EP. 136: HARD TRUTHS ABOUT ADDICTION

Nov 6

WITH KEITH HUMPHREYS, PHD

A psychologist and pioneer in addiction medicine discusses how addiction transforms the mind and the redemptive power of social connection in helping patients recover.

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Episode Summary

Addiction is often misunderstood not just by the public, but also by clinicians. It challenges us as individuals, families, and communities. To understand addiction is to understand not only human behavior and neuroscience, but also social networks, public policies, and bioethics. Our guest on this episode, Keith Humphreys, PhD, is a psychologist who specializes in addiction and has served on the White House Commission on Drug Free Communities during the Bush administration, and as Senior Policy Advisor to the White House Office of National Drug Control Policy during the Obama administration. His research on recovery support systems like Alcoholics Anonymous and on the opioid crisis has shaped how we understand addiction recovery.

Over the course of our conversation, Dr. Humphreys shares how he became interested in addiction medicine, what happens to our brains when we become addicted, the difficulty of balancing interventions with a respect for patient autonomy, why social networks can be powerful tools in addiction recovery, possible solutions to the opioid crisis, and how clinicians can better establish trust with patients facing addiction.

Keith Humphreys, PhD is the Esther Ting Memorial Professor in the Department of Psychiatry and Behavioral Sciences at Stanford University. His research addresses addictive disorders and the translation of science into public policy. In addition to over 400 scientific publications, he has written extensively for outlets like The Washington Post and The Atlantic.
Dr. Humphreys’ public policy work includes testimonies to U.S. House and Senate Committees, to the Canadian and U.K. parliaments, and in many state legislatures. He served on the White House Commission on Drug-Free Communities during the Bush Administration and as Senior Policy Advisor in the White House Office of National Drug Control Policy under President Obama. He created and co-directs the Stanford Network on Addiction Policy, which brings scientists and policy makers together to improve public policies regarding addictive substances. To recognize his service to addiction-related scholarship and policy, Queen Elizabeth II made him an Honorary Officer in the Order of the British Empire in 2022.
In this episode, you will hear about:
• 2:36 - How Dr. Humphreys became interested in studying the psychology of addiction
• 4:34 - The neuroscience of addiction
• 9:15 - Whether addictive behavior is a matter of personal choice
• 16:27 - How clinicians can address patients who do not yet recognize their addiction as a problem
• 21:36 - What GLP-1 inhibitors can tell us about the mechanisms of addiction
• 26:07 - The benefits of peer support groups (like Alcoholics Anonymous) for addiction recovery
• 32:55 - Dr. Humphreys' work on drug policy
• 37:32 - The rise of the opioid crisis
• 43:05 - Policy models to address substance abuse
• 48:24 - How medical professionals who are struggling with addiction can seek help
• 51:25 - Dr. Humphreys' advice for clinicians on how to connect with patients who are struggling with addiction
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson : [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson : [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:02] Addiction is often misunderstood not just by the public, but also by clinicians. It challenges us as individuals, families, and communities. It tests the limits of our health care systems and our approaches to treatment and recovery. To understand addiction is to understand not only human behavior and neuroscience, but also social networks, public policies, and bioethics. Our guest on this episode, Doctor Keith Humphreys, is a pioneer in thinking about these issues. A psychologist who specializes in addiction, he has served on the white House Commission on Drug Free Communities during the Bush administration, and as senior policy advisor to the white House Office of National Drug Control Policy during the Obama administration. His research on recovery support systems like Alcoholics Anonymous and on the opioid crisis has shaped how we understand addiction recovery over the course of our conversation. Dr. Humphreys shares how he became interested in addiction medicine. What happens to our brains when we become addicted? The difficulty of balancing interventions with a respect for patient autonomy, i.e., what we can do to help a patient who appears to not want to be helped. Why social networks can be powerful tools in addiction recovery, possible solutions to the opioid crisis, and how clinicians can better establish trust with patients facing addiction.
Henry Bair: [00:02:30] Keith, welcome to the show and thanks for being here.
Keith Humphreys: [00:02:33] Thanks so much. Really glad to be here.
Henry Bair: [00:02:36] To start us off, I'm wondering if you can take us all the way back to the start and tell us what led you to dedicate your career to this psychology of addiction.
Keith Humphreys: [00:02:47] So as context is probably helpful to know, I'm from West Virginia and I had intellectual interests, but I think the culture there is to think about jobs that are pragmatic in some way, that interface in the world, you know. So, for example, my family and a lot of generations had done things like coal mining and been in the military and worked in steelworks and things like that. So I was never probably going to become a theorist, but I was interested in ideas, and I had an inspirational high school teacher who gave me some psychology books I really liked. And I thought, psychologist seems good because it's got that intellectual stuff. But then there's this practical thing, and I'm supposed to be practical because I'm a West Virginian, so I'll be a psychologist then, just through happenstance, really. I was an undergraduate, and I was looking for a research job that paid better than flipping burgers, which was what I was doing. And I got a job in the medical school focused on addiction, and I would have taken it if it focused on depression or schizophrenia or anything. I just thought this was first great not to have to wear that Wendy's uniform.
Keith Humphreys: [00:03:44] And second, you know, I was just excited to work on science, but it turned out to be an addiction project, and I immediately found it very compelling, both as people. In other words, talking to people as I did in this project, I would meet them when they entered treatment and do an assessment of them. I was sort of moved by their stories, their aspirations, their hopes, and found it just sort of a fascinating thing that human beings do, in fact, get addicted. You know, so it's it is partly a thing your heart feels like, oh, God, how sad. But also, you know, as just an intellectual thing, like, why do we do this? I mean, why why is it that we, we will literally throw away our health for, you know, powders that have no nutritive value? That is sort of a fascinating thing. And those two things have kept me in it for now, 35 years. The fact that it pulls on my heart, I feel for people. And then intellectually, it's just fascinating that this even occurs at all to Homo sapiens.
Tyler Johnson : [00:04:34] So, you know, I remember when I did medical school at the University of Pennsylvania and we had a one like two and a half month block during the preclinical years of medical school called Brain and Behavior, which was, for us, everything from neuroanatomy through neurology and then into psychiatry and to whatever degree we talked about psychology, also psychology. And I remember talking in that block, we had some lectures on addiction and then talked a little bit about addiction medicine. But I remember during that time when you really got right down to it, like, I feel like addiction is one of those things that everybody assumes that everybody knows what it means and that everybody shares the same definition. But then when you got down to brass tacks and tried to say, what is addiction? Right. And you see this come up also in, you know, sort of lay media discussions about, are people really addicted to video games or are they really addicted to pornography or are they really addicted to, you know, whatever the thing du jour is. So I guess it would be a good idea to just have you start by talking about what is addiction, how do you define addiction? And as a psychologist, how do you know, for instance, if a patient that you're working with is addicted to something or not?
Keith Humphreys: [00:05:46] You're absolutely right. The word is now sort of in the popular culture and people use it for, you know, I'm addicted to this TV show or I'm addicted to jogging or something like that, but it does have a more precise meaning. So if you're looking at it as a neuroscientist would, and you know where they would be looking at addiction in animals, the phenomenon you would see is an animal repeatedly engaging in behavior despite destructive consequences in order to obtain some addictive substances. So an example would be, you know, experiments where a rat will run across the floor of an electrified cage to get cocaine that they're addicted to, or will consume a drug like, say, you know, a stimulant in preference to water. Even when they're so thirsty they could die. That's what it is in animals. That repeated behavior despite destructive consequences. Now, humans, of course, are different that we're animals, but we can do something animals can't do, which is we can talk about our interior states and describe what's going on in our head. So when you diagnose it with people, there's usually more than that. So you ask things like how much of your time do you spend either planning to get the substance, using the substance, and recovering from the substance? Do you have a subjective experience of losing control where you, you know, you have an intention of, I'm going to go into this bar and I'm just going to have one beer, and then four hours later you walk out after 15 beers.
Keith Humphreys: [00:07:05] Do you find yourself craving the substance? You know, really desiring it powerfully in a sense that it's hard to control those kinds of things, is what with a human patient, for example, you would say that. And then the harm is what makes addiction. And that is also why the harm is, by the way, when people say, I'm a I'm addicted to the TV show succession, we would say, well, that's not really addicted because you're not experiencing great harm. You know, if it turned out that, you know, every time you watch succession, you had shooting pains in your arms and legs, you would stop doing it. But, you know, you just mean you like it a lot. But the addiction isn't really about liking it a lot. It's continuing to want it even when it's a destructive. And in fact, by the way, even past the point when people really feel much subjective liking, but they do feel really intense wanting of something they don't even like anymore.
Tyler Johnson : [00:07:54] So just to be clear, though, just because I think this does get brought up a lot in lay media discussions, it could be appropriate if you have a person who, for example, has an like a whatever sort of online life, that's the one that comes up a lot, right? Whether it's looking at pornography or whether it's social media use or, or it could be Netflix, whatever, if they're consuming that in to such a degree that it is interfering with their actual relationships with their loved ones or their ability to perform at work or in school or whatever, and yet they keep doing it repeatedly anyway. It could be appropriate to describe something like that as an addiction, even though there may be other cases where we use addiction in those contexts in a way that does that is sort of colloquial, but doesn't really stand up to clinical muster. Is that fair to say?
Keith Humphreys: [00:08:40] Yeah. That's right, that's right. So it doesn't necessarily have to involve the consumption of a drug, which is sort of the classical type of addictions. A good one. Actually, a lot of people will be aware of is gambling. So there's people who literally the second they get their paycheck, go down to a, you know, electronic slot machines and play for 18 hours until they literally pass out and they lose all their check and they don't have enough money for groceries, and there's no drug. But that is like classically an addictive behavior, doing great harm person feeling they can't keep control, feeling cravings and it consuming also a huge amount of their time and energy.
Henry Bair: [00:09:15] There are many pockets of society that I think conceive of addiction as a matter of personal choice. Based on your understanding what you've observed in clinical practice, based on your understanding of the research, how much of addictive behavior is a matter of choice.
Keith Humphreys: [00:09:32] At the beginning, it's entirely a matter of choice. I mean, no one is compelled to, you know, go out for the first time and drink a vodka or, you know, or snort some methamphetamine or that sort of thing. But over time, the ability to exercise self-control gets weaker. And there are reasons for that. You know, we can document in the brain in terms of the frontal areas where you normally exert executive control over impulses, you know, becomes less active. Also, you have adaptations in another part of your brain called the extended amygdala, that may produce more dysphoria as sort of a standing state in your mood, such that drugs become more appealing, which gives you more drive. Now, can you still stop? Well, yeah, in a practical sense, because there's something like 23 million Americans in recovery. So it's not as if if you're addicted, you're going to be addicted for the rest of your life. But it gets harder and harder and harder to exercise that healthy choice. So many people like to make this simple and say, people have just chosen this, ergo they deserve no sympathy or they have zero control ever. In which case we can't expect anything of them ever. And the truth is, it's going to be in between those things, depending on how far along the person is in their addiction and you know, in other aspects about their life, you know, that might help restrain them if they're not able to restrain themselves.
Tyler Johnson : [00:10:57] So it does seem to be a sort of a fascinating paradox, right? I think probably all of us have had the experience, maybe we ourselves, or have at least had the experience of knowing someone who at least to one degree or another, is addicted to something. And you alluded to this earlier, but what's really interesting about it is that in many, if not most cases, in fact, as doctors, one of the ways that we screen for people who are addicted to alcohol is effectively that they have a consciousness that this is a bad thing. And in fact, in many cases, they're even conscious of wanting to stop whatever the thing is. And yet they keep going back to it and keep going back to it and keep going back to it. Right? So it's like their inner state is divided against itself, with a part of it wanting to stop sometimes. Wanting desperately to stop. Right. In some severe cases, they can sort of see their life slipping away, and yet they can't. I remember very vividly when I was an intern in internal medicine, rotating at one of the local hospitals here, seeing this guy who was only in his 20s, who was addicted to methamphetamine. And if you have ever seen, if you're a doctor in training or what have you, if you've ever seen an echocardiogram, normally an echocardiogram, you know, you see sort of the the fist of the heart and it just, you know, it looks like in a 20 year old, most of the time it looks like it's pumping like a machine.
Tyler Johnson : [00:12:16] Right? It's incredibly strong, incredibly efficient. You can see it's pumping about 70% of the blood volume in the left ventricle out every time it pumps. And this person who we saw who was addicted to methamphetamines when we looked at the echocardiogram of his heart, I remember it so distinctly because it looked like a Ziploc bag that had been filled with water, both in the sense that it was sort of ballooned. Out, and in the sense that when it tried to, you know, what normally would be this efficient muscular contraction just looked like this kind of vague fibrillation that hardly moved any blood because the part had been so weakened by these methamphetamines. And yet he continued being admitted, and he knew that this was happening, at least to some degree. But and yet he kept being admitted to the hospital with, with side effects of, of acute ingestion of methamphetamine. So all of that is to say, as a psychologist who specializes in addiction, what is going on that they keep coming back to this thing that they know they should stop and often want to stop, and yet they keep coming back for more.
Keith Humphreys: [00:13:20] Addiction is an extreme case of something I think almost every human being experiences at some time or another, which is having intentions to do good things and then not being able for some reason, to do them. I mean, just take something obvious, like over half of people in the United States are now overweight. Dieting is incredibly common. It's a, you know, bazillion dollar industry. Diet books. 98% of the weight that is lost through diets are regained. And so it's very common to have experience of like, I really I don't want to eat that. Ho ho, I should go for a walk and say, well, I'll just have a little bit of the ho ho, and I don't. I've eaten a pack of ho-hos. I don't really feel like going for a walk. That is an extremely human experience, and it has to do with like it is very effortful. It requires, you know, mastery, concentration, sometimes also, life defeats our abilities to behavior change. Life can be incredibly chaotic. When we're under great stress, it's harder to exert self-control. So then take all those common human experiences and then ramp them up to, you know, this goes to 11 and then you have addiction where cases like you described where this is not just whether you're going to be 2 or 3 pounds heavier or not, you're literally going to destroy an organ that you need to survive, or you're going to take an opioid that will stop you from breathing to the point that you will get lifelong brain damage and people still do it.
Keith Humphreys: [00:14:36] And that is due to the impairments that the repeated administration of these substances do to our brains. They are working on existing evolved systems of neurotransmitters that are normally very helpful to us, to teach us things like, you know, that was a good thing to do. You should do that again. Remember this experience. It's going to be helpful. This would have helped us through our evolution for things like how do I know where to find food? How do I know you know where to go to get warm when it's cold? How do I find a mate? All those kinds of things you need to do. But now imagine that same incredible apparatus is being triggered by alcohol, by cocaine, by methamphetamine, by heroin. And it's telling your brain, this is super important stuff. This is survival, important stuff. You really want to keep doing this again and again. And it's giving you the spike of the neurotransmitter dopamine that far exceeds these natural rewards.
Keith Humphreys: [00:15:32] And so it's sort of fooling you into thinking I really should keep doing this. And the other impairment people have is that it impairs their ability to update what happens when they do something. So normally if you touch a stove when it's hot, you go, oh, wow, that hurt. And you never do it again. You just get this thing like your brain. Just remember, every time you touch a stove, it's hot. But that function doesn't work as well in addiction. So the person thinks, well, you know, this time it's actually it's going to be good. It's going to be good. This time I think I'm going to touch the stove. Oh it wasn't you think now they've got it. And yet then they look. Next time they look at a hot stove, I think this time it's going to be really good. And that's, that's an impairment. I mean that's a neurological impairment that the drugs are able to produce. And that's how people get stuck in this what looks like, you know, you know, the sort of common definition of insanity, doing something over and over again and expecting a different result.
Henry Bair: [00:16:27] So I promise we'll we'll get to the whole policy component of your career. But but the last question that Tyler asked, and your response made me think of an experience that leads me to want to ask a more ethical, philosophical question here. I also remember taking care of a lot of patients with addiction. During my first year of residency. I worked in an urban hospital in the middle of Philadelphia. So you're going to get a lot of those patients coming in through your emergency room. And to Tyler's point and to your point, one of the definitions of addiction, how we recognize addiction is that the patient is aware this is a bad thing, but they are unable to do anything to change their behavior. And so we help them. But there have been multiple times, I remember when a patient comes in and maybe they come in for a complication of excessive alcohol use, or they come in with an unrelated issue. And then during our conversation it comes up that they have they use a lot of alcohol, but they when you ask them about their use, they don't recognize that it's a bad thing or they don't recognize how it's negatively affecting their lives. And I remember I would go talk to my attending and bring this up, and this is what we would call in medical parlance.
Henry Bair: [00:17:48] This is like they're in the precontemplation stage, right? Where it's like they don't even realize that this is something that needs to be addressed. And the attendings oftentimes would tell us to drop it because it's they're not ready. This is not your job. And I remember at one point I would I asked my attending, but we can see the adverse effects. You know, I can see for one of my patients, the excessive alcohol use was alienating this person from his family, from his friends. He had no more social support, and yet he didn't mind it. Honestly, based on how he was describing his situation. And my attendees response was partly, you know, she had prefaced it by saying, you know, I agree with you. But this as an exercise, let me ask you, who are you to say that this is a bad thing? If he doesn't think it's a bad thing for him, who are you to step in and say no, this is actually a bad thing that we should and we should try to address it for you on your behalf. I didn't have a great answer for that. That felt applicable on a moral level universally. How would you respond to that?
Keith Humphreys: [00:18:50] So I'll be concrete. I volunteer up in the tenderloin, and when I go up there, I carry naloxone, a fast acting opioid antagonist. And that's because if I see somebody who's dying of an overdose, I want to be able to spray it up their nose in hopes of saving them. I do that without their consent. Is that okay? Who am I to do that? Maybe they want to die, but I've never heard anyone ask that. Who raises the question you just asked? They say, well, of course you should do that. I say, why? Well, because they're not in a fit state to save themselves. So you save them and you're sort of the ally of the rational person they would like to be, but are not at this moment. Their condition is stopping them from being able to do that. And I think almost everyone will concede that point. There are times like that, and then it becomes a question of, well, we're just really arguing about the price at that point. Like where do you draw that line? Let's say the person is conscious, but they're high in methamphetamine and standing in a busy intersection on a cold day with very few clothes, screaming and yelling. Is it okay then? Because they're not, you know, they could die at any moment, but they're not overdosing and, you know it. Would it be okay for a police officer to pull them out of the intersection, even though that's where they say, I really like being in this intersection. I don't want to leave this intersection. So, yeah, it is, you know, because, you know, you're impaired.
Keith Humphreys: [00:20:11] And so there are other conditions like this, you know, schizophrenia, Alzheimer's disease, where we accept that the person is not in the state to make decisions on their own best interest, and so we try to make them for them in the hopes that if they get to a better state, they would see. They'll say in retrospect, thank you. Now, it is absolutely true that at a social level, when you do that, there's always a chance that you violate somebody's rights because you are simply guessing what they want. Also, just the realities of life are you could walk out there in that intersection. The person could, you know, start a fight with you or run from you and get hit by a car. Things like bad things can happen when you don't have people's consent. But I think the general principle in medicine is established that we do things to save people when they are not in a state to do that for themselves. And I've definitely seen this with addiction over and over again. Most people who come in for addiction treatment are being leaned on by somebody mom, dad, brother, sister, boss, legal system, doctors, whatever. And they may be really resentful of those people, but very commonly when they're in recovery, 6 or 12 months later, they're going back to kiss the feet of those people saying, thank you for making me do that, because I didn't. I just couldn't see how important it was. And now I do see. So that's very common.
Tyler Johnson : [00:21:36] I did want to ask one other question, which I think has become really interesting recently, more about the sort of the causes and the, I don't know, neural circuits or pathophysiology of addiction, which is that there have, you know, there's been a host of fascinating articles in the last, I don't know, year, let's say, in various different places about the effects of ozempic and drugs like ozempic on the brain. Right. And I remember reading one in particular in the Atlantic. So for sorry, for those who may not be aware, ozempic is a drug that was initially or a drug just like it. It's a little confusing the names, but anyway, it was initially used for diabetes. Then it was noted that people who took it for diabetes tended to lose a lot of weight, which was also good for their diabetes. So then folks in pharma thought, well, what if we just used it for weight loss? So then they trialed that in weight loss. And then another medicine that is like ozempic but even more powerful called Mounjaro. And they work on this receptor called GLP one. And so what I have read over and over again, and in particular, there was this one article in The Atlantic where this person who had, I gather, been a person who was relatively heavy and who really ate a lot, had started taking one of the medicines, I think it was ozempic, but I don't remember. And basically they said that within 24 to 48 hours of the first, you have to titrate the dose up a little bit, but within 24 to 48 hours of taking the first sort of full dose, they said that it was astonishing because only in retrospect did they recognize that they had been sort of subjected for, in effect, their entire life to this just unceasing chorus of voices saying, you need to eat, you need to eat, you need to eat, you need to eat.
Tyler Johnson : [00:23:18] And then they took the medication and the chorus went completely quiet, but that they didn't even realize that there was quiet to be had, because they had become so accustomed to this chorus of voices that they didn't even know it was there anymore. They just thought that's how everybody's, you know, interior, whatever life was until the chorus was gone. And it has been, although I know that this remains controversial and the, you know, the data is as yet uncertain, but there are a lot of people who are now wondering if drugs like Ozempic might help with things like alcohol addiction and other forms of addiction for precisely related reasons. Right? You can imagine that if you have a chorus of voices telling you whatever to drink alcohol or use a methamphetamine or what have you, that maybe it could be helpful in a similar way. So I guess I'm just curious, given how much these are in the news right now and how commonly they are being prescribed, what does that sort of experience of that person and similar experiences tell you about the neural circuitry of addiction and both what's going on with it and what might be effective in terms of addressing it.
Keith Humphreys: [00:24:19] Yeah, I think this is the fifth conversation I've had about this topic in the last week. It's definitely on people's minds. I'm deputy editor in chief of a journal called addiction. We actually invited an editorial from Nora Volkow, who's the head of Nida, about this, and she is quite bullish on Glps. And she points out correctly, you know, there hasn't been like a direct study, but there are a number of studies where people are taking it for weight or diabetes, and then they're reporting smoking. Desire is dropping. Alcohol desire is dropping. So that's pretty fascinating. And, you know, I hope that the companies that make this will pursue tests of this directly on addiction. It's not clear that they will because big Pharma often shies away from studying addiction. Other than you know, smoking is okay, but they definitely, you know, sort of worry more about unfortunately, I wish they would test it, know it could work the same way. And that chorus of voices is something people in addiction are very familiar with. You have both kind of like what's going on in the brain is sort of if I'm going to switch metaphors here, but it's like a car where the gas pedal sticks to the floor and also the brakes aren't so good. So if you can fix either one of those things, you're in much better shape. If I don't feel that thing of you need to score heroin and use heroin. You score heroin, or I restore that ability to resist urges because we all have urges that we normally resist, then we're much better off. It is an interesting experience when you talk to, say, say, someone who's been addicted to heroin and taking it and scoring and chasing heroin for years and years and years. And they say they get on methadone, which is an opioid agonist therapy, and they don't really know what to do with their day because they've been a professional, heroin addicted person now for 20 years. It's structured every single moment. It's like, oh, now I don't have to chase opioids. What would a normal people do when those voices are finally quiet?
Tyler Johnson : [00:26:07] So can you talk to us a little bit about maybe the at least one of the things that you are known the most. For long before GLP-1 drugs, we had groups like Alcoholics Anonymous. Right. And I think that as doctors, this is one of those things where it's kind of like that's one of the like black boxes of medicine, right? Like, you know that there is a thing called that and you know that maybe sometimes your patients go to it or you might even refer patients to it, but what it really is or how it really works, let alone why it really works, is sort of nebulous, right? So could you maybe walk us through, for those who maybe have heard of it but are not familiar, what are the principles that unified the groups like this that can be helpful and just how helpful are they? And why do you think that they work?
Keith Humphreys: [00:26:50] So we have to go back in time, about a century where if you were what was then called alcoholic on a term we use so much anymore, but, you know, hospitals would throw you out. Nobody wanted to treat you. There was really no sense that you could be helped. And in desperation, people with that problem turned to each other and they found that, you know, a couple remarkable people early on, Bill Wilson and Bob Doctor Robert Smith for the first two that in talking to each other about their struggles, they experienced a healing effect, you know, a sense of being free of the desire to drink, a feeling of being understood, a feeling of not being ashamed. And that was really powerful, that peer help. Now, since that time, of course, there are zillions of studies showing that this is true across diseases, that sometimes talking to people who have the same condition, it can be a super powerful experience, even more powerful than talking to the most gifted health professional in the world. From this insight, they started to form the group that became Alcoholics Anonymous, and it spread like wildfire. And they had two members in 1934 and they had 50,000 by 1950. And now they have several million. What does it do? Well, first off, you say it's free. You don't need insurance. You can just show up. You don't need an appointment. It's all peer run. There are no professionals involved. And they, you know, share their experience and strength and hope.
Keith Humphreys: [00:28:09] They've been around so long. There are quite a few people who have been sober ten, 20, 30, 40, 50 years who give advice to individual members that they sponsor. The meetings are also a great moment of social connection. It's a spiritually focused program. There's a lot of focus on spiritual growth. It's about not drinking, but it's about much more than that. It's about attaining a sort of a full, serene lifestyle and repairing relationships, atoning for things you've done wrong and all that kind of stuff. And it has inspired many other such groups, you know, for all kinds of different problems. So I first heard about these when I was starting on this first job, and I didn't really know anything about addiction. And I was in the medical school, and I had a very derisive view of them, honestly. And I think I just picked that up from my mentors and colleagues that they weren't trained, you know, they didn't have any medical technology, there was no devices, there was no medication. They were outside the health care system. You know, they weren't licensed. They were foreign. So it had to be it had to be pretty flaky and folky. But I was fortunate in that several people on the project were in these programs and spent some time talking to me, and it sounded a lot more sensible when they talked about it. And a couple of them took me to what's called an open meeting where you're allowed to visit if you're not a member.
Keith Humphreys: [00:29:17] And I was very moved by the caring and the wisdom in those rooms to the point that when I did my master's thesis, I thought, I'll study this, because we had gathered all this data on these groups in this big study we were doing of assessing treatment. And there were really impressive outcomes that people who were involved in these groups were far more likely not to be using drugs and alcohol, far more likely to be back with their families. Their marriages were happier, they're more likely to be employed, and this sort of thing. At that time, that data was sort of correlational and cross-sectional since then, partly due to a lot of investment from federal agencies like the National Institute on Alcohol Abuse and Alcoholism and the VA, the Veterans affairs system of which I'm a part, there's more and more rigorous studies, including a lot of randomized trials, which have shown, in fact, that AA is quite effective. You know, on average, you know, if you go to AA, the odds that you will be abstinent a year later are dramatically higher than if you don't go. And it actually stacks up pretty well, even with good psychotherapies like I was trained to deliver, like a behavioral therapy, relapse prevention and so on. And we did. Maybe this is my atonement for my initial snotty a take on AA. But, you know, many years later a colleague and I did what's called a Cochrane collaboration, which is a very rigorous review.
Keith Humphreys: [00:30:36] And we pulled together data from like 35 different studies done all over the world. More than 10,000 participants integrated all that, and it was really impressive how consistently AA came out, including in rigorous, you know, trials and quasi experiments and, you know, studies done by different people with different viewpoints, different parts of the country, men, women, different populations came out really well. So they does, in fact help a great many people, and I always feel comfortable suggesting that as a first try, because it's free, you can just go, you know, it's not like surgery. You're not going to if you go to a bad AA meeting. It's not like anything bad's going to happen to you. It's okay. You've seen a bad movie. You're out 15 bucks in an evening, you go to bed. Aa meeting, you're only out for the evening. But to go ahead and try it, we're including to people who are in treatment. Sometimes it's a nice supplement and those kind of things add some. I think we're very lucky. Those of us who treat this, that those kinds of organizations exist. And by the way, there are many options, not just AA, there's women for sobriety. There's there's lifering recovery, lots and lots of variety because it can do a lot of things that it's actually pretty hard to do in medical care.
Keith Humphreys: [00:31:41] Basically, you can stick around with somebody on their journey through life right up to the end decades if you want to, which is pretty much impossible. With health care, you can get friendship. And we obviously we care about our patients, but that's different that we can't become their lifelong friend. But that certainly happens there And a lot of people in our country. Every indicator shows are lonely and don't have any friends, and that is hard. It just feels sad. But also it is bad for our health. So it gives all those things that it's pretty hard to get out of the health care system and a lot of practical, a lot of practical wisdom and support. So I have gone from being totally dismissive of them to now based on the evidence, you know, realizing this is actually a great that we have it. All that said, does it work for everybody? Absolutely not. Nothing works for everybody. I mean, obviously nothing works for everybody in lots of conditions, but certainly with addiction, nothing works for everybody. So if somebody goes and they give it a really good try and it doesn't, you know, it doesn't really work. No shame in that. You know, thankfully there are other other, other options available. And those should be offered to people. And no one should be made to feel bad if they went and it wasn't helpful for them. Maybe that just wasn't their their thing, not what they needed.
Henry Bair: [00:32:55] Well, thank you very much for that beautiful explanation of those kinds of options for people who are dealing with addiction. Speaking of your personal journey, let's turn our attention towards the policy piece of it. Is there something, a moment, an experience, a story you can point to in your life that moved you towards that direction?
Keith Humphreys: [00:33:14] Yeah, very vivid one. So I worked. I finished my undergraduate degree in psychology at Michigan State. Then I worked in the medical school for a year, and I decided I was trying to decide psychiatrist, psychologist. I decided I was going to be a clinical psychologist. I applied to graduate school and I got in and I thought, I'm going to be a therapist. And it was Memorial Day of that last summer. I was playing basketball with my friends, and I suffered a terrible fall in a spiral fracture of my femur and was taken to the hospital and had to have multiple surgeries. And I spent basically the whole summer learning how to walk again and being in a lot of pain. So that was very bad. But the other thing that did give me a lot of time to read because I couldn't do much else. So I did an awful lot of reading. And I read a book by a guy named Seymour Sarason, who was a professor at Yale. I had never met, and he was talking about what psychology is for. And he said there's no defense needed of the individual clinical endeavor. It's noble and it's caring and it's good. But if you really want to affect a lot of people, you need to change policies. And he argued all this out, like the difference between, you know, helping women who've been battered by their husbands one at a time versus changing the laws in society so that women don't get battered in the first place, and they have more equality and they have more safety, those kinds of things.
Keith Humphreys: [00:34:32] And it just really kind of broke my clinicians heart. Not that I didn't want to get clinical trained, I did, but I just realized, boy, you know, there's just another level to this game. And I would like to go back to this pragmatic orientation. I would like to affect a lot of people. So I need to learn about this kind of stuff. So between the time my program accepted me and when I got there, I was much more fired up to do, you know, in this area was called community psychology, but that sort of stuff. And I was already and, you know, within like a year in this town, I was in Champaign-Urbana. I was working with the mayor on trying to improve the quality of public housing projects for the mental health of the people there and working to create, you know, programs for families that would prevent them from having trouble, that kind of thing. So that's how I got to that sort of level of thinking, you know, beyond the clinical. And then I came out here in 1993, and I was fortunate in that my appointment, you know, I have a VA, I've had a VA appointment now for like 30 odd years, but I was in a program evaluation center that had a national scope that was responsible for the entire VA's substance use care system, not just the one here in Palo Alto.
Keith Humphreys: [00:35:40] And so that connected me to Washington. And I started to do things for, you know, like the undersecretary has to present to Congress about how many veterans are addicted to cocaine and what are we supposed to do about it. And so my team and I would be putting those together. And that was that was connecting me more to that policy world. And I got and that gave two things. One, I got a taste for sort of federal politics, but also I got known a bit as someone who knew something, and that eventually translated more that I was asked to do some work on some first off, the mental health restoration of Iraq, which is the federal government, HHS, Health and Human Services worked on. I was known, I said, why don't we bring Keith to do addiction stuff? So I did that. That sort of made more people know me in Washington. And then when President Obama was elected, his vice president, now President Joe Biden called a friend of mine, Tom McCullagh, they were friends and said, why don't you come work for us? As the as a drug policy lead, Tom felt this anxiety like, I'm just a college professor.
Keith Humphreys: [00:36:42] I don't understand policy. But he remembered my friend Keith understands policy. So he called me and he said, I thought it was a very nice thing to say. He said, you know, I, I know I should do this, but I'm frankly frightened, so I'm only going to do it if you say you're going to go with me and said, okay, I'll go with you. So I took a year off from Stanford, and then I went and worked in the white House, what's called the white House Office of National Drug Control Policy. When the ACA was being developed and all that kind of stuff at a very fertile time with a president who had a big mandate, and there was a lot of opportunities to do stuff in health that sort of catapulted me into this really being like my main thing. Like, once I came back, I thought, I can never I'm going to still do science, but I'm never going to be out of policy because it's too important and too interesting. I've seen what can be accomplished. And so since that time, I've been doing policy stuff almost every day. I would say since I worked, worked in the white House.
Tyler Johnson : [00:37:32] So let me ask you, as a person who does have a background in both the scientific and the policy worlds, one of the questions that I think is really interesting in terms of addiction over the last 20 or so years, but it's become a well-recognized recognized fact that comes up in political campaigns and that everybody is talking about all the time to talk about the opioid epidemic, right? That's a very commonly used phrase. But the thing that's so interesting to me about that is, I mean, first of all, as you said, we should recognize that this is a heartbreaking and life ending thing, right? This is not theoretical. It's not abstract for the people whose lives are affected by this. It takes lives in a way that is every bit as real as a car crash, or a heart attack, or a stroke or cancer or what have you. So I want to, you know, be clear about that. At the same time, what is so interesting to me is that normally when we use the term epidemic as doctors, right, we're actually talking about an infectious disease, right? Like the pandemic that we had with Covid and with Covid, or even with the flu, with Covid, because it was new, a new strain of the virus and with the flu, with actual influenza because it mutates.
Tyler Johnson : [00:38:45] And so you have new strains available in those cases, the reason that an epidemic becomes an epidemic almost always is because you actually have a new infectious organism that the sort of collective human immune system is not primed against. And so then it causes these ravaging effects that normally it wouldn't be able to because we have no collective immunity. But when you talk about something like the opioid epidemic, I mean, opiates have been around since time immemorial, right? Humans, at least to some degree, have had the ability to procure them if they really wanted to. And of course, there have been people addicted to opiates since time immemorial. Right. And so it seems that it should maybe be a little bit more provocative than it sometimes is to us to say that there is this time limited thing called the opioid epidemic. And so what do you think that that means that we have an opioid epidemic. And what do you think gave rise to this over the last couple of decades in a way that is in some ways different and in other ways at least more prominently recognized than ever before. Even though the drug per se has been around since forever.
Keith Humphreys: [00:39:54] Drug addiction does spread in a way from person to person is that people with problems sometimes introduce other people to drugs. And we know, for example, if you if someone in the house is prescribed opioids, there's more risk that a, you know, a teenager in that house will start experimenting with opioids, things like that. But it's you're absolutely right. It's not like a virus. I led something called the Stanford Lancet Commission on the North American Opioid Crisis. And the reason I used crisis, and they had asked me to use an epidemic. I said, that's not really the right word because it's not an infectious disease, and it's not going to be resolved in the way you would resolve a traditional, you know, epidemic. So I agree with you. It's not the best thing, but but something did happen different than important, you know, different than, you know, the fact that opioids have been around forever. Because of course, you can make an opioid right from the poppy plant, which has been cultivated for thousands of years. It's about a 400% per capita increase in the availability of pharmaceutical opioids in the space of about 10 or 12 years. That's what was different. And I think the corruption of regulators by opioid manufacturers, painkiller, you know, manufacturers and distributors, epic overprescribing that generated an enormous amount of addiction, overdose and misuse and then set the stage for resurgence of the illicit market. So, you know, once there were many, many, many people addicted to legal drugs like OxyContin, smart, if sociopathic, but certainly smart heroin traffickers realize, boy, we could convert a lot of these people over to heroin because it's it's potent and cheaper. And they expanded their business in a way because we'd always had heroin, but they expanded it to places that it hadn't really existed much before.
Keith Humphreys: [00:41:38] A lot of small towns, for example, in Appalachia, they hadn't really had much heroin in those places, started servicing the people who were on prescription opioids. And of course, then fentanyl, which is the super powerful synthetic opioid, was introduced into supply and made everything even even worse, switching over people who were on OxyContin or heroin. And that's how we got into this crisis, which is the term I prefer to use. The other reason we use the word crisis rather than epidemic is opioids are not like cholera. You know, the less cholera you have, the happier you are. If you could eliminate cholera, you would win a Nobel Prize. But we don't want to eliminate opioids. Opioids are fabulously useful, as you both know, as physicians. You know, I was in a hearing, a legislative hearing. Why don't we just ban fentanyl? And I said, well, I volunteered in hospice as a counselor for like ten years. And I can tell you, fentanyl is a magnificent medication for people with incredibly serious pain. We can't control any other way. It's also used in a range of surgeries. The opioids aren't the problem. It's how they used. By whom? Under what conditions? We have to. In that sense, it's a harder problem, right? We have to have them. They can kill us and addict us, but we also can use them for good. And so that's much more challenging than in a straight infectious disease. Like, you know, if you get rid of Covid, no one would miss it or get rid of cholera. No one would miss it.
Henry Bair: [00:43:05] So speaking about what to do about the range, I mean, we talked about earlier, there are you can be addicted to many different things, tangible and intangible. But let's talk about substance use, opioid being one of them. There have been so many different kinds of models experimented by governments around the world in trying to solve this problem. On one hand, you have like very prohibitionist models where you just criminalize everything under the sun and then you have varying degrees of permissiveness from decriminalization. There is no criminal penalty, you for using and possessing substances. And then you have Netherlands, for example, or cannabis in many parts of North America that are legalized and regulated, so varying degrees of permissiveness. And then you have harm reduction strategies as well, based off of your expertise, experience in regulation and health policy. When it comes to substance use, in your view, is there a model that works best?
Keith Humphreys: [00:44:06] I don't think you can answer that. Apart from looking at normative values, you know, of the society and the people in it. So in this sense, drugs aren't really a problem in that they don't really have a solution. It's more you get to pick the kind of problem that you have, and you can pick the one that you are the most comfortable dealing with. So extremely controlled societies like Singapore, you know, have very low drug use and very low addiction, very low overdose. There also are less free societies than ours are. You could say that about, you know, also, you know, more autocratic societies. Legalizing the production and sale, which is really different than decriminalizing use. Now there could be some gains from it. I mean, I drink alcohol, so, you know, it's accessible to me. Other people like to drink it. There can be some joy in that. You can get a job as a bartender or, you know, working in the industry, a legal job. You pay taxes, there's that kind of stuff. And that drug also kills 2 million people a year. Tobacco isn't even, you know, a more powerful example, you know, with legalization, killing about 8 million a year. So you can say, well, if we legalize production and sale, you know, we're not having so many people being arrested. People are freer in one sense. But on the other hand, every single illegal drug put together times ten does not cause as many deaths as just those two legal drugs, just alcohol and tobacco. So. So when people tell me, like, you know, I've jolted so many people. They say, you know, if we just legalize drugs, you know, and let everybody make them, they wouldn't have these problems.
Keith Humphreys: [00:45:40] I love to respond to sort of innocently and say, oh, what do you think are the three great achievements of the tobacco industry in promoting public health? And they're sort of jolted, like, what do you mean? It's like, well, that's a legalized drug, right? We've been taught to think that it isn't, but that's exactly what it is. I mean, it's nicotine, it's legalized tobacco, it's legal. That is what legalization can look like. You know, there's not, again, a right or wrong answer without some sort of normative judgment of what do you care about? Ditto with decriminalization. So that decriminalization means just the user. There's not penalties towards the user. So you could say in some sense, if there's no penalties at all, no pressure at all, the people are very free to use drugs. If you say you maximize freedom, on the other hand, people do a lot of stuff when they're addicted or they're intoxicated they wouldn't otherwise do, including lots of things that impinge everybody else's freedom. And that gets to be a challenge. And when if there's no formal mechanism in any or any kind of punishment at all, or any kind of leverage you can get on people, it's possible for communities to just turn over to open drug use. And we saw some of this in Oregon, you know, during their decriminalization. It was basically, you know, the city parks are gone. A lot of people are just, you know, using their all the time. But, you know, we've we've said it's all okay. So this is what it looks like. And there were a lot of people who thought that sounded okay in the abstract.
Keith Humphreys: [00:47:00] But then it was like, wow, there's nowhere safe for me to go for a walk. My kid can't play in the park anymore. And they realized, oh, that that is impeding my now, my freedom. I see that a lot when I go into places like the tenderloin. I mean how complicated these things are and how easy it is if you, particularly if you live in a nice, safe neighborhood, to suggest a regime of sort of libertarianism for someone else's neighborhood, it's really different when you actually have to live in that environment. And so that goes back to what do we care about the most? And we have to pay the piper somewhere. There'll be costs cast no matter what we do. Can we get to policies where we get at least more of what we want? I absolutely believe that. Or I wouldn't do what I do. I've done particularly things. On trying to get the criminal justice system to stop doing things that it can't do, or things that actually make life worse and start doing things that it can do that make life better. That's a big one. Another one I've worked on a lot is just trying to make it possible for people with addictions to get health care. And that's about insurance reform. That's about training staff and so on. That's about reducing the stigma of being addicted. I think those things would maximize social good. There will be people who are against them as they are against everything. But I think together that could move us to a place where we are still a pretty free society, but we're also a healthier society.
Tyler Johnson : [00:48:24] Yeah. You know, I think it is one of those things where it's I'm so heartened to hear you basically say everything has an opportunity cost, right? We often talk in politics and public policy as if there's this obviously correct policy that if we just did that policy, then all the things would be good and there would be nothing bad, as if it would not be the case if that were lying around, that somebody wouldn't have picked it up 30 years ago to use it. Right? I mean that those kinds of discussions, usually...
Keith Humphreys: [00:48:48] to govern is to choose.
Tyler Johnson : [00:48:49] Right? Those are usually kind of kind of silly. But I want to ask you along a similar lines, and I know this is not necessarily per se the area of your expertise, but I do think it's really important for our community, most of whom are health care providers of some stripe, to think about. What about when a health care provider is addicted to a substance that is impairing their ability to do their job right? This strikes me as a particularly acute case of, on the one hand, not wanting to stigmatize it so much that they won't come forward and get help. But on the other hand, I mean, you can't pretend that it's not a big deal if the hospital's cardiovascular surgeon is coming to work drunk or, you know, whatever the thing is. I mean, it's a big deal, right? So I'm just curious. And I know we're about out of time, so maybe this will be our last substantive question, but what are what are your thoughts about policy around that?
Keith Humphreys: [00:49:40] There's so much to learn for how we take care of addicted physicians and also addicted airline pilots, where the management strategy is the same. So states have programs that give doctors treatments and then monitor them for years. Regular, you know, testing for drugs all the way through. There's a lot of support, but there's also a lot of accountability. And if at any point when you're in a physician's health plan or efficiency monitoring program, if you test positive you like, you can't practice, you know, you have your license is suspended. Again, you may have to go back to treatment. It's very intense, but it's swift, certain monitoring expectations that you know you will not use anything, coupled with a lot of support and the documented biologically documented with biological testing. Five year outcomes for the population is about 80% of perfect sobriety over that period. Ditto for pilots. No one should feel anxious, but there's something like 1000 commercial pilots who are addicted. But they're all in this really careful monitoring program. So, you know, and with that, you really should feel better off, you know, if your doctor is in one of those than otherwise. Like if you come into the Ed with an injury on the night after New Year's Eve, asked for an addicted doctor because, you know, that's the person who will be very tightly monitored and will not be hungover, whereas any other physician might be. But the insight is really important, because that's not the kind of care we give most people. And that's not the kind of stuff we do in the criminal justice system very much. But it went with those occasions when we do like, say, in drug courts and other places where there's a lot of support, but there's also really careful monitoring and accountability. The outcomes are superb. And so there's a lot to learn from how we how we take care of physicians.
Henry Bair: [00:51:25] Well, I'd like to close with one question that I think we often close with, which is some advice you might have for clinicians. One of the hardest things I think consistently that I did as a first year resident was taking care of patients with addiction because oftentimes the medically right thing to do isn't actually that obscure. If someone comes in withdrawing from something, there's often protocolized treatments like just follow the algorithm. It's all in the electronic medical record. It's all in the hospital's handbook. Um, if someone comes in overdosed, same thing. I think what makes it so challenging is just the actual interaction. The interactions you have with the patients, because oftentimes you really feel as if you're dealing with a patient who doesn't have the urgency to try to help themselves or have the desire. That's what it seems like. I know you've talked to us about how the brain chemistry itself changes, but, you know, just in that moment, that's what it feels like as you're trying to help them. There's also it takes a lot of patience. It takes a lot of empathy. It takes a lot of time. All of which were sort of short of when in our hard pressed healthcare system. But from your experience, certainly drawing from your experience as a, as a clinician who has, you know, found a lot of meaning in these kinds of interactions, in helping patients go through these difficult moments. What advice do you have for clinicians about better connecting with their patients and motivating them to get out of this cycle?
Keith Humphreys: [00:52:57] To avoid burning out? Working in addiction, you have to accept the limits of your own control, which, by the way, is the same thing they're trying to trying to accept that they're out of control, that you can't fundamentally, as a psychologist, psychiatrist, ed doctor, make them do anything. And if you try, usually they'll get defensive. You'll become frustrated, and you might even get mad at them. And so just accept that, like in the end, I can't make you do that. So what can I do is perhaps I can help increase the likelihood that you want to do this, which is you're the person who's with you all the time. And I'm just here for a moment. And the strategy most people use for that is called motivational interviewing. Don't lecture them, but you do ask them like, what is it that you want? What is it you are trying to achieve and try to get them to articulate well? What I really want is I want to feel good during the day. I want to be a good father. I want to get a decent job and then ask them, Non-judgmentally does your substance use help you pursue those goals or not? And if you do it that way, it's not. It's not my agenda. I want to know what your agenda is. And now that I've heard it, now I'm just curious does does this stuff you're doing serve your agenda or not? And that can be the beginning where the person realizes, oh, this is not about pleasing my doctor or pleasing my spouse who's nagging me, or like, I would like this stuff and this thing I'm doing is stopping it.
Keith Humphreys: [00:54:27] And that can be the beginning, where people can get some motivation because it feels like, you know, sensible to them from their from their worldview that this is a problem and not just other people telling a problem. And, you know, that kind of approach delivered with empathy, can be really meaningful, even in short interactions. And we have some evidence to that effect, like moving people. You talked about being contemplative and moving them along to the point where they're at least thinking about change. So I would try to recommend that. It's hard work, that's for sure. Let me add one other thing you should ask, which is everyone should know this. There are 23 million Americans who, in national surveys say they are in recovery from an addiction. So the other thing you can have as a provider, which is easy to lose track of, is hope. Many, many people do recover. And you convey that to the patients, you know. Do you know that? Because there's a lot of people who know they have a problem, but it's like they just feel beaten? I'm not trying because I've tried 50,000 times. It hasn't worked. So there are 23 million people in recovery. There's always a rational reason to have hope. That's another thing we can always give people.
Tyler Johnson : [00:55:34] And I think that's particularly important because my experience as a clinician is that one of the most difficult things about especially very deep addiction is that partly because of the stigmatization and also because the person recognizes the effects that the addiction is having on their life, is that it becomes almost inherently atomizing, because they sort of wall themselves off from people to try to sort of isolate the damage that they're causing. But then the more isolated they become, the more hopeless it seems, right? Because there's no one around them and that, as you mentioned earlier, is probably part of the power of something like Alcoholics Anonymous is just that. You see, people who have walked the path and can say, I can help you and you can do this right. And so I think as a clinician saying, you know, I have seen patients or at least I know of data that this actually can get better in the long term. Like you can beat this I think is enormously powerful.
Keith Humphreys: [00:56:26] Yeah. And you're absolutely right to that is a real important part of AA because of course they wall themselves off. But other people in their lives wall, wall them off, you know, like they just because they can be hurtful, disappointing, frightening. And sometimes the only other person who will who will take you in is someone who's been in exactly that spot. And the way they convey it in a it's interesting they don't cite statistics about recovery, but what they do is they tell stories, and you listen to somebody who's been sober for 20, 30, 40 years. And they describe starting in this complete misery. And these people go like, oh, that's where I am right now. That's where that guy that gal was. And now, you know, he looks healthy, happy, she looks healthy and happy. I'll have what she's having to quote when Harry met Sally.
Henry Bair: [00:57:08] Well, with that, we want to thank you so much, Keith, for sharing your humane and empowering message to a very difficult problem. And we want to thank you so much for all the great work that you do in this sphere.
Keith Humphreys: [00:57:20] Thank you.
Henry Bair: [00:57:25] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the Doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson : [00:57:44] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient, or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:57:58] I'm Henry Bair
Tyler Johnson : [00:57:59] and I'm Tyler Johnson. We hope you can join us next time. Until then, be well.