, wait, so you, the, this meso limbic pathway is mediated by the release of dopamine, which is kind of, in some ways the new opioid receptor is a control knob for it.

Mm-hmm. So that kinda explains why you can feel euphoria. Also, you can have psychotic symptoms with, with extensive use of opiates in some people. Mm-hmm. And [01:02:00] then maybe blocking it doesn't allow you to get that same reward. Right. So then possibly that positive reinforcement isn't as strong. Yeah. Yeah. Um, the one other thing we have to think about with naltrexone, so Naltrexone, you started out as daily and you see if people can tolerate it.

One issue with it is obviously liver disease, as we've mentioned, can co-occur with alcohol use disorder. So it's metabolizing the liver, it's metabolizing the liver. Yeah. Yeah. Um, and so you have to consider that, although. I, I think like we thoughtfully consider it depending on someone's liver function, um, depending on each clinical situation.

Mm-hmm. But if they look good on like LFTs generally, um, then utilizing it is fine, but still testing it for a couple days. People can have some GI side effects and then you can do long acting. So Vivitrol, which is the injectable form that you can get once every month. Um, people have actually have mixed feelings [01:03:00] about not mixed feelings, different people like getting that medication in their recovery different ways.

So some people like actually taking a pill each day to remind themselves of like kind of their promise to sobriety is what I've heard patients say it as, some people are like, I forget the medication, and then suddenly I'm craving and I forgot to take it and or I choose to not take it one day on purpose and I don't wanna give future me that ability to choose.

So I think there's different kind of. Things that resonate more with people for the Naltrexone. Um, and that either of those is fine, although the, the long-acting may be more effective on a population level. Um, but I think if some, if I have a patient who's like, I do take it every day and I notice it helps me more to be reminded of that promise and there's someone who like shows up to appointments and has that insight over the long term, then I think that makes a lot of sense.

But I also think Vivitrol can be a great set and forget [01:04:00] option. Yeah. I think it'd be cool if, you know, we can start getting it to longer than a month or three months. Yeah. Or you know, 'cause I think for Pal Perone we have, we now have Invega half year, six months. The name is, it makes me laugh. Yeah. So, so it's like if you could get a six month injection of Naltrexone, like that could be like really helpful for people that are going through these different levels of stress and, you know, something that could break their coping skills may cause a relapse, but with the set and forget, like you said, it wouldn't happen.

Yeah. Okay. So Naltrexone is one you're biased towards. Yeah. What's another medication? The next one is a Campress eight, which is the one that you take, uh, three times a day and you, it, the reason I don't use it as much is just because I think most people don't do well with the three times a day medication.

Mm-hmm. Um, well it's super annoying. It is annoying some people though, for the similar reason. You wake up at lunch Yeah. At dinner. Yeah. It's also [01:05:00] dosed in a way that it is, it, it's 666 milligrams. Yeah. Three times a day. And it's like, what I, I think, I don't know, that is always suspicious to me of like, what, what was going on there that they were trying to like be like, let's make it this devil number.

Like, why, why did you do that? It's the Satanic way to get off of alcohol. I, I Devil assisted treatment. Sorry, uh, d but I, so yeah, taking it three times a day and then there's no long acting form. Um, I think there's also some, I don't know, I have different attendings say different things in terms of like efficacy levels.

I think they both can be very effective. And then the one I do not tend to use is disulfiram. Just because it's like if people drink, they, if they drink, it's gonna, they're gonna have a very bad reaction. 'cause that's kind of the what positive punishment. Positive punishment. So same for the people who, who aren't familiar with the pharmacology of a camper state.

[01:06:00] How does that one work? I'm not remembering right now. It's, it's okay. So it, a camper, say mostly functions as an antagonist or a modulator of the glutamate receptor. Right. Okay. So we're, we're affecting pleasure. And then I don't know exactly how changing these glutamate receptors can affect cravings, but mm-hmm.

Just kind of calling back to how we were thinking about the receptors that are affected by alcohol and how that informs these receptors that we're treating. Right, right. Yeah. Okay. And then diam, how does that one work? This one that punishes you? Yeah. It interrupts the alcohol like metabolism pathway basically.

So you end up mm-hmm. With a more, you, you end up with more of the basically like metabolites that don't cause pleasant sensation and cause the negative like physical sensations, like I think. Like flushing, nausea. Yeah. Things like that. So, and so, it's, it's very unpleasant. It's like, and you have to choose to take it also, right?

So like, if you're gonna [01:07:00] drink, like you just don't take it that day. Yeah. It's like you wake up every day and you're like, okay, time to hire the bodyguard to follow me around and punch me if I drink. And then one day you wake up and you're like, you know, man, why don't you take a day off? I, I got it today.

Don't worry. I'm wondering, I got it, don't I, pinky promise? He's like, okay. Yeah. So I, I think that it would be helpful if there was a long acting version of disulfiram. It's like you hire 'em for six month installments, but that can be dangerous. Like the sul reaction can be Dan, not just unpleasant, but like dangerous and is why we clinically also don't use it.

'cause I don't know, sometimes people are like. There are psychiatrists who are okay with their patients suffering and being like, yeah, we're gonna have a consequence. But I think it's gotten to the point where there's been like cardiac impacts or like nausea, vomiting so extreme that it's like, yeah, okay, wait, hold on.

So, so, and also what you think about it is you have a positive punishment with not drinking, but we're trying to introduce a stronger, positive punishment [01:08:00] to drinking so that that punishment's so much stronger than the other punishment that yield us win. Like it's just, it's not the best way to modulate behavior in general to introduce more punishment.

Right. Rather than to take away reinforcement or something like that. So, so just kind of psychologically or awkwardly conditioning ourselves, it's mm-hmm. Not the best approach I think. Yeah. If you're a, um, a trainee and you're listening and you're like, okay, what if I get this on my step test it, uh, inhibits aldehyde or acid aldehyde.

Yeah. That is hydrogen. The common, um, distractor is alcohol dehydrogenase, but that would mean that it doesn't break down alcohol at all. Right? Mm-hmm. Because that's the one we're inhibiting. So if you, in, if you don't inhibit alcohol dehydrogenase, you just have a buttload of alcohol and you would probably, you would just die because you would never be able to metabolize your alcohol.

So you get stuck with a bunch of acid alde hide, and that's what makes you red and itchy and uncomfortable. Right. Right. And so we, we know, um, classically, like the Asian glow mm-hmm. Is people from, [01:09:00] um, Eastern Asian countries don't have as active acid aldehyde dehydrogenases, so they can have some of this diol frame reaction almost.

Yes. The spontaneously just from drinking. Yeah. Yeah. Um, and this is also part of why, like what happens in the, like why drinking is bad for the liver. Mm-hmm. Um, even without these meds, is functionally a buildup of these in pro-inflammatory that like metabolite products as well as, um. Can I say my formaldehyde?

Fun fact. I know. I knew you were gonna bring up formaldehyde. I knew you're so toxicology coated. And I was like, I can just feel him being like, do you know what that is? Like Yes. You can go. Okay. So, um, the reason why formaldehyde's, it, it binds to your optic nerve. It can cause you to go blind. It causes toxicity in your optic nerve.

And formaldehyde is, um, one oxidation step from methanol, so a single carbon. And [01:10:00] so that's actually why a lot of shiners in like the Appalachian mountains will go blind is because mm-hmm. In the distilling process, you're supposed to boil and distill your moonshine like eight times. Mm-hmm. Because each time you get a little bit less methanol in the final product.

But if you're a lazy shiner and you only distill it like five times, there's gonna be a high enough content of methanol in there that when your body drinks it, it's gonna convert the methanol and formalde. It's gonna cause you to slowly go blind over time. How did you learn that? So. Me. Yeah. Where'd that, where'd it come from?

I was, I was a chemistry major, and also I stayed, how did I not know this? In like in Western Appalachia. 'cause so I did my med school in North Carolina, so we had some like rural rotations out there. Yeah. And I was like sitting with my Airbnb host and she was just like, yeah, we used to shine here in these parts.

My grand used to rob banks on the eastern seaboard. Then they took all the money out here and then they run shine back and forth to Nashville. And I was like, nice, I won't go in the basement. [01:11:00] And then she would've stories about people going blind and shining, all this other stuff. So I was like, oh this. I was like, wow, this connects with all the science that I learned before.

It's fun. You were like, life is so cool. You are like, this is experiential learning. I like, there's just so much life to be lived. So Yeah. So that's why you should be weary of alcohol in a mason jar that someone from West Virginia gives you Really? Or some hipster dude in the city that has decided to start making his own because, you know, he's not doing that eight times.

Yeah. He, he's probably not a judicious shiner, you know, only, only by reputable. Um. Street alcohol. Um, a couple, I think other things we wanted to touch on. And I'm, I'm curious at your point in training, like what do you think about this therapeutically? We've touched on the meds. We could go on about meds and there's other ones that can be considered, like gabapentin can be helpful, topiramate can be helpful.

I know you had mentioned GLP one emerging, but we've, we've talked [01:12:00] about the neurobiology and exposed Yeah. The things I need to brush up on before my boards. Um, but what do you think of therapeutic approaches when someone comes to you and says, I want to change this. Um, and they're in your longitudinal, like, what do you think of things that'll help?

Them cope with without coping with alcohol. Mm-hmm. In your work with them in a therapy. And you already said that the exact thing I was gonna focus on, which is coping. Mm-hmm. So I think our biggest challenge is gonna be to help this person find a way to cope mm-hmm. Without a substance in their life.

And, and it, for a lot of people, they end up replacing that substance. So for a lot of people who are trying to kick alcohol, they end up taking up cigarettes. Mm-hmm. And they kind of come to this acknowledgement that's the lesser of the evils for them. Mm-hmm. You know, like we were saying earlier in episode, pick your carcinogen and they're like, you know what, I'll take cigarettes over alcohol.

Mm-hmm. And when people do that, I'm like, huh, I can't fault them for it. Mm-hmm. [01:13:00] You know? It's their way of stopping drinking. Right. And I think personally, when I think about ways that I cope mm-hmm. And can get better, it's reinforcing, um, community and activities for people giving someone a regimen.

Because you can get a lot of stability from your routine. Yes. Yeah. That can kind of give you some inertia so that when things go sideways, you don't relapse as quickly as you, as you would otherwise. Right. So one thing that I actually have been talking about with some of my longitudinal patients is I just kind of sit down and say like, okay, like what do you do when you get home?

And sometimes it's like, I literally just watch the V and go to bed. I'm like. Like, how easy would it be if like that was your routine just kind of fall back into drinking? Like mm-hmm. It'd be pretty easy 'cause mm-hmm. You're just trying to sit there and be like, okay, like let me do deep breathing. Let me try to like mm-hmm.

Draw or listen to music, which are like all the classic coping skills we hear, but Right. And they're so abstracted from, from people. 'cause it's just like, yeah. Yeah. It's a word with no salient attachment to it. So then, so then I say like, okay, [01:14:00] like where do you find community? Like where do you hang out with people?

Mm-hmm. And some of them will be like, oh, you know, I don't do much. I'm like, what do you like to do from one patient? They liked stargazing and so I made this plan for them to like invite their neighbors over and do like stargazing sessions. 'cause they had this like super expensive telescope. Mm-hmm. And I was like.

Do you have like families in your neighborhood? People are interested in astronomy and he is like, yeah. I just never like thought about reaching out to them. Yeah. So I'm like, okay, if we can kind like get like, yeah. Once a week, you know, you have this thing you're coming back to and then all of a sudden you have a bad day and you're like, I can't drink.

Like I don't wanna drink. I like, mm-hmm. They're coming over later. We're gonna do this thing together. There's like a sense of external accountability and also some new reprieve that comes from that. Right. I mean, it makes me think of the like, you know, loneliness epidemic thing that we've talked about over the last five years and that drinking and substance use went up during the first couple years of covid.

Mm-hmm. And that, you know, substance treatment, like with your patient has to happen in community. Like it has to happen with [01:15:00] supports with how hard this process is that like having people who are kind and caring to you, but also need you to show up to the star gazing event, right? Mm-hmm. And need will notice if you're drinking.

They'll notice it as much as hard as that is, but the, like, the, the being held accountable is like the core. Mm-hmm. I think, you know, part of this. Yeah, absolutely. And, and, you know, we look at things like Alcoholics Anonymous. Mm-hmm. I've, I've seen people talk about how the 12 step program doesn't have evidence or isn't verified scientifically, which 12 Step program aside, you have a organization where people are finding support with each other.

Right. And like, I've always encouraged that. Like, you have, you have a, an individual person who's like your, what you call it, like your mentor, I think. Yeah. Um, or your sponsor. Your sponsor, yeah. Who's gonna support you. Mm-hmm. And like be that community for you. So like that's effective in and of itself, and.

All those are things. I [01:16:00] try to support the peer model in a lot of substance clinics now of like having peer coaches that are kind of removed from the AA model. And then there's like the smart recovery that are more based on like, it's sort of similar where it's like a group that continually meets and like affirms a vision of life without alcohol and trying to stay in recovery.

But it's less kind of, it's not the language of AA and it's more kind of psychology based. And, and then because AI is pretty religious, right? Yeah. It's gotten, it's tried to get away from it, but yeah, the foundation is on there being a higher power and, and quite a lot of, you know, kind of coming to a sense of what you've done wrong and how you're powerless without God is the original language from the, like the book by the creators of it.

Um, a couple other things, just therapy wise that I think are important is. Sleep and alcohol, obviously alcohol impacts sleep. We [01:17:00] won't get totally into that today. Um, but a lot of people use alcohol to help them sleep and they are going to struggle with insomnia even if they didn't before, if they were drinking at night.

And so thinking about other medications to help with insomnia, thinking about sleep hygiene, but maybe more importantly like CBTI approaches if you're doing therapy with them mm-hmm. To help them consolidate their sleep. Uh, and then the other kind of specific coping of, as we talked about, we love exercise.

Exercise in particular can be a very powerful, um, way of coping slash also baseline reducing distressing emotions and cravings in folks with addiction. And then I think mindfulness. Even like I do mindfulness in session with a fair number of my patients. Like we'll start or we'll end with like a five minute mindfulness part together.

And I think, can you do mindfulness with me sometime? Yes, I can. Podcast. I love, I love Live. Podcast. Podcast leading mindfulness. [01:18:00] That should be our cold open next time podcast. Oh, we're just gonna start. Start leading mindfulness. Start with mindfulness. Yeah. Yeah. I love it. And I love leading people through it.

It's also just like, it's weird, but it's like a cool way of connecting with patients when you do it together in session. Even over Zoom. 'cause you, we both close our eyes and I verbally leave us through it, but it's a moment of like, we both are a little vulnerable in it, so I love it. Anyway, but all of those things and some other stuff as well in terms of stress management approaches and coping ahead plans and exactly what you talked about of like creative ideas to find out what is, you know.

What is the structural part that alcohol's holding up in their life and how do we think proactively about, it's gonna be hard to do that part of your life without it, what might be able to put some things that maybe won't feel as good as alcohol and like mm-hmm. Openly it won't, but might replace it. So things like, you know, my, you know, I did make fun of big mocktail, but like [01:19:00] have, if having a ritual where you get to just relax, you can still have that without alcohol, so.

Mm-hmm. All of those things I've found important with my patients, both at the beginning and then ongoing, honestly, with, even if they're not like struggling with alcohol, alcoholism, even just people who are like, I feel like I started needing a drink after work five nights a week and I'm not comfortable with that.

Mm-hmm. Which gets us back to what we started with of like, is all alcohol bad? Can I drink? How do I change my relationship with it even if I don't think I have like a substance use problem? Mm-hmm. Well, I, I think that's a good place for us to kind of start to wrap up and, and I feel like it's a, an apt conclusion.

Um, I was looking through some of the veer submissions, and I think most of these are questions that we've kind of answered or at least touched on in the pod today. So some, someone asked, you know, is there a way to enjoy alcohol without it being a, a part of your life is related to enjoy life without needing alcohol?[01:20:00] 

Mm. Some questions on alcohol affecting sleep. So just if, if you're specifically concerned, like alcohol decreases the amount of REM you get. So, um, and it also increases stress levels during sleep, so you're not gonna get as much deep sleep. So think about deep sleep as a way to heal your body. REM is a way to heal your mind.

Mm-hmm. Really simple aphorism there. It's gonna decrease both of those. So, like, you may sleep more, but it's lower quality sleep. My Garmin actually tracks my sleep. And if I drink, it's like your sleep score is an F. First night, shit, it's me in 25. Get up, we're going on a run. There was one other question where someone asked about, I can, we can't, I can't speak to every psychiatric med with this, but I can speak to the specific question of SSRIs and alcohol and why it says like, don't drink on them.

Important concept with this is pharmacokinetic interactions and pharmacodynamic interactions. Pharmacokinetic being more based in metabolism and how our body, [01:21:00] you know, processes and gets rid of and excretes drugs. And then pharmacodynamic being how kind of the impacts or side effects of drugs and specifically in psychiatry kind of collude together.

For SSRIs specifically, you know, ones like Zoloft or Serline, Prozac, fluoxetine, classic SSRIs. I'm not speaking to SNRIs right now. It's more of a pharmacodynamic, um, interaction. Predominantly meaning some SSRIs can make people tired. So can alcohol, people who are on SSRIs have anxiety, alcohol because of all the things we've talked about, can make it so that you're more anxious after you've been drinking.

It can make it so, oh, pain, anxiety, right? Your sleep is bad. Yeah. So it can worsen anxiety. So there's like kind of counterproductive. SSRIs already can suppress REM too. Yeah. Yeah. And then there are other gen like types of antidepressants, like TCAs [01:22:00] that lower can lower people's seizure threshold, can make you very tired.

Alcohol also can have interactions in terms of people's seizure threshold, both when drinking and more. Frequently when in like withdrawal or it's leaving the system. And then MAOIs are always, we don't prescribe them as much anymore, but especially for systemic ones. So not the patch as much, but interactions with wine.

Very, uh, yeah. So so that's a more kinetic interaction. Those, that is a kinetic interaction. Yeah, you're right. Yes. Yeah. Good clarification. So with, with, um, things that have contained romine and Yes. Can affect the, the metabolism of the, like catecholamines, right? Right. And there was, um, other psychiatric meds.

There's too many to list in terms of, there is some overlap like with, um, like if you're on any pain medications or other, other things can be in the same [01:23:00] metabolic. Basically like sip processing system. SSRIs generally aren't, but other kind of psychotropic meds can be, or pain meds like Tylenol is in the same mm-hmm.

Um, enzymatic pathway to some extent. And so it's metabolism like there was an interesting study I was reading preparing for this. I was talking about like the double hit of if you're drinking chronically and like then also take a bunch of Tylenol and how people with alcohol use disorder who are heavy drinking are more likely to have more intense, even if they don't previously have like elevated a ST or a LT, they can be more likely to have very severe outcomes from like a Tylenol overdose.

So if you're someone with like depression and struggle with alcohol use, there's pharmacokinetic overlap there. So point of that being is it's prob it's not. It's not recommended because at odds with SSRIs other meds, there's a [01:24:00] different kind of situation on the direct med interactions from a metabolic perspective.

Mm-hmm. Sorry, I feel like that's like a fair, the, I I wanted to get that. I was like, what is going on there? Yeah. And it's like one of those where you have to add a million caveats to it Yeah. Is like, this is not medical advice and we don't know about your specific situation. Yeah. Because I think when people are like, well, what's the deal with drinking on them?

I, I almost feel like there's an implied like, can I actually drink on my ssri? Like, does, is that what you're asking? We can't, we can never answer that. Right. Right. Um, the last thing that I wanna leave us on is GLP ones, which mm-hmm. We didn't talk about. Mm-hmm. So, GLP one affect leptin and ghrelin levels.

And so if you're not sure, um, peptide is. Exactly what it sounds like. It's something that mediates our um, feeling of satiety. So when um, you release a bunch of glucagon, you're like full. So it kind of tricks your body into feeling full. And so a lot of people, they feel full all the time because they take this [01:25:00] medication so they eat less, their metabolism kind of slows down.

They're not absorbing as much food so they lose weight. That's kinda how we understand how G appeals work. But it turns out that in your cerebellum, there's a lot of leptin and ghrelin receptors that can mediate your cravings. So some of the thought is that in regions of our brain that we know affect inhibition and our relationship with alcohol, there may be different sources of those cravings.

So maybe GLP ones could have some effect on that. That's all we know so far. I think there's currently a couple trials for it. Hmm. We're kind of doing this thing that we do with a lot of drugs where we we're just like, let's try it on everything. What if it works for everything? See if it works. Yeah. No, seriously.

Like we're doing that with TMS right now too. So we do with naltrexone that too. Think we're trying. Um, smoking cessation in GLP ones as well. Mm-hmm. I think we're trying a DHD with GLP ones. Hmm. Like, it's across the board, so we'll see as a society, we'll see what sticks and, and what doesn't. Yeah. Yeah.

But that's kind of the theory, at least for al use disorder. [01:26:00] Yeah. I think, um, final words on this. I would say if you have questions about your relationship with alcohol, talk to one, talk to a clinician, talk to your therapist. Um, talk about it with your friends. I think more people struggle with this than we realize in terms of just being uncomfortable with our relationship with alcohol and know that there are ways, there are a lot of ways to get help with it, and it doesn't always have to feel like this.

Um. Mm-hmm. And that the information is morally neutral. I think, you know, that if you struggle with this, a lot of people struggle with it, and it's, it's something that. There's a lot of shame and stigma around, but I think too much though, and it prevents people from being able to get help and get better.

Well, thank you all so much for listening. Please let us know how the show was. If you want us to answer different questions or write in other things, we're always [01:27:00] happy to hear it. You can message us directly on our account. So I'm is Prerow and she's at Bad Art every day. Or you can find the IG and TikTok at Human Content Pods, or you can contact the team directly at how to be patient pod.com.

Special thank you to channeling Van Gogh as our, our first shout out in the post section. He said, uh, or he or she said, I'm a young attending physician in a different field slash subspecialty, but very much enjoy this podcast. It resonates both as a person and a physician on many levels. Well done and thanks.

I can't wait to see and hear how it evolves. Wow, that sounds super political, but here we are. That's okay. I always sound super political when I say things and I'm trying to be like fun and spontaneous. It's like the whole point of our podcast. So anyways, channel Van Gogh. You're doing great. This, this gave me the fuel I need to make it through a couple more podcast episodes.

Okay. Now my presence doesn't, oh, also, also Margaret. She, she just, she's what I, why I get up in the morning. That's true. [01:28:00] Saved It. Full episodes can be found on my YouTube channel. Each week at its prera. We'll also do like kind of teaser and fun trailers from the videos to We make, we make shorts because we're hit.

Um, thanks to you again for listening. We're your hosts Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, her Margaret Duncan, will Flanary Kristin Flanary Aaron Korney, Rob Goldman and Shanti Brook. Our editor and engineer is Jason Portizo. Our music is by Omer Ben-Zvi to learn about our program, disclaimer and ethics policy, submission verification and licensing terms, and our HIPAA release terms.

Go to our website, how to Be patient pod.com or reach out to us at how to Be patient@humancontent.com with any questions or concerns. How to be patient is a human content [01:29:00] production.