Podcast: The Growing Epidemic of Addiction in High Achievers, with Dr. Peter Grinspoon

In this episode of Status Check with Spivey, Mike interviews Dr. Peter Grinspoon—physician, Harvard Medical School instructor, and author of Free Refills: A Doctor Confronts His Addiction, in which he writes about his struggles with and recovery from opiate addiction. Mike and Dr. Grinspoon discuss mental health and wellness for high performers, why lawyers have such high rates of addiction and depression, antidotes for the factors that lead to these high rates, the story of Dr. Grinspoon's 2019 debate on medical marijuana at Yale Law School, and more.

Listeners of this podcast are welcome to contact Dr. Grinspoon via his website, www.petergrinspoon.com—he loves talking to students, is able to discuss sensitive and confidential questions, and responds to all communications personally.

You can listen and subscribe to Status Check with Spivey on ⁠⁠Apple Podcasts⁠⁠⁠⁠Spotify⁠⁠⁠⁠YouTube⁠⁠, and ⁠⁠Google Podcasts⁠⁠.

Full Transcript:

Mike: Welcome to Status Check with Spivey, where we talk about life, law school, law school admissions, a little bit of everything. This is a special podcast for me, because we had the great fortune to talk to bestselling author Dr. Peter Grinspoon, who in medical school developed a severe addiction that almost cost him his life to opioids. But what he said on the podcast, which I hope stands out to you because it really stood out to me, particularly having been a dean at two law schools and having seen this, is addiction is a disease. And like any other disease, if you're underslept, undernourished, you're not eating the right food, you're not sleeping enough, and particularly you're overstressed, just like most other diseases, this is where addiction develops. This is where it developed for Dr. Grinspoon.

He wrote a tell-all book, Free Refills, about that, and my hope is you read the book. But in this 50-minute podcast, some of the wisdom he gives from his experience, I would hope stays with people—maybe not now, but if you're in law school, and things are getting so stressful, and you find yourself medicating, escaping on anything, it doesn't have to be a substance, it can be a behavior, and its continued use has spiked negative consequences. What we do with this podcast is, for about 50 minutes, we tried to dissect what are the early warning signs, so that you don't have to have it happen to you like it happened to Dr. Grinspoon, again he’s very open, where the police are showing up at your door and you have three felony charges against you.

In other words, if the stress of law school or practicing law becomes overwhelming, and anyone listening to this down the road is escaping through substances or behaviors, I think this podcast will come back to you. It's not an admissions podcast. We do end a little bit about a debate Dr. Grinspoon had at Yale Law School, which I think is interesting too. But this is very much a well-being podcast. You might not need it now, you might not need it down the road, but I think it's just for anyone interested in the human condition and resiliency and a comeback story. This is a great listen. Without further delay, here's me and Dr. Grinspoon.

Peter, great to see you, and thanks for coming.

Dr. Grinspoon: Thanks for having me.

Mike: Your book was very powerful. Do you want to start where you believe you should start, whether it was 12 years old when you had your first scotch and threw up in the guest bedroom, or downstream when it really became more of an issue?

Dr. Grinspoon: I would always experiment with drugs, and I was a pot smoker in high school. We don't recommend pot smoking for teens, but I have to say, I never didn't get an A from my first puff of pot and through college, so I don't think it really affected me academically. I was in medical school, and medical school is really hard and really stressful. You work 100-hour weeks and don't get much sleep, and I was in a very stressful marriage as well. And the combination of the two, I think, made me susceptible, made me vulnerable. I mean, as a general rule of thumb, if you don't take care of yourself—you know, sleep, nutrition, exercise—you’re more susceptible to all kinds of diseases, including addiction.

And a friend of mine, actually it was in late medical school, we were just experimenting. We had some samples of Vicodin, which is a very strong narcotic, just like OxyContin, Oxycodone, Percocet. We tried it. And my friend thought, “This is fun,” and then she moved on and never took it again. But unlike every other drug I had tried—and again, in college I'd experimented—when I took Vicodin, I became so profoundly euphoric, it would transform my life, ultimately in a bad way. Ultimately not in a good way. But something in my brain changed. I would just started seeking out narcotics, opiates, for the next 10 years.

I had a lot of access to opiates, because I'm a doctor. That's why I called my first book Free Refills. I had open access to medication. And with any addiction, you start taking it, and it feels really good, then you search for more, and then you start taking it and it feels pretty good, and then you don't have any left and you start to feel sick, and then most of the time you feel awful, and you spend most of your time thinking about, "how am I going to get more drugs?" And when you do take the drugs, at least the opiates, instead of feeling great, you just don't feel sick. So how you feel during an addiction goes downhill pretty quickly. There's a popular misconception that people who are addicted are these happy people enjoying life. It's the most miserable thing in the world.

But I was in denial, very, very deep denial, because I didn't want to think of myself as someone who had a problem, who had an issue with drugs. I was, you know, at the same time a successful doctor. I completed residency. I was at a prestigious practice. And it wasn't until February of 2005 when the state police and the DEA raided my office for some very, very bad prescriptions, that I realized, “Wow, something is really wrong.” I still didn't even believe at that point that I had an addiction, but I got into so much trouble. Fingerprinted, arrested, charged with three felony counts. I actually lost my medical license for three and a half years, because I had really a hard time kicking the habit. I was sent to rehab for 90 days, which was very excruciating because I had two small children. I had a five-year-old and a six-year-old, which I didn't see for 90 days. And then this organization called the Physician Health Service, which takes care of physicians and also works with the medical board, drug tested me for five years, one to three times a week. And eventually, you know, they said, “If you ever want to be a doctor again, you have to stop failing drug tests.”

Mike: Because you were taking so much water too, right?

Dr. Grinspoon: Yeah, exactly. I was also trying to fake out the test by drinking a lot of water. They're very sophisticated, the drug tests they give to doctors, because doctors are so good at defeating them. They do all kinds of things. And if you drink too much water, you get in trouble. They look at that and they consider it a negative test if you drink too much water.

So eventually, I got my act together. And I've now been 15 years in recovery from opiate addiction. And five years after my recovery, I was invited to work with the same Physician Health Service, and I sat at the same table, just on the opposite side of the table, helping other doctors who were just being dragged in with their addiction, who were angry, confused, withdrawing, in denial. And I got a chance to help hundreds of other doctors with addiction, and I feel like I understand addiction having been involved with it from any angle, and I'm really delighted to be here today talking about it.

Mike: Yeah, so thank you, and congratulations. It's a weird word to say, but it's inspiring to talk to anyone who has been down that path.

Dr. Grinspoon: I'm lucky to be alive, so thank you.

Mike: Let’s explore that. To you, the intervention per se was the state troopers, all these police officers who were walking to your door, correct me if I’m wrong, you knew exactly what they were there for.

Dr. Grinspoon: Well, I sort of pretended I didn't, because it was too overwhelming to think about the implications and the consequences, so, I played dumb. But then they were like, “Cut the crap doc, we know you're writing bad prescriptions.” But even at that point, I rationalized and justified. And the minute they left, I took five Percocets that I had hidden in an Allegra—a bottle for like an antihistamine. So it took me a real while, a long time to really slowly absorb the fact that actually, I was addicted. 25 million Americans are, but really when it happens to you, and it's a slow, insidious descent, it's really hard to come to the terms of it and to identify it.

Mike: Yeah, the slow descent is where I think we can help people here. Of course you took five Vicodin or Percocet. I mean, what is addiction if not escaping reality? Your reality had just been talking to several police officers, I'm guessing at the front door of your house with your neighbors.

Dr. Grinspoon: No, in my office.

Mike: Oh, even worse.

Dr. Grinspoon: Much worse.

Mike: Right, colleagues...

Dr. Grinspoon: My patients and colleagues, it was awful.

Mike: Was there a moment, looking back with clear eyes and sobriety, when should you have noticed that you were an addict and the negative consequences had overridden any sort of benefit?

Dr. Grinspoon: Yeah, the one scene in my book, Free Refills, when I had a blackout and couldn’t remember what happened, that's obviously a bad sign. If you have a blackout, you are in trouble with alcohol—with any drug. I mean, the fact is that opiates should not be a recreational drug. Right? Recreation drugs are alcohol and cannabis. You know, alcohol is more dangerous, they're both dangerous, and you get addicted to both if you use them compulsively. And I should have noticed many, many times.

My behavior became so weird. I was, like, sneaking out of, like, dinner parties and going upstairs and searching the medicine cabinets. Like, who does that? I was, like, stealing medications from patients, which I’m embarrassed to say. Who does that? And eventually, I was writing prescriptions in the name of my wife and picking them up for narcotics. Like literally, nobody does that. So when my behavior became so aberrant, so out of the range of what normal people do, that should have triggered me that I was addicted. And again, you know, addiction changes your brain, and it makes it really hard to come to terms with the fact that you're addicted. But if your behavior starts to be, like, out of the norm—you know, I like eccentric people, and we all have different personalities—but if your behavior, like, searching medicine cabinets, I mean, stealing drugs from people from patients... So there are many, many times that I should have known.

One thing I'll say about addiction that’s really interesting is, I was at a physician support group meeting, and one guy said, “The first time I tried alcohol, it made me so euphoric, I never stopped drinking since that time at age 14.” And for me, alcohol's never done very much. I never liked it; it just makes me sleepy. But then at a book talk, a woman said to me, “Percocet and Vicodin”—you know, the drug I got addicted to—“After my c-section, I hated that stuff. I don't see how anybody could get addicted to that.” And it's interesting, one person gets addicted to alcohol, one person gets addicted to opiates, one person can take them and doesn't get addicted.

So I think part of it is your life circumstance. If you're miserable and unhappy and not taking good care of yourself, or the demands of your job or school are too much, you're set up for addiction. But part of it is also, like, Russian roulette, luck of the draw, it’s just like your brain chemistry, I think some of us are just more susceptible than others to certain drugs. I'm not anti-drug, but the more we use addictive drugs, particularly alcohol and opiates, the more likely we are to end up with an addiction.

Mike: Choice has always been so fascinating to me because, and correct me if I’m wrong, it all hits the same dopaminergic pathway. And I know Dr. Lembke even in her book, Dopamine Nation, talked about "X drug is a hundred times more potent than food," "sex is I don’t know 50 times more potent," but I don't know how you measure that, because we have different drugs of choice, and from an evolutionary standpoint that kind of makes sense. If we were all craving the same strawberry patches, we would fight and kill each other for it and we wouldn't be here as a species today. But I don't think they figured out why your drug of choice might be an opioid-based drug and mine might be caffeine or heroin. And I don't think they know yet, right?

Dr. Grinspoon: It's really interesting. That's a great question. There are things we know and there are things we don't know. We don't know why someone picks a particular drug of choice. Why me, it was opiates, why for someone else it's alcohol, for someone else it's cocaine or methamphetamine. We do know that they affect different receptors. Cannabis affects the cannabinoid receptors. Opiates hit the opioid receptors. So we do understand how these drugs affect the brain. Ketamine, we don't understand that well at all; it affects the glutamate receptors. But then we do understand that after they hit whatever—the cannabinoid, the glutamate, the opiate receptors—they go to a final common pathway, which is our reward system. Our dopamine system. Our system that says, “Yes, this is good. Give me more.”

And as you mentioned, our evolutionary biology is really important, so we know what's pleasurable. Eating those strawberries as hunter-gatherers is pleasurable. Eating a big roast chunk of wooly mammoth is pleasurable, and that gives us dopamine, and that's our reward system. But you're absolutely right, different activities give you different levels of dopamine. Eating a nice dinner gives you like 50 units, you know? Having sex gives you like 100 units. And, like, methamphetamine will give you like 1000 units. So it sort of circumvents our natural reward system, and that's part of what happens with addiction, like, the drug takes over more and more and more of your reward system. Getting drugs, taking drugs, and the other activities become less rewarding. A hug, hanging out with a friend, going for the walk in the woods become less rewarding, because it's hijacked by these drugs. And part of recovery is actually finding a way to make these other things more meaningful again. A hug, asking for help, going for a walk, exercising, trying to make those things genuine, more meaningful again, so that you’re a happy and balanced person, and there's less room for the addiction that insidiously sneak in again.

Mike: That's serendipitously how I discovered you. You're famous in your field, but it was actually through me googling "dopamine fasting" before we interviewed Dr. Lieberman, the author of The Molecule of More. And I was curious about dopamine fasting, and your point to the article I read that was written by you was, in a sense, we've been dopamine fasting for thousands of years—being mindful, being balanced, enjoying nature—but in an extreme, avoiding eye contact and all this nonsense people are talking about today, that's deleterious, that's not helpful. So you had three felony counts against you, is that correct?

Dr. Grinspoon: Yeah, that wasn’t something I'm particularly proud of, but I had three felony counts against me. I was fingerprinted, booked. I had to be on probation for two years, which meant that every week—at least, unless she got suspicious and wanted to see me more—I had to go to the probation office in the basement of the dingiest courtroom with all the other more hardened criminals. And like, I dropped my kids off at preschool, then I go to my probation officer, and I couldn't leave the state without her permission. And if she thought I screwed up anything, she could send me back to the judge, and I potentially faced jail time.

And I don’t think people with drug charges should face jail time. I’m not a big fan of the war on drugs and the whole criminalization. People need more treatment if they're making mistakes; they don't need to be rotting in prison. But still, I was in so much trouble, and eventually after two years, I was able to complete my probation, and now I don't have a criminal record. Which was very good for getting back to medicine, which I’ve been back to happily or at least productively—I don’t know about happily as a primary care doctor—but productively for 15 years. But believe me, the consequences of an untreated addiction are brutal. They say in the original book from Alcoholics Anonymous, addictions end in jails, institutions, or death. Luckily, I didn't end up in death, because I'm obviously here talking to you. But institutions, I was in rehab for 90 days. That was awful. Honestly, I think rehab is a big waste of time, but that's a whole other conversation—it’s much better to treat people with, like, methadone or suboxone and give them a therapist in their own home environment so they don't go home and relapse.

I also, you know, got in a lot of trouble with the criminal justice system. So I say to people who are starting to struggle with substances, you know, the person who's binge drinking or drinking more than their friends, or the person who tried cocaine in college and then, you know, they keep using it and their friends don't. You will get help for your addiction. I absolutely guarantee it. But the question is whether you get help on your own terms—you say, “I'm having trouble with this,” you talk to a dean or a counselor or an addiction person or your doctor—or you get help like I did, because your addiction just gets worse and worse, and you do something absolutely crazy, and you get in a lot of trouble for it—or, God forbid, you overdose, because a lot of these drugs today are tainted with fentanyl. When we were in college, you could try a pill, you could try a drug, which wasn't a great idea, but you didn't have to worry about dying. These days, cocaine, pills, Vicodin, Xanax, all of these pressed to look like these pills, but many of them are tainted with fentanyl, so you could really overdose and die—and I'm not trying to fearmonger, but as someone who's been through it, it's much more dangerous these days to play around with these drugs.

Mike: I agree with you 100%. You can get help either way. You can get help on your own early on. I just imagine you walking up the stairs at a friend's dinner party, you know, there's eight people downstairs, and you're walking up to use the bathroom, and your mind is already cranking, “Okay, the first thing I'm going to do is close the door, lock it, and rather than use the restroom, I'm going to open their medicine cabinet.”

Dr. Grinspoon: Keep in mind, there's a downstairs bathroom, and that's what most people use. But I contrived to have my beeper and say I had a page and needed privacy. I mean, that's what my addiction did to me. Completely hijacked my brain. Friends, relatives, instead of enjoying the fact they invited me over for dinner, were feeding me, and the great conversation, I'd pretend to get a page, pretend I needed privacy, go upstairs, and ruffle through drawers and medicine cabinets. I mean, if that's not addictive behavior, what is? But I couldn't recognize it at the time.

Mike: This is a pretty candid question, and hopefully it's not offensive. Do you think it was arrogance, lack of humility, overconfidence? Because addictions do funny things to people’s brains. Almost by definition it makes every addict a liar; unless you have no intersocial connectivity, it's almost impossible not to lie and be an addict at the same time. But I'm curious what the other, maybe, components were that didn't allow you—again, if we want to help people check themselves early—what wasn't allowing you to check yourself when you were in that bathroom, rifling people's medicine drawers?

Dr. Grinspoon: Well part of it was, I was a doctor, and that was where the arrogance came from. And that's why it was so difficult to admit that I might have a problem. Part of it was what's called "terminally unique." You justify. “I need this because I'm working so hard and, you know, helping so many other people,” it’s very easy to rationalize. But I would say the main thing that drove it was pure and utter desperation, because I was withdrawing. If I ran out, I'd be—opioid withdrawal doesn’t kill you, but you feel like you want to die. You're like nauseous, you're barfing, you're anxious, your stomach cramps, diarrhea, shakiness, restlessness, so I would say pure desperation is what was driving this bizarre behavior. And the fact is that addiction changes your brain. It makes you involved socially with the drug; that drug becomes the main source of your social connection, and everything else becomes periphery.

And another part of recovery is reconnecting with people in a meaningful way. It's all about connection. Addiction is about isolation. And I was like this robot seeking for drugs; I wasn't really at the dinner party. The dinner party was a means to the medicine closet. And part of getting through recovery is reconnecting genuinely and mindfully to other people, and it's actually a wonderful thing. I don't take any of my social connections for granted at all. I really cherish, I'm grateful for all of them. So you know, the recovery from the addiction can be a really wonderful thing. It can really bring a lot of, like, humility and connectedness and mindfulness. But when you're addicted, you just tune everybody out. So it's rough.

Mike: There's two more questions on your story. Question one, you're basically in this cycle of obtaining the prescription medication, in your case, opioids, which happened to be, correct me if I’m wrong, easier for you because you're walking around with a prescription pad and you can write your own prescriptions.

Dr. Grinspoon: If I could just say, that might have saved my life, because a lot of people start with prescription drugs, and then their doctor won’t prescribe them anymore. Now that the DEA is putting such pressure on doctors not to prescribe these drugs, people are desperate. Or the supply dries up, and they end up buying drugs in the street, and that's when it's contaminated with fentanyl. Or they overdose with injection drugs like heroin. So it really might have been my easy access to legitimate prescription opiates that stopped me from buying street drugs and overdosing or overdosing in heroin.

Mike: That's interesting. I hadn't thought of that. So you're taking these prescription narcotics, then you're coming off of them, and you're practicing medicine. So a lot of our listeners are going to be lawyers, some will be doctors, who knows what? CEOs of companies, political figures, really high performers. And that's a whole other podcast about the addiction for high performers. You're performing. You’re in the hospital, seeing patients, and I'm going to posit, tell me if I'm wrong, you're either high or you're in the words in your book, I never heard it before, but "dope sick."

Dr. Grinspoon: Yeah, mostly dope sick. I didn't get to the point where I was using at work or before work. Each day I was addicted; the addiction took over a different part of my brain; a few brain cells defected to the addiction side. And I'm not sure that I wouldn't have started doing that at some point, but deep inside me as a doctor, I was very committed to my patients. So I never used drugs—the one thing I can say is—I never used drugs before going to work. But I was so far from my best, because I was withdrawing, I was groggy, I was nauseous, I had diarrhea. I was really, really sick when I was seeing patients. So I never harmed anybody, and I never screwed up as a doctor, which I'm proud of. But at the same time, I was much less empathic and connected than I would have been otherwise, because I was all consumed with my own problems, not with the problems of my patients. So it's impossible.

There are high-performing people with addiction, but it's absolutely impossible to be at your best or anywhere near your best when you’re addicted. And again, there's so many times when I could have been caught stealing medications. It just is lethal to your career, whether you're a doctor, a lawyer, a businessperson. Lawyers have a huge problem with alcohol, because being a lawyer is so stressful, and the addiction will take everything away from you if you don't get help.

Mike: You mention lawyers and alcohol, and we have a lot of data on even law school. Your start was in med school. The data shows that globally, not at the micro level of course, but globally, students come out of law school less happy, more depressed, more addicted than coming into law school. So even at the law school level, I think about a former research assistant of mine who in their first job in what’s called "biglaw," he called me absolutely drunk out of his mind at 6:30 AM at a firm-sponsored bus trip to a ski resort. So they were all drinking on a bus—part of the firm culture—at 6:30 AM heading up to the ski mountains.

Dr. Grinspoon: That's addictive behavior; there's no way around it. Not that everybody on the bus was addicted, you know, some people just sort of go along on vacation; “Sure, I'll have a drink if this is what everybody else is doing.” But generally speaking, to be drunk at 6:30 in the morning, that would raise such red flags for me. I would probably wait til they’re back from the trip and then like just have a very, very frank talk with them, perhaps with some family members there and sort of demand they get help. That is an alarming story. You know, again, I'm not anti-alcohol or anti-drug, but that's equivalent to me going through the medicine closet. That's really bizarre behavior, if you ask me, that's not what most people do. Not that what most people do is necessarily the right thing; in Nazi Germany most people were Nazis. So the right thing to do is, generally speaking, if your behavior is, like, so out of the norm and involves a substance, that's a really big red flag.

Mike: That is exactly where I'm going with this. Alarming behavior, and not only did my former research assistant not notice, but the firm didn’t notice, because they were sponsoring this trip.

Dr. Grinspoon: And it’s part of the culture. I mean something like a fifth of lawyers have trouble with alcohol. You know, where it’s like 10 to 15% of doctors have addiction. The normal for population is like 9%. So lawyers are really, really susceptible to alcohol because of the culture, the stress, because a lot of them are completely miserable. Something needs to be done about that more proactively. There's sort of a like, “let boys be boys,” but half of them are women, but, you know, sort of a "let boys be boys" attitude, and it’s harming people.

Mike: Well hopefully we're putting a minor dent in it right now; it might be extraordinarily minor, but we're trying, and it's important. So, even putting that dent in that culture, you mentioned you got in a sense lucky, you were taking clean prescription medication instead of buying from a drug dealer off a street. What would be—you know, the classic model is tolerance, to craving, to addiction. But I don't think most of us lay people think in those terms. Based on your experience, what would be some poignant signs to someone listening to this, five years down the road, they're at a large law firm. And one to me that you brought up that just pops in my head would be, you go from taking what your doctor prescribes you to buying drugs off the street. That to me is an obvious sign. I'm sure you know some others.

Dr. Grinspoon: Oh, yeah, like contriving excuses to get medications from your doctor. I used to have quote-unquote "migraines" all the time and call the doctor. And the doctor was friendly, and at one point they said, “Don't call me at seven o'clock at home for Vicodin." Like again, it's when your behavior starts becoming out of the norm. Or we had a neighbor who was a lawyer who was obviously an alcoholic. He also wasn’t a very nice person, but that's neither here nor there, maybe it was the alcohol, but. He walked around with a flask and sort of proudly would like take a swig in the middle of a conversation when you're on the street, and like, I know in the movies, old-fashioned people used to walk around with a flask, but these days most people don't walk around with a flask of alcohol. And then I would say when you're at a party and like people have a drink or two, but if someone gets like rip-roaring drunk in a social situation, that would raise a red flag too. Again, a college student, they might not know any better, and so they have like four or five drinks or six drinks. And six drinks is binge drinking, and if a college student does that regularly, that raises a red flag. But an adult getting totally hammered at a party, that raises a red flag to me when everybody else isn't getting hammered. When everybody's getting hammered at a New Year’s party, that's a different type of issue and problem. But if someone's getting hammered at a work party and other people aren't, that's really a red sign too.

I've seen a lot of people among the doctors, for example, that I took care of when I worked in the Physician Health Service, who were in there, and their story was everybody else went to the bar after work or to the Christmas party, and I got so drunk, I had to be driven home. And I think that's another red flag as well.

Mike: Yeah, negative consequences to me is a huge one. Am I starting to neglect my social connections? Am I neglecting my work, my pet, my loved ones? The things I do like hiking or running for joy, whatever one's positive aspects of their lives are, if those start being neglected because of the substance or behavior—make no mistake about it, workaholism is an addiction too. Society might reward you, but you might be escaping something. So those negative consequences to me, once people start noticing those, that's the time to say, maybe this is when I should be getting help.

Dr. Grinspoon: Absolutely. My best definition of addiction is "continued use despite negative consequences." You know, and that sort of encompasses all the other theories. Is it a brain disease? Is it a learning disorder? You have to keep in mind that if you start neglecting—like a colleague of mine, if they start neglecting their work or looking disheveled and they're not enjoying anything, it could be depression. I mean, it's not necessarily addiction. 70 to 80% roughly of people with addiction have inadequately treated anxiety and depression. So it could be that they're depressed and self-treating, so you have to really treat them.

But you also have to disentangle, as we talked a little before the show, what's causing the addiction? Are they depressed and they're self-medicating? Are they anxious and they're self-medicating? Did they just try the wrong drug and it like solved too many problems for them, so it just took over? Or are they in a lot of emotional pain? Where as, you said Dr. Gabor Maté—“Treat the pain, not the drug.” I think you have to treat both equally; I don't think it's just about the pain, but I think it's a really important point. Do they have a genetic predisposition, which is—I've taken care of some Irish patients who say, “Everybody in my family is an alcoholic,” and there is a genetic tendency. So there's a lot to disentangle, but it's hard to start disentangling until the person has the humility to realize, recognize, and admit they have a problem, and most importantly to ask for help. It's really hard to ask for help, particularly, I'm sure, as a lawyer or a businessperson, but as a doctor, “Physician, heal thyself.” You have to be so humble to ask for help. It's very difficult.

Mike: These things, they grow in the dark and they die in the light. So having that humility and courage to express to someone, it doesn't have to be the world. I don't think people need to get better by writing a tell-all memoir and then posting it online, but telling people who care and are concerned so that it doesn't keep growing in the dark.

You clicked on the second part of this that we mentioned a little bit when we were speaking beforehand. You know, there's these theories on addiction. And I get that it’s not black and white. I am curious where you most side on. You know, the genetic predisposition theory. In the old days, it was the moral failing, but let's just throw that out because that is so ridiculous, I don't even want to go there.

So genetic predisposition would be one. Dr. Gabor Maté sort of, you know, really bangs the drums of, in his definition, he adds in, you're anesthetizing or escaping some sort of trauma or stress. There's the environmental one, and this is the one I'm interested in. I never drank or did drugs in high school. I mean, I think I drank twice. Because my friends, we were all athletes, we just weren't big partiers. My significant other wasn't a partier. So the people I was around. But then in college, we drank a ton, and the people who were around were big drinkers. So there's environment, there's Dr. Lembke's notion of, in today's world, things are much more potent. They hit those dopamine systems much harder, and they're 24/7 available now. You can binge a Netflix show right after you and I get off this podcast.

Dr. Grinspoon: Absolutely. I was going to say there's, like, delivery fentanyl. I was treating someone recently. Their mom walked out of the room so I could talk to her more confidentially. I'm like, “How do you get your fentanyl?” She's in Houston. And she said, “I just have it delivered.” I was like, delivery fentanyl, talk about on-demand.

Mike: Picture Ben Affleck, that horrible picture of, it's really sad that it was posted online, but he was on a bender and he was having alcohol delivered to his house. Some paparazzi got a picture of him out there just looking horrible.

Dr. Grinspoon: There's also the learning disorder, it becomes a habit because you learn maladaptive traits—that's Maia Szalavitz.

Mike: And then the final one would be, it's like many other diseases. This is almost offensive that I'm telling you my idea of this definition disease, but it changes something in your biological makeup, changes the hard wiring of your brain.

Dr. Grinspoon: I have to say that I think there's a piece of truth in all of those. I think genetics, everybody has genetics, and some people do have a genetic predisposition, addiction can run in families. But it doesn't have to. You could be the first one in your family, the pioneer to become addicted. But it definitely increases your risk.

Certainly childhood trauma absolutely is associated with addiction. I think addiction can be a learning disorder; think of a teenager and cannabis. Again, we don't recommend teenagers to smoke cannabis; I have a whole chapter in my recent book, Seeing through the Smoke, about what cannabis does and doesn't do to teenagers, because there's a lot of nonsense. But think of a learning disorder, like, they're stressed, anxious, social anxiety, a lot of boredom as you’re teenager. And then you take a puff off your vape and that all goes away. So you can learn to use the drug to soothe yourself. And obviously the dopamine, as we talked about before, there's such a huge hit to our reward system that it's just rewarding, and it can, especially in susceptible individuals, it can really drown out all the other rewards, all the other things that are trying to tickle your dopamine receptors.

But I think that environment, which you mentioned second, is very, very important. I had spine surgery about eight years into my recovery and had to use opiates. Nobody goes through spine surgery without opiates. There are a few hardcore addiction counselors that I had at rehab that were like, “You can never use a drug again, even if you have surgery.” I mean, these people are like absolutely out of their minds. They're living in a different world. I mean, everybody who has major surgery needs opiates. And the question was, how do I not get addicted? But I found that I didn't have trouble at all, eight years later, controlling the opiates. For many reasons. I wrote a whole blog about this for Harvard Health. But you know, you’re very different taking two to alleviate the pain, physical pain, than snorting ten to like get rid of your emotional pain. And then I wasn't up all night, I wasn't sleep-deprived, and I had this whole social network and was much more happily married. If you're a happy, connected, balanced person, and you've worked on your issues under the hood openly and fearlessly, and you've treated your mental and physical health, there's much less room for the seductive allure of these pills. I mean, I really think if you're in a law school and you’re depressed, you're in med school and you're depressed, you're much more susceptible than if you're healthy, happy, and stable.

Mike: Yeah, I mean stress and depression and trauma would be huge ones. I mean, there's all these things conspiring against us like we talked about. Are you familiar with Leslie Jamison, the name? She's an author.

Dr. Grinspoon: A little bit, yeah, she wrote—what's the name of the book she wrote?

Mike: The Recovering.

Dr. Grinspoon: A little bit, yeah, not off the top of my head, but I am familiar.

Mike: Amazing writer. I think probably one of the top one or two writers around today, a gift to writing. She wrote, as we mentioned, The Recovering, and in that book, she wrote, “Addiction doesn't surprise me at all. Sobriety surprises me.” Because of all these things conspiring against us. One of them—and this is how I discovered you again was the mindfulness—being stressed. Law school students, law school applicants, medical school students. Or let’s just take the applicant. A lot of our listeners are applying to graduate school right now. They submitted applications in September, and they haven't heard a single thing, but boy can they sign online and see that 15 other people within five minutes just got admitted to their dream school, that causes a tremendous amount of stress. What are ways to escape that stress? Well, one of the ways would be go have a drink, go have two drinks, go have three. What are some of the healthy interventions so that someone doesn’t escape with a behavior or a substance that leads to negative consequences down the stream?

Dr. Grinspoon: That is a great question, but it also raises the point, like we didn't mention social media.

Mike: Right.

Dr. Grinspoon: Like they haven't studied it yet, but I think social media is going to play a role in addiction. It makes people unhappy. You're a teenager, and you just always see everybody else having fun, because for some reason, like these teens and these young adults, college kids curate all the fun stuff they're doing. They don't post when they're alone in their room bored and lonely. So it just looks like everybody else is having fun all the time and you're being left out. So really interesting that you mentioned checking online and seeing that other people are getting in—social media is going to be a big part of this puzzle. But you know, anxiety comes with life. You know, having kids, and my dad is a psychiatrist. He was a legendary psychiatrist and cannabis expert actually.

Mike: The grandfather of medical marijuana.

Dr. Grinspoon: Yeah, he is. My dad, Dr. Lester Grinspoon, but he was the start of the legalization movement. But he said to have kids is to have anxiety, always. Job has anxiety, and relationships have anxiety, and waiting to hear if you get into grad school has anxiety, and honestly a lot of kids have anxiety about the future because of climate change, and like, what's the world actually going to look like in 20 years? I know a lot of young adults are very, very stressed out, but that's the reason why it's all the more important to have healthy habits to keep yourself balanced and stable. Exercise is a huge one. You know, hard to get started with exercise, but once you do it every day, you get addicted to it. Your mood's better. You sleep better. You're just less anxious.

Nutrition is really important. They tell us in like third grade, “You are what you eat.” I mean, that's sort of true. Sleep is critically important. People skimp on sleep. In medical school, you don't get any sleep, and that’s part of why you’re susceptible to addiction. I mean, your mood is so much better if you get enough sleep.

So sleep, exercise, and nutrition are really important.

And the fourth thing I’ll say is just social connection. Reach out to people, be vulnerable, be present. You know, if you're stressed, go for a walk with a friend and say, “I'm stressed.” Talk about it. Don't just keep it inside then it festers. If you get it out in the open, it's much easier to contend with and there's someone else sharing it with you. So I think those are some off the top of my head suggestions that are obviously much healthier than, like, you know, having a drink or, people smoke cannabis recreationally, and I'm not against it. They shouldn't do it if they’re under 18, but you know, if you start smoking it every day, all the time to deal with your anxiety, again, that is not a healthy way to use a drug or to manage your anxieties. So you also have to pay attention to that. People think cannabis isn’t addictive. Cannabis can be and is addictive. I treat people for cannabis addiction.

So if you start using a drug—pot, alcohol or other drugs—more and more and more, the final thing I should say is, if you're feeling really anxious or unhappy, see a therapist or see a psychiatrist. There’s whole fields of medicine open to help people struggling with these problems. And you only really get in trouble if you don't admit that you have a problem and don't get help, and help is available.

Mike: For someone listening to this—and there will be some—who say, "Something Dr. Grinspoon or something Spivey mentioned have me concerned about myself." Maybe it's the medicine drawer thing or maybe it's the, “Oh, I'm the one at 6:30 AM having a drink.” What would your leading prescription for that person be?

Dr. Grinspoon: Talk to someone you trust. Ideally, talk to your primary care doctor who you know and like. However, these days there's a huge crisis in primary care, which is a whole topic of another show, and people can't get in to see and many people don't even have primary care doctors anymore. My entire hospital system just stopped taking new primary care patients. But it'd be great if you had like a doctor that you knew, or if you had a therapist already that you had a relationship, that would be great. You could tell a trusted friend. You could tell your parents if you have a good relationship with them. Find someone you trust and talk about it. And then there is help available. There's therapy. There are addiction specialists. That's why I like starting, if you can, with your primary care doctor, because they can refer you directly to a psychiatrist or to an addiction specialist.

Help is out there. Even if you think you might have a problem, it never hurts to get help, because that can keep you from developing an actual problem. So I'm all for, like open, honest communication, for reaching out to people and for taking advantage of your community and for continually building community. So you hosts of people that love you and care about you and will help take care of you.

Mike: Yeah, the reason why either instinctively or having lived it or through research or through research or a combination of all three, you just nailed it, is, there's an interesting statistic I read that no antidote is any more efficacious than any other. Point being, AA, although its disciples laud it, has about a 10% success rate over X amount of time, blah blah blah blah, so too does medical intervention, so too does cognitive behavioral therapy, and I could name 100 more, and they're all at about the same percent of success. Here’s why. Because the underlying thing is the person with the problem has to first want to get help. And if you're talking to someone, it's vastly important to have a leader you look up to, a mentor, a parent as you mentioned, a friend who can non-judgmentally listen to your story. So your point would be it starts with verbalizing it to someone who cares about you.

Dr. Grinspoon: Yeah, absolutely. But it doesn't have to wait until you develop a full-fledged addiction. If you feel bad, talk to someone. That's how you manage your feelings. Community is everything, and it really protects you from addiction. And some of the newer drugs have a little bit higher than a 10% rate. Like the suboxone for rescue from overdosing. But you're absolutely right, no one's on suboxone until they either get in trouble, they overdose, which is scary, or they ask for help. So the asking for help is the one way to get help without risking your life.

And again, 100,000 people a year, in this country alone, are overdosing on opiates. It's like people—again, it's just concept of like "terminally unique"—people think, “It can't happen to me,” but if you're misusing drugs, you can get in a lot of trouble, and you just have to get help, because it's much less miserable, much less painful to get help on your terms than to get in trouble with law enforcement or to overdose or have something really tragic happen to you. So again, help is available, and all you have to do is ask for it.

Mike: Yeah, there’s pharmacological help. There's help through candid, open conversations. Your help came in the wrong form. It’s Martin Luther King Day today that we're talking—do you think the legal system was fair to you, and do you think if you had been underrepresented minority addict, it would have been less fair to you going through the process?

Dr. Grinspoon: Oh, absolutely. There's such a racial component to the war on drugs. Just look at the cannabis, whites and blacks use cannabis at the same rate, and over the last 50 years, we've had 20 million arrests for nonviolent cannabis possession, just for using cannabis. Four times as many blacks get arrested as whites, and they use cannabis at the same rate. And you know, I was once on a radio show, I think it was like NPR talking about my success story, and there was a caller who was really angry. He was like, “I'm Black, I would have ended up in prison if I were you.” And I just said, “I absolutely agree with you.” And it's awful, and I think the criminal justice system is just so racist. We really, really need to reform it. And the war on drugs has been a war on people with dark skin from the very, very beginning. I mean, white people can get ensnared if they do really outrageous things, like in my case, write illegal prescriptions. But absolutely—I mean, interestingly, when there was like the crack epidemic, that's when people were like, “Oh, this is moral inadequacy. That's why you're moral failing. That's why you're addicted,” because it was like partly a black epidemic. And then when heroin started affecting white people, that's when our society as a whole really started being empathic to people who were addicted. And what I said to this caller, “First of all, I agree with you that it's just awful that you would end up in prison, and me, a doctor would end up with just probation, which was difficult, but compared to prison, it was a slap in the wrist. But the fact that our society as a whole is just starting to talk about addiction more humanely when it starts predominantly affecting white people.” So the whole war on drugs and our society's whole conception of addiction treatment and recovery, there's such an ugly racist history behind all that. I could go on for hours about this. This is a really hot-button topic for me.

Mike: It's real, and I'm glad that you're talking about it, and you're spending time talking about it. It’s a good way to segue to your trip to Yale Law School, where you had a debate with a New York Times reporter. Did you drive down from Boston?

Dr. Grinspoon: Oh yeah, I drove up from Boston with my wife. I was nervous before the debate. It was a big-picture debate at Yale Law School. We had some coffee in a coffee shop where I practiced my arguments. And this guy Alex Berenson doesn't know anything about cannabis, and he wrote a book about it, and he was saying, “Cannabis makes people psychotic, which makes them violent, blah, blah, blah.” And we had a debate, and in all true humility, I destroyed him in that debate. I've never destroyed anybody that badly in debate. Whenever I talked people would clap. And you know, his arguments were so specious. It's like, cannabis can trigger psychosis, and it's not recommended for people with a family history of psychosis, but it doesn't cause schizophrenia. The rates of schizophrenia have been stable at 1% through the last 70 years, and the number of cannabis users across the world has gone from like 300,000 to 300 million. It's increased a thousandfold, and there's no way that cannabis can cause schizophrenia if the rates of schizophrenia have been rock solid at 1% in our population. But he said, "cannabis causes people to be schizophrenic and psychotic people are violent." But in reality, we treat our mentally ill people really poorly in this society. Many of them are homeless. And a lot of the psychotic people are victims of crimes, not perpetrators of crimes, and they really need our compassion and help, not to be stigmatized and blamed and derided. So I really strongly disagreed with him and was happy to do so in public, and under scrutiny, the arguments did not hold up.

Again, there are harms of cannabis. I talk a lot about this in my book, Seeing Through the Smoke, there are people that shouldn't use it. Teenagers shouldn't use it, you know, unless they’re sick and have cancer or something. Pregnant people, we don't know that it’s safe, breastfeeding. People shouldn't use it before driving, and you have to be extremely cautious, if at all, if someone has a history of bipolar or schizophrenia. But aside from that, cannabis is a lot safer than tobacco and alcohol, which are legal and not even scheduled. And an adult cannabis user, using it moderately, there's very little to any risk if they use it responsibly and modestly. So I just didn't agree with Alex Berenson at all and was happy to debate him. That was one of the most fun things I’ve ever done.

Mike: So walking into Yale Law School, which I’ve done many times, can be intimidating. You're actually being modest when you say you cleaned his clock. There are numerous news articles about people who were in that audience who did say that you won the debate. Your Wikipedia page says you won the debate, which was an amusing read before I met you and read those articles that someone could win a subjective debate. On a side note, I was once offered to debate Sam Harris at the University of Colorado. Instinctively, I knew I would lose that debate. He tends to be a very dispassionate debater, and I tend to get pretty passionate; someone who's dispassionate is always going to come across as sort of a bit more clear-headed winner. In one of the rare moves of strategic success in my life, I opted out of debating Sam Harris. I didn't have to have your Yale Law School experience, but you came out on top.

This whole arena of the stress we put upon people in today's society, we mentioned Gabor Maté, I love the way he worded it. If you were to take, in the lab, and build a society the most prone to addiction, anxiety, depression, suicidal tendencies and thoughts, you name it. This is the exact society you would build, with social media in availability and potency. So this is such an important topic, and I don't think people understand that the high-performer is under—you mentioned it in your book, at the very end of the book. You thought to yourself, “Hey, I'm at Harvard and people are lined up to see me, so I don't have a problem.”

Dr. Grinspoon: It makes it easy to rationalize. As they say, denial is not just a river in Egypt. It's so easy to fool yourself.

Mike: So what would you say to the final sort of closing—not argument, but words of wisdom to someone... it's recreational now that they're in college. They're experimenting with a few things. But things change in law school. I've been at three law schools; I've seen it. The partying gets out of hand, and it becomes chronic and a lot of it is stress-induced. What's your parting message? I mean, what would you have said to yourself before the police showed up at your door?

Dr. Grinspoon: I think with drugs, they should be legal, and we're allowed to experiment with our consciousness. And that in a perfect world, we'd all meditate and do yoga and exercise and no one would need anything at the end of the day. But in reality, most people need a drink or a puff at the end of a really, really hard day. And the question is, what is your relationship to the drug? Is it helping your life or is it making it worse? And again, are you experiencing any behaviors different from your friends? Do you feel like you need to use more and more and more? Do you find the drug or alcohol supplementing other activities or connections? And the most important thing is two things.

One is to be really honest with yourself, because it's really easy to trick yourself. And if you're starting to develop an addiction, that could contribute to fooling and tricking yourself. So you've got to be really honest about what you're doing and whether the substance use is getting out of control and whether it's actually helping your life or making it worse.

And number two, it's all about connection with other people. Ask someone's opinion, say, “Hey, I drink three drinks, five nights a week. Do you think that's too many? Do you think that's destructive?” Ask your doctor, ask your close friends, if you're close to your family ask your family, and just be open to asking for help. Because again, help is available. And if you can address early addiction, it's infinitely better and less painful than waiting until you get into trouble, until it's out of control, and you lose something really important to you like your job, your medical license, your family. If you get help on your own terms, it's going to be much more humane, much more empathic, and much less painful. So openness, honesty, and open communication with those around you.

Mike: And I'll end with sort of an analogy. If you were at Harvard Law School, and part of the equation to get you there was someone would come with a crowbar and smash your knee once a day, the first thing you would do is go to the hospital every day. For some people, the stress of trying to be at the top of the mountain is so great that they're causing someone to smash their mind every day with a substance that they're not getting themselves out that stress. So please, for people listening, I would love for you to be at Harvard Law School or Harvard Medical School, pick your poison. It's great to enjoy the view at the top of the mountain, but not if getting up to the top of that mountain causes so much harm that the view isn't even enjoyable anymore, which was your pathway. Congratulations on the recovery, the book, all the great you're doing. Thank you so much for your time, for being here, Dr. Grinspoon.

Dr. Grinspoon: Oh, it's my pleasure, and just—if any of the listeners want to get in contact with me, my website has a contact me button, and I answer emails right away. I really love talking to especially college students. So my website is just www.petergrinspoon.com. Grinspoon is "grin like smile, spoon like fork." So it's www.petergrinspoon.com, and feel free to ask me questions, you know confidential questions—I can't treat people, but I can answer confidential questions, and I'm happy to help.

Mike: Love it. Thank you. We'll link it in our show notes too, so people can ask you questions.

Dr. Grinspoon: Okay, well thank you for this great conversation.

Mike: Thanks again.