Why Quitting is So Hard: Understanding Addiction

August 12, 202600:17:20

Why is quitting so difficult, whether it's alcohol, nicotine, gambling, social media, or another addictive behavior? In this episode of Health Matters, Dr. Jonathan Avery, an addiction psychiatrist at NewYork-Presbyterian and Weill Cornell Medicine, explains what addiction really is, how it affects the brain, and why recovery is about far more than willpower. Dr. Avery discusses the complex mix of biology, mental health, environment, and life experiences that can contribute to addiction. He explains how substances and behaviors hijack the brain's reward pathways, why withdrawal can make quitting especially challenging, and how treatments ranging from therapy and medication to community support can help people recover. The conversation also explores the stigma surrounding addiction, the importance of connection and compassion, and why many people go on to build meaningful, fulfilling lives in recovery.

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[00:00]
Dr. Jonathan Avery
Quitting is really hard. You're going against what's happened to your brain. You're going against whatever mental health struggles you're in. You're going against whatever environment you're in. That makes it very hard to do a different behavior. And so it takes a lot of intention and work often to curb an addictive behavior.
[00:17]
Courtney Allison
Welcome to Health Matters. Your dose of the latest in health and wellness. From New York Presbyterian, I'm Courtney Allison. This season on Health Matters, we're covering your health from eight, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at Q for quitting. It can be difficult to talk about addiction. In this episode, we talk with Dr. Jonathan Avery, an addiction psychiatrist at New York Presbyterian in Weill Cornell Medicine, to better understand what's happening in our brains when we're addicted to a behavior like online gambling or to a substance like alcohol and why it can be so hard to quit. As he explains the importance of reducing stigma around addiction, Dr. Avery shares thoughtful ways to support those who may be struggling and the therapies and treatments that can lead to a successful long term recovery. Doctor Avery, thank you so much for joining us today.
[01:25]
Dr. Jonathan Avery
Hey, Courtney, thanks for having me.
[01:26]
Courtney Allison
It's such a pleasure to have you here on the show. A fellow podcaster, I'm very excited for our conversation. Something that struck me when I was listening to some of your episodes. You've said that thriving doesn't mean the absence of loss or struggle, but finding a way forward through it. Could you elaborate on that? What does it mean to thrive with addiction?
[01:44]
Dr. Jonathan Avery
Traditionally, we think of addiction as something that you have and that you overcome or something that other people have and they overcome. And I think when we create these narratives about overcoming addiction or thinking of it as something in the past, we miss that it really is all around us. And so I think to really address and understand addiction, you have to recognize it in each of us. In large part because of the stigma of addiction, we really don't look at it in ourself or others. And I think that creates a lot of trouble.
[02:13]
Courtney Allison
I appreciate what you're sharing because I think whether we're struggling with it ourselves or have family members or loved ones, it is really out there.
[02:19]
Dr. Jonathan Avery
It's tens of millions of people that struggle with classic substance use disorders, things like alcohol and cannabis, and increasingly aware of behavioral addictions like gambling and gaming and sex addiction. But there are probably more than even that. I mean, I'm addicted to my phone right now and we all go through these phases in our life. Where different things grab our attention, Hijack our dopamine. And so I do really believe that it's in all of us. And we all have to monitor our behaviors.
[02:48]
Courtney Allison
What exactly is addiction?
[02:50]
Dr. Jonathan Avery
Addiction's complicated. And it's not just one thing. There are a spectrum of behaviors and neurobiologic processes. There's genetics and social determinants of hell, spiritual factors. But at its core, in the most simplest form, Addiction is the chronic use or compulsive engagement with a substance or behavior. Despite negative consequences. And this is often driven by impaired regulation of reward, stress, executive function systems. But I think even more importantly, Addiction is often a response to pain, to disconnection, to trauma, unmet needs. I think when we simplify addiction to just being about a substance. Like everyone who gets exposed to acceptance gets addicted. That's not true if we make it just about the brain and genetics. That also doesn't encompass how addiction develops. Because some people have the genetics. They have a vulnerable brain, and they use, and they don't get stuck. It's often that vulnerable brain plus exposure to the substance. Plus different factors in their life, including mental health and trauma. A difficult living situation, access to substances, availability. So there's a lot that goes into this behavior that we call addiction.
[04:06]
Courtney Allison
So understanding there's many different factors. And it's not just what's happening in the brain. What is happening in the brain when it comes to addiction, what does it have to do with dopamine, Our reward pathways, things like that.
[04:18]
Dr. Jonathan Avery
So we initially thought addiction was all about dopamine, and that's still partly true. And the reward pathways in the brain were you use something, you get this big dopamine spike. And then with time, you start to get this dopamine spike. About acquiring the substance. And so your reward system is driven to use. But we've learned over time that so many other neurocircuits and processes from the parts of the brain that, remember, the parts of the brain in the frontal cortex. That are involved with decision making. And putting the brakes on behavior. All the way throughout the body, in fact, too, is impacted by substances. The other thing that drives substance use forward. Is that when you use a substance chronically. You get withdrawal states when you remove it. So it's both the hijacking and then when you remove it. How terrible you feel in your body and brain when that's taken away. And some substances have very wicked withdrawal states. That make it very hard to stop.
[05:08]
Courtney Allison
Can you walk us through some of the common addictions we all might encounter. I mean, you mentioned before your phone. That's very relatable.
[05:15]
Dr. Jonathan Avery
Well, as a father of three young kids, I'm especially interested in how social media and online and YouTube and all these other things are addictive. But the classic addictions we think of are these substance use disorders. And the main thing we treat in addiction is alcohol still, like, as much as marijuana and youth vaping and opiates are in the press. If you're gonna get st on any substance, it's alcohol. But we're in the opiate epidemic, the fentanyl opiate epidemic, especially where we have a lot of a contaminated drug supply around the country that's impacting and causing people to lose a lot of lives and become addicted. And then there are behavioral addictions, not just social media, but the ones we've studied the most are gambling. Gaming and sex addiction. And you would think they act differently on the brain than the substances, but they actually act very similarly, and we treat them very similarly in addiction.
[06:01]
Courtney Allison
What do all these have in common? What does gambling have in common with alcohol? Cannabis screens?
[06:08]
Dr. Jonathan Avery
The striking thing about these behavior addictions is that they are neurotoxic in the same way these substances are. You see the same changes in the brain, and you see a similar set of behaviors that evolve around these things as well. The striking thing about gambling is one, it lights up the brain sometimes even more than substances. It does something to our reward pathway, and that is really remarkable. And then you can even get withdrawal states when you stop gambling. You can feel physically unwell from not gambling when you have a severe gambling disorder.
[06:36]
Courtney Allison
And how is the new availability, accessibility of gambling betting on smartphones, how has that impacted people?
[06:43]
Dr. Jonathan Avery
The phone. The phone is such a troublemaker. You know, the phone has really increased the availability of a lot of these behavioral addictions. We wouldn't give our kids vodka at age 10, but we have them on social media at that age. They have availability to see difficult sexual content at that age. And then the sports betting has just taken over Especially young male culture where if you watch any sports game these days, you watch the game and you see all the betting odds, and it's become what kids talk about. And the phone makes it easy to gamble and wager. And then for the developing brain, all these behaviors, all the substances and all the behaviors may especially be more engaging and especially harder to put the brakes on as the brain keeps developing until 25.
[07:28]
Courtney Allison
Are there any surprising things that someone might be addicted? I think I saw validation could be an addiction that surprised me a little.
[07:34]
Dr. Jonathan Avery
Yeah, there's love addiction, there's food addictions. Even though some of these things may not sort of light up the brain the same way, different behaviors are helpful to think about in an addiction lens because of a lot of the things we do that we'd rather not be doing. If we applied some of these addiction principles, we could help moderate those things. Be careful not to eat junk food when you're hungry, angry, lonely, tired, for example, things we're telling people always to be mindful of those states around substances to not doom scroll after a long day at work, but try to do something healthier. So some of these addiction principles can apply to a bunch of these things.
[08:11]
Courtney Allison
That's really helpful. Could you say more about that? So being aware of your state. Hungry, angry, lonely.
[08:16]
Dr. Jonathan Avery
Did you say hungry, angry, lonely, tired, halt. And then we always say and sometimes bored. These are the triggers for substance use. When you are either trying to be absent or trying to moderate. You don't want to be chasing feeling states. If you're going to have a healthy relationship to something, you want to be doing it intentionally and because you're enjoying it, not because you're trying to get rid of a feeling.
[08:38]
Courtney Allison
What are some signs that you might be teetering into that harm category?
[08:42]
Dr. Jonathan Avery
It often happens subtly, which makes it hard to recognize. But once it starts getting in the way of things you value and starts to impact your function, that's when we think you start veering into addiction.
[08:53]
Courtney Allison
And so say you're noticing that. What's the first step to try to manage it?
[08:58]
Dr. Jonathan Avery
The first step is to raise your hand. There are more treatments in health than ever. Sometimes people feel when they raise their hand. There's only one option, which is to quit substances entirely. Go to 12 step work. But that's not the case. There's different therapies, different groups, there's online options, there's in person options. And then the biggest sea change in the last 10 to 15 years in addiction, psychiatry and medicine is there are actually medications that can help with what you're self medicating, but also help with craving towards substances and behaviors. We've had great meds for alcohol use. Some which help you drink less, some which help you maintain abstinence. If you struggle with opioids, the gold standard is to be on medications that either replace or block your opiate system and really improve outcomes. And then there's other meds that help with craving for marijuana and cocaine and good meds that help you stop smoking cigarettes or vaping nicotine. Just ask your doctor. If you have a kid that's struggling, ask the pediatrician.
[09:52]
Courtney Allison
Is there potential for GLP1s to help with addiction? What are the studies showing?
[09:56]
Dr. Jonathan Avery
Yeah, it's very promising. The weight loss on them have been tremendous, obviously, and their role in chronic medical conditions has been notable. And there's studies, including pretty solid larger studies now showing that the GLP1s help curb drinking and binging on drinking and helping people enter recovery states. But there might also be promise for even some of these behavioral addictions like gambling. There's a lot more that I think is going to come out in the next couple years, but there's some real
[10:25]
Courtney Allison
promise there that's really exciting to hear. And so when it comes to addiction, can people get better?
[10:31]
Dr. Jonathan Avery
People get better. That's the thing. Most people get better. There is a real large community of people who have gotten better. But you got to raise your hand. I think part of what makes it scary for people to raise their hand is they feel like their initial step is to go to rehab and be completely abstinence. But in fact, a lot of people can recover with moderation. A lot of people can recover without going to intensive treatment. And I think one contributor to stigma is that those people that recover in non traditional ways or non 12 step ways often don't have the space to share their story. Because addiction is so secret and stigmatized. People often don't have the vision of themselves in recovery in their head just because they haven't seen it in others.
[11:16]
Courtney Allison
You mentioned how your work focuses on stigma. Why is stigma so dangerous?
[11:22]
Dr. Jonathan Avery
Well, I saw friends and family struggle with addiction around me growing up, and I noticed that they were treated differently than people that had other health conditions. And intuitively, to me, that never made sense. It was sort of obvious to me that these folks, if they could do better, they would, but they couldn't for complex reasons. And our studies show sort of what I'm describing, that people's attitudes are worse towards those with substance use disorders or addictions than towards any other medical or psychiatric condition. And these attitudes even exist in the places that should be the safest, like among healthcare providers, lawyers, and even our own family. And that's dangerous and problematic because when there's all this stigma all around, saying that you're a moral failing and not acknowledging how we can thrive with addiction creates a situation where people feel bad about themselves. It makes them not want to seek help, and it results, I think, in a lot of untreated addiction. I think there's Been some improvement. There's actually a number of people here at Cornell working on the stigma of addiction. I do think things are getting better, more people are talking about it and open and honest. But still there's a long way to go. It's still really a hidden condition.
[12:28]
Courtney Allison
Can you talk more about the importance of community and what that looks like in recovery?
[12:33]
Dr. Jonathan Avery
Substance use and other addictions can be really isolating. People often can feel very alone with it and stigmatized. And one way out is through the therapies and the groups and the meds and adjusting the mental health. But no one recovers alone. And there's all sorts of famous quotes about how the opposite of addiction isn't recovery, but connection. But it's true. You need an extended community. You really benefit often from having other people in recovery in your corner as well. Because then you have people you can lean on, people you can be honest with, and people that can be with you through it. And that often results in building a life that's much more meaningful, much more connected, and goes a long way to solving a lot of what sometimes brought about the substance use, this isolation and disconnection.
[13:15]
Courtney Allison
Would you say more about isolation as a risk factor? If raising your hand is an answer, what about for people who don't feel like they can raise their hand to anyone?
[13:23]
Dr. Jonathan Avery
Because of the stigma, people do often end up isolated with their substance use disorder or behavioral addiction and other conditions that one might have, like depression, anxiety, other mental health conditions, they can often be isolating and are often co occurring as well as. And so if you feel like you can't, I would encourage you to just start anywhere, go online, talk to someone that you feel like you can trust and build up that ability to just share it with even one person.
[13:53]
Courtney Allison
Could you say more about how other mental health conditions might overlap with substance use disorders?
[13:59]
Dr. Jonathan Avery
One of the driving hypotheses around addiction and substance use disorder is the self medication hypothesis. And part of that recognizes that when you have a substance use disorder, addiction, behavioral addiction, you often have a co occurring mental health condition, depression, anxiety. The odds ratios are through the roof. It's one of the biggest risk factors for developing addiction is having a mental health condition or having trauma. You can't often address the addiction without addressing those things at the same time, without also treating the mental health and the trauma. And sometimes the addiction becomes the loudest thing in the room. And so you've got to take care of that first. But you can't forget the whys.
[14:35]
Courtney Allison
So if there's someone in your life, who's struggling? What could be the most helpful thing you could do for them to support them? And maybe what shouldn't you do as?
[14:44]
Dr. Jonathan Avery
Well, People often think they need to scare or punish people into recovery. And I think we have to meet them instead with kindness and understanding. Understand that they're doing this behavior for a reason. It's doing something for them. And to meet them in that space with kindness, to offer resources and support them as they try to navigate this difficult health condition.
[15:08]
Courtney Allison
And it's not easy to quit, right?
[15:10]
Dr. Jonathan Avery
Quitting is really hard. You're going against what's happened to your brain. You're going against whatever mental health struggles you're in. You're going against whatever environment you're in. That makes it very hard to do a different behavior. And so it takes a lot of intention and work often to curb an addictive behavior.
[15:25]
Courtney Allison
What could people look forward to if they can get through recovery? What stories do you see of how people thrive?
[15:30]
Dr. Jonathan Avery
There's so many stories of how people thrive when they stop using substances or doing a problematic behavior. I think part of what happens in the brain is that the thing that's lighting your brain up most are these substances and you sort of lose all these other passions and interests. And so when you enter recovery and everything sort of gets right sized, you start to find a lot of joy again in life, in your relationships and your work. You're physically healthy, which goes a long way. And so the people I see in recovery are some of the happiest, well adjusted people I see. And also for going through that struggle, you learn a lot. There's a certain wisdom and expertise that comes with having learned to thrive with a substance use disorder that I think we really could all benefit from. It is worth acknowledging that this is a condition that can take us to our knees sometimes and can be really hard. And we do lose lives. If you're stuck, I'd say start anywhere. It's worth the effort.
[16:24]
Courtney Allison
Dr. Avery, thank you so much for joining us today on Health Matters and for this wonderful conversation and helping break stigma and provide strategies for people.
[16:32]
Dr. Jonathan Avery
Thanks for having me and all the work you're doing.
[16:37]
Courtney Allison
Our many thanks to Dr. Jonathan Avery. I'm Courtney Allison. Health Matters is a production of New York Presbyterian. The views shared on this podcast solely reflect the expertise and experience of our guests. To learn more about Dr. Avery's work with patients, check out the show notes. New York Presbyterian is here to help you stay amazing at every stage of your life. Join us next time when we talk about running from preventing injury to preparing for a race that's in two weeks right here on Health Matters so you don't miss it. Be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get podcasts.

Why Quitting is So Hard: Understanding Addiction

August 12, 202600:17:20

Summary7 min read

Podcast Summary: Health Matters — "Why Quitting Is So Hard: Understanding Addiction"

Episode Overview Host Courtney Allison speaks with Dr. Jonathan Avery, an addiction psychiatrist at NewYork-Presbyterian and Weill Cornell Medicine, to unpack why quitting an addiction—be it to substances like alcohol or behaviors like gambling—is so difficult. The episode covers the neurobiology of addiction, the pervasive nature of behavioral and substance addictions, the roles of stigma and community in recovery, practical advice for recognizing and addressing addiction, and the latest treatments transforming recovery possibilities.

Main Discussion Points & Insights

1. Thriving with Addiction and the Stigma Surrounding It

Addiction is everywhere: Dr. Avery emphasizes that addiction is not rare or limited to “others.” It exists on a spectrum and often goes unrecognized due to stigma.
- “If we create these narratives about overcoming addiction or thinking of it as something in the past, we miss that it really is all around us… In large part because of the stigma of addiction, we really don't look at it in ourselves or others.” (01:44)
Stigma's effects: The prevailing attitudes toward addiction are more negative than towards any other medical or psychiatric issue, even within healthcare, law, and family environments. Stigma discourages people from seeking help and perpetuates isolation.
- "When there's all this stigma all around, saying that you're a moral failing and not acknowledging how we can thrive with addiction, ...people feel bad about themselves. It makes them not want to seek help..." (11:21)

2. What Is Addiction? — Beyond Dopamine and Willpower

Comprehensive definition: Addiction is the chronic or compulsive use of a substance or engagement in a behavior despite negative consequences, influenced by genetic, biological, social, and psychological factors.
- “Addiction is complicated… At its core…Compulsive engagement with a substance or behavior despite negative consequences… often driven by impaired regulation of reward, stress, executive function systems.” (02:50)
Pain and trauma as root causes: Addiction often arises as a maladaptive response to pain, trauma, and disconnection—not merely brain chemistry or weak willpower.

3. The Brain in Addiction

Reward system hijack: Dopamine “spikes” initially fuel substance use, but anticipation and routine take over, rewiring reward pathways. Chronic use also leads to withdrawal symptoms, reinforcing the cycle of use.
- “With time, you start to get this dopamine spike about acquiring the substance. And so your reward system is driven to use.” (04:18)
- “You get withdrawal states when you remove it. So it's both the hijacking and then... how terrible you feel...when that's taken away.” (04:48)

4. Common and Emerging Addictions

Substances: Alcohol remains the most prevalent addiction, despite the opioid crisis and emerging concerns around marijuana, vaping, and fentanyl.
Behaviors: Gambling, gaming, sex, and even phone/social media use are recognized as behaviorally addictive and neurobiologically similar to substances.
- “You see the same changes in the brain, and you see a similar set of behaviors that evolve around these things... The striking thing about gambling is... it lights up the brain sometimes even more than substances.” (06:01)
The role of technology: Smartphones and online accessibility have dramatically increased addictive behaviors, especially among young people.
- “The phone is such a troublemaker. You know, the phone has really increased the availability of a lot of these behavioral addictions.” (06:42)

5. Spotting and Managing Addiction

Red flags: When a behavior starts interfering with values and functioning, it may be crossing into addiction.
- “Once it starts getting in the way of things you value and starts to impact your function, that's when we think you start veering into addiction.” (08:42)
First steps: Raising your hand and seeking help is crucial; a wider range of treatments—including moderation, therapy, groups, online options, and medications—is now available.
- “The first step is to raise your hand. There are more treatments in health than ever… The biggest sea change… is there are actually medications that can help…” (08:57)
Trigger awareness: Emphasizes “HALT-B”—recognizing triggers like being Hungry, Angry, Lonely, Tired, and Bored to prevent compulsive behaviors.
- "Be careful not to eat junk food when you're hungry, angry, lonely, tired... we always say and sometimes bored. These are the triggers for substance use." (08:16)

6. Treatment and New Horizons

Medication advances: There are medications for various addictions (alcohol, opioids, marijuana, cocaine, nicotine). GLP-1 agonists, primarily used for diabetes and weight loss, show promise for reducing cravings for alcohol and potentially gambling.
- “There's studies… showing that the GLP1s help curb drinking and binging on drinking... there might also be promise for even some of these behavioral addictions like gambling.” (09:56)
Recovery looks different for everyone: Not all need total abstinence or intensive rehab—some recover with moderation or less traditional supports.
- “A lot of people can recover with moderation. A lot of people can recover without going to intensive treatment… those people that recover in nontraditional ways… often don't have the space to share their story.” (10:31)

7. The Importance of Community and Connection

No one recovers alone: Recovery thrives on connection to others, particularly peers in recovery—community combats the isolation that often drives or worsens addiction.
- “The opposite of addiction isn’t recovery, but connection. But it’s true. You really benefit often from having other people in recovery in your corner as well…” (12:32)

8. Addiction and Mental Health

Overlap with other conditions: There’s a strong link between addiction and mental health issues like depression, anxiety, and trauma.
- “One of the biggest risk factors for developing addiction is having a mental health condition or having trauma. You can't often address the addiction without addressing those things at the same time…” (13:58)

9. How to Support Someone Struggling (and What Not To Do)

Approach with kindness: Confrontation and punitive approaches aren’t effective; empathy and support are vital.
- “People often think they need to scare or punish people into recovery. And I think we have to meet them instead with kindness and understanding… offer resources and support them as they try to navigate this difficult health condition.” (14:43)

10. Hope and Life Post-Addiction

Recovery is possible and fulfilling: The majority of people get better, often stronger and with a newfound appreciation for life, relationships, and health.
- “The people I see in recovery are some of the happiest, well adjusted people I see. And also for going through that struggle, you learn a lot. There's a certain wisdom and expertise… that we could all benefit from.” (15:30)

Notable Quotes & Moments with Timestamps

“Quitting is really hard. You're going against what's happened to your brain...whatever mental health struggles you're in...whatever environment you're in. That makes it very hard to do a different behavior.” — Dr. Jonathan Avery (00:00, repeated at 15:09)
“It's tens of millions of people that struggle with classic substance use disorders… but there are probably more than even that. I mean, I'm addicted to my phone right now…” — Dr. Jonathan Avery (02:19)
“We wouldn't give our kids vodka at age 10, but we have them on social media at that age...” — Dr. Jonathan Avery (06:42)
“If you feel like you can't [ask for help], I would encourage you to just start anywhere, go online, talk to someone that you feel like you can trust and build up that ability to just share it with even one person.” — Dr. Jonathan Avery (13:23)

Key Timestamps

[00:00] — Why quitting is so hard: biology, mental health, environment
[01:44] — The stigma and personal narratives of addiction
[02:19] — Addiction is common—some personal admissions
[02:50] — Defining addiction: factors and misconceptions
[04:18] — What happens in the addicted brain
[06:01] — Similarities between substance and behavioral addictions
[06:42] — Technology’s impact: phones, gambling, youth
[08:16] — Recognizing triggers (HALT-B) and applying addiction principles to daily life
[08:57] — First steps and treatment options, including medications
[09:56] — GLP-1 medications and future possibilities
[10:31] — Different recovery journeys, more than abstinence/rehab
[11:21] — The pervasive and dangerous nature of stigma
[12:32] — Building community as a pillar of recovery
[13:58] — Addiction, mental health, and trauma’s interconnectedness
[14:43] — How to support (and not to support) someone struggling
[15:30] — Finding joy and wisdom after recovery

Final Takeaways

Addiction is a complex, multifaceted chronic condition, affecting millions and driven by intersecting biological, emotional, and social factors.
Recovery is both possible and common—no one should feel alone or hopeless.
Breaking stigma, fostering community, and seeking or offering compassionate support are essential for lasting change.
Treatment is increasingly effective: therapy, community, and even medications offer real paths forward.
“Raise your hand” and take the first step—help and recovery look different for everyone.

For more, see Dr. Avery’s work and additional resources in the episode’s show notes.

Loading summary

Transcript46 lines

[00:00]
Dr. Jonathan Avery
Quitting is really hard. You're going against what's happened to your brain. You're going against whatever mental health struggles you're in. You're going against whatever environment you're in. That makes it very hard to do a different behavior. And so it takes a lot of intention and work often to curb an addictive behavior.
[00:17]
Courtney Allison
Welcome to Health Matters. Your dose of the latest in health and wellness. From New York Presbyterian, I'm Courtney Allison. This season on Health Matters, we're covering your health from eight, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at Q for quitting. It can be difficult to talk about addiction. In this episode, we talk with Dr. Jonathan Avery, an addiction psychiatrist at New York Presbyterian in Weill Cornell Medicine, to better understand what's happening in our brains when we're addicted to a behavior like online gambling or to a substance like alcohol and why it can be so hard to quit. As he explains the importance of reducing stigma around addiction, Dr. Avery shares thoughtful ways to support those who may be struggling and the therapies and treatments that can lead to a successful long term recovery. Doctor Avery, thank you so much for joining us today.
[01:25]
Dr. Jonathan Avery
Hey, Courtney, thanks for having me.
[01:26]
Courtney Allison
It's such a pleasure to have you here on the show. A fellow podcaster, I'm very excited for our conversation. Something that struck me when I was listening to some of your episodes. You've said that thriving doesn't mean the absence of loss or struggle, but finding a way forward through it. Could you elaborate on that? What does it mean to thrive with addiction?
[01:44]
Dr. Jonathan Avery
Traditionally, we think of addiction as something that you have and that you overcome or something that other people have and they overcome. And I think when we create these narratives about overcoming addiction or thinking of it as something in the past, we miss that it really is all around us. And so I think to really address and understand addiction, you have to recognize it in each of us. In large part because of the stigma of addiction, we really don't look at it in ourself or others. And I think that creates a lot of trouble.
[02:13]
Courtney Allison
I appreciate what you're sharing because I think whether we're struggling with it ourselves or have family members or loved ones, it is really out there.
[02:19]
Dr. Jonathan Avery
It's tens of millions of people that struggle with classic substance use disorders, things like alcohol and cannabis, and increasingly aware of behavioral addictions like gambling and gaming and sex addiction. But there are probably more than even that. I mean, I'm addicted to my phone right now and we all go through these phases in our life. Where different things grab our attention, Hijack our dopamine. And so I do really believe that it's in all of us. And we all have to monitor our behaviors.
[02:48]
Courtney Allison
What exactly is addiction?
[02:50]
Dr. Jonathan Avery
Addiction's complicated. And it's not just one thing. There are a spectrum of behaviors and neurobiologic processes. There's genetics and social determinants of hell, spiritual factors. But at its core, in the most simplest form, Addiction is the chronic use or compulsive engagement with a substance or behavior. Despite negative consequences. And this is often driven by impaired regulation of reward, stress, executive function systems. But I think even more importantly, Addiction is often a response to pain, to disconnection, to trauma, unmet needs. I think when we simplify addiction to just being about a substance. Like everyone who gets exposed to acceptance gets addicted. That's not true if we make it just about the brain and genetics. That also doesn't encompass how addiction develops. Because some people have the genetics. They have a vulnerable brain, and they use, and they don't get stuck. It's often that vulnerable brain plus exposure to the substance. Plus different factors in their life, including mental health and trauma. A difficult living situation, access to substances, availability. So there's a lot that goes into this behavior that we call addiction.
[04:06]
Courtney Allison
So understanding there's many different factors. And it's not just what's happening in the brain. What is happening in the brain when it comes to addiction, what does it have to do with dopamine, Our reward pathways, things like that.
[04:18]
Dr. Jonathan Avery
So we initially thought addiction was all about dopamine, and that's still partly true. And the reward pathways in the brain were you use something, you get this big dopamine spike. And then with time, you start to get this dopamine spike. About acquiring the substance. And so your reward system is driven to use. But we've learned over time that so many other neurocircuits and processes from the parts of the brain that, remember, the parts of the brain in the frontal cortex. That are involved with decision making. And putting the brakes on behavior. All the way throughout the body, in fact, too, is impacted by substances. The other thing that drives substance use forward. Is that when you use a substance chronically. You get withdrawal states when you remove it. So it's both the hijacking and then when you remove it. How terrible you feel in your body and brain when that's taken away. And some substances have very wicked withdrawal states. That make it very hard to stop.
[05:08]
Courtney Allison
Can you walk us through some of the common addictions we all might encounter. I mean, you mentioned before your phone. That's very relatable.
[05:15]
Dr. Jonathan Avery
Well, as a father of three young kids, I'm especially interested in how social media and online and YouTube and all these other things are addictive. But the classic addictions we think of are these substance use disorders. And the main thing we treat in addiction is alcohol still, like, as much as marijuana and youth vaping and opiates are in the press. If you're gonna get st on any substance, it's alcohol. But we're in the opiate epidemic, the fentanyl opiate epidemic, especially where we have a lot of a contaminated drug supply around the country that's impacting and causing people to lose a lot of lives and become addicted. And then there are behavioral addictions, not just social media, but the ones we've studied the most are gambling. Gaming and sex addiction. And you would think they act differently on the brain than the substances, but they actually act very similarly, and we treat them very similarly in addiction.
[06:01]
Courtney Allison
What do all these have in common? What does gambling have in common with alcohol? Cannabis screens?
[06:08]
Dr. Jonathan Avery
The striking thing about these behavior addictions is that they are neurotoxic in the same way these substances are. You see the same changes in the brain, and you see a similar set of behaviors that evolve around these things as well. The striking thing about gambling is one, it lights up the brain sometimes even more than substances. It does something to our reward pathway, and that is really remarkable. And then you can even get withdrawal states when you stop gambling. You can feel physically unwell from not gambling when you have a severe gambling disorder.
[06:36]
Courtney Allison
And how is the new availability, accessibility of gambling betting on smartphones, how has that impacted people?
[06:43]
Dr. Jonathan Avery
The phone. The phone is such a troublemaker. You know, the phone has really increased the availability of a lot of these behavioral addictions. We wouldn't give our kids vodka at age 10, but we have them on social media at that age. They have availability to see difficult sexual content at that age. And then the sports betting has just taken over Especially young male culture where if you watch any sports game these days, you watch the game and you see all the betting odds, and it's become what kids talk about. And the phone makes it easy to gamble and wager. And then for the developing brain, all these behaviors, all the substances and all the behaviors may especially be more engaging and especially harder to put the brakes on as the brain keeps developing until 25.
[07:28]
Courtney Allison
Are there any surprising things that someone might be addicted? I think I saw validation could be an addiction that surprised me a little.
[07:34]
Dr. Jonathan Avery
Yeah, there's love addiction, there's food addictions. Even though some of these things may not sort of light up the brain the same way, different behaviors are helpful to think about in an addiction lens because of a lot of the things we do that we'd rather not be doing. If we applied some of these addiction principles, we could help moderate those things. Be careful not to eat junk food when you're hungry, angry, lonely, tired, for example, things we're telling people always to be mindful of those states around substances to not doom scroll after a long day at work, but try to do something healthier. So some of these addiction principles can apply to a bunch of these things.
[08:11]
Courtney Allison
That's really helpful. Could you say more about that? So being aware of your state. Hungry, angry, lonely.
[08:16]
Dr. Jonathan Avery
Did you say hungry, angry, lonely, tired, halt. And then we always say and sometimes bored. These are the triggers for substance use. When you are either trying to be absent or trying to moderate. You don't want to be chasing feeling states. If you're going to have a healthy relationship to something, you want to be doing it intentionally and because you're enjoying it, not because you're trying to get rid of a feeling.
[08:38]
Courtney Allison
What are some signs that you might be teetering into that harm category?
[08:42]
Dr. Jonathan Avery
It often happens subtly, which makes it hard to recognize. But once it starts getting in the way of things you value and starts to impact your function, that's when we think you start veering into addiction.
[08:53]
Courtney Allison
And so say you're noticing that. What's the first step to try to manage it?
[08:58]
Dr. Jonathan Avery
The first step is to raise your hand. There are more treatments in health than ever. Sometimes people feel when they raise their hand. There's only one option, which is to quit substances entirely. Go to 12 step work. But that's not the case. There's different therapies, different groups, there's online options, there's in person options. And then the biggest sea change in the last 10 to 15 years in addiction, psychiatry and medicine is there are actually medications that can help with what you're self medicating, but also help with craving towards substances and behaviors. We've had great meds for alcohol use. Some which help you drink less, some which help you maintain abstinence. If you struggle with opioids, the gold standard is to be on medications that either replace or block your opiate system and really improve outcomes. And then there's other meds that help with craving for marijuana and cocaine and good meds that help you stop smoking cigarettes or vaping nicotine. Just ask your doctor. If you have a kid that's struggling, ask the pediatrician.
[09:52]
Courtney Allison
Is there potential for GLP1s to help with addiction? What are the studies showing?
[09:56]
Dr. Jonathan Avery
Yeah, it's very promising. The weight loss on them have been tremendous, obviously, and their role in chronic medical conditions has been notable. And there's studies, including pretty solid larger studies now showing that the GLP1s help curb drinking and binging on drinking and helping people enter recovery states. But there might also be promise for even some of these behavioral addictions like gambling. There's a lot more that I think is going to come out in the next couple years, but there's some real
[10:25]
Courtney Allison
promise there that's really exciting to hear. And so when it comes to addiction, can people get better?
[10:31]
Dr. Jonathan Avery
People get better. That's the thing. Most people get better. There is a real large community of people who have gotten better. But you got to raise your hand. I think part of what makes it scary for people to raise their hand is they feel like their initial step is to go to rehab and be completely abstinence. But in fact, a lot of people can recover with moderation. A lot of people can recover without going to intensive treatment. And I think one contributor to stigma is that those people that recover in non traditional ways or non 12 step ways often don't have the space to share their story. Because addiction is so secret and stigmatized. People often don't have the vision of themselves in recovery in their head just because they haven't seen it in others.
[11:16]
Courtney Allison
You mentioned how your work focuses on stigma. Why is stigma so dangerous?
[11:22]
Dr. Jonathan Avery
Well, I saw friends and family struggle with addiction around me growing up, and I noticed that they were treated differently than people that had other health conditions. And intuitively, to me, that never made sense. It was sort of obvious to me that these folks, if they could do better, they would, but they couldn't for complex reasons. And our studies show sort of what I'm describing, that people's attitudes are worse towards those with substance use disorders or addictions than towards any other medical or psychiatric condition. And these attitudes even exist in the places that should be the safest, like among healthcare providers, lawyers, and even our own family. And that's dangerous and problematic because when there's all this stigma all around, saying that you're a moral failing and not acknowledging how we can thrive with addiction creates a situation where people feel bad about themselves. It makes them not want to seek help, and it results, I think, in a lot of untreated addiction. I think there's Been some improvement. There's actually a number of people here at Cornell working on the stigma of addiction. I do think things are getting better, more people are talking about it and open and honest. But still there's a long way to go. It's still really a hidden condition.
[12:28]
Courtney Allison
Can you talk more about the importance of community and what that looks like in recovery?
[12:33]
Dr. Jonathan Avery
Substance use and other addictions can be really isolating. People often can feel very alone with it and stigmatized. And one way out is through the therapies and the groups and the meds and adjusting the mental health. But no one recovers alone. And there's all sorts of famous quotes about how the opposite of addiction isn't recovery, but connection. But it's true. You need an extended community. You really benefit often from having other people in recovery in your corner as well. Because then you have people you can lean on, people you can be honest with, and people that can be with you through it. And that often results in building a life that's much more meaningful, much more connected, and goes a long way to solving a lot of what sometimes brought about the substance use, this isolation and disconnection.
[13:15]
Courtney Allison
Would you say more about isolation as a risk factor? If raising your hand is an answer, what about for people who don't feel like they can raise their hand to anyone?
[13:23]
Dr. Jonathan Avery
Because of the stigma, people do often end up isolated with their substance use disorder or behavioral addiction and other conditions that one might have, like depression, anxiety, other mental health conditions, they can often be isolating and are often co occurring as well as. And so if you feel like you can't, I would encourage you to just start anywhere, go online, talk to someone that you feel like you can trust and build up that ability to just share it with even one person.
[13:53]
Courtney Allison
Could you say more about how other mental health conditions might overlap with substance use disorders?
[13:59]
Dr. Jonathan Avery
One of the driving hypotheses around addiction and substance use disorder is the self medication hypothesis. And part of that recognizes that when you have a substance use disorder, addiction, behavioral addiction, you often have a co occurring mental health condition, depression, anxiety. The odds ratios are through the roof. It's one of the biggest risk factors for developing addiction is having a mental health condition or having trauma. You can't often address the addiction without addressing those things at the same time, without also treating the mental health and the trauma. And sometimes the addiction becomes the loudest thing in the room. And so you've got to take care of that first. But you can't forget the whys.
[14:35]
Courtney Allison
So if there's someone in your life, who's struggling? What could be the most helpful thing you could do for them to support them? And maybe what shouldn't you do as?
[14:44]
Dr. Jonathan Avery
Well, People often think they need to scare or punish people into recovery. And I think we have to meet them instead with kindness and understanding. Understand that they're doing this behavior for a reason. It's doing something for them. And to meet them in that space with kindness, to offer resources and support them as they try to navigate this difficult health condition.
[15:08]
Courtney Allison
And it's not easy to quit, right?
[15:10]
Dr. Jonathan Avery
Quitting is really hard. You're going against what's happened to your brain. You're going against whatever mental health struggles you're in. You're going against whatever environment you're in. That makes it very hard to do a different behavior. And so it takes a lot of intention and work often to curb an addictive behavior.
[15:25]
Courtney Allison
What could people look forward to if they can get through recovery? What stories do you see of how people thrive?
[15:30]
Dr. Jonathan Avery
There's so many stories of how people thrive when they stop using substances or doing a problematic behavior. I think part of what happens in the brain is that the thing that's lighting your brain up most are these substances and you sort of lose all these other passions and interests. And so when you enter recovery and everything sort of gets right sized, you start to find a lot of joy again in life, in your relationships and your work. You're physically healthy, which goes a long way. And so the people I see in recovery are some of the happiest, well adjusted people I see. And also for going through that struggle, you learn a lot. There's a certain wisdom and expertise that comes with having learned to thrive with a substance use disorder that I think we really could all benefit from. It is worth acknowledging that this is a condition that can take us to our knees sometimes and can be really hard. And we do lose lives. If you're stuck, I'd say start anywhere. It's worth the effort.
[16:24]
Courtney Allison
Dr. Avery, thank you so much for joining us today on Health Matters and for this wonderful conversation and helping break stigma and provide strategies for people.
[16:32]
Dr. Jonathan Avery
Thanks for having me and all the work you're doing.
[16:37]
Courtney Allison
Our many thanks to Dr. Jonathan Avery. I'm Courtney Allison. Health Matters is a production of New York Presbyterian. The views shared on this podcast solely reflect the expertise and experience of our guests. To learn more about Dr. Avery's work with patients, check out the show notes. New York Presbyterian is here to help you stay amazing at every stage of your life. Join us next time when we talk about running from preventing injury to preparing for a race that's in two weeks right here on Health Matters so you don't miss it. Be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get podcasts.