WEBVTT - Ep137 "Do cures ever create the next crisis?" with Thomas Goetz 0:00:05.040 --> 0:00:07.720 Today we're going to talk about the fascinating world of 0:00:07.920 --> 0:00:13.720 prescription drugs and their intersection with culture and society. And 0:00:13.800 --> 0:00:16.240 for that we're going to be joined by science journalist 0:00:16.480 --> 0:00:21.880 Thomas Getz. Medications are some of the most consequential advancements 0:00:21.960 --> 0:00:26.720 of modern life, but their stories are often quite nuanced 0:00:26.800 --> 0:00:30.840 and complicated. What if some of our most common diseases 0:00:31.040 --> 0:00:35.519 are design flaws of modern life? In other words, we 0:00:35.600 --> 0:00:39.920 always need to be asking when we're treating biological illnesses 0:00:39.960 --> 0:00:43.760 and when we're medicating our way around the world that 0:00:43.800 --> 0:00:47.440 we've built. Also, does it matter if we are fixing 0:00:47.479 --> 0:00:51.880 a root cause versus just circumventing it. If a pill 0:00:52.040 --> 0:00:57.200 can quiet hunger or pain or anxiety, is that cheating? 0:00:57.720 --> 0:01:02.200 Do cures ever create the next crisis? So today we're 0:01:02.200 --> 0:01:06.720 going to talk about the larger stories of social ills 0:01:07.000 --> 0:01:14.120 and public health. Welcome to enter cosmos with me David Eagleman. 0:01:14.240 --> 0:01:17.160 I'm a neuroscientist and author at Stanford and in these 0:01:17.200 --> 0:01:21.480 episodes we sail deeply into our three pound universe to 0:01:21.560 --> 0:01:42.280 better understand the world around us. Generally, when we think 0:01:42.319 --> 0:01:46.399 about medicine, we picture a simple story, which is a 0:01:46.520 --> 0:01:51.560 disease appears science identifies the cause and a drug fixes 0:01:51.600 --> 0:01:57.040 the problem. But biology is sufficiently complicated that it rarely 0:01:57.440 --> 0:02:02.240 cooperates with stories that are that your body is trying 0:02:02.280 --> 0:02:06.920 to regulate hunger and mood and pain and sleep and anxiety. 0:02:07.320 --> 0:02:11.440 It balances internal signals against the outside world. But the 0:02:11.480 --> 0:02:15.960 fact is that world has changed faster than our biology 0:02:16.160 --> 0:02:20.519 ever could, and we now live in environments saturated with 0:02:20.919 --> 0:02:27.280 calories and stimulation and stress and chemical shortcuts, and much 0:02:27.320 --> 0:02:30.320 of the world that we've built is designed explicitly to 0:02:31.000 --> 0:02:35.079 capture our attention and to override satiety and to make 0:02:35.160 --> 0:02:39.160 us feel better fast. So it's no surprise that many 0:02:39.240 --> 0:02:45.640 of the most common conditions of modern life, obesity, anxiety, insomnia, 0:02:46.160 --> 0:02:52.239 chronic pain, heart disease, are what scientists sometimes call mismatched diseases. 0:02:52.480 --> 0:02:56.440 In other words, we are ancient biological systems operating in 0:02:56.480 --> 0:03:00.120 a world that we weren't really designed for, and when 0:03:00.160 --> 0:03:05.720 those systems strain, we reach for medications. Now, prescription drugs 0:03:05.800 --> 0:03:10.400 are fascinating from a biology perspective because they are in 0:03:10.480 --> 0:03:15.799 a sense controlled perturbations. You stick some molecules into the bloodstream, 0:03:16.320 --> 0:03:20.200 and those cross barriers and binder receptors and nudge the 0:03:20.280 --> 0:03:24.280 activity in some circuits, and then we watch what happens. 0:03:24.760 --> 0:03:29.040 Sometimes the effects are kind of miraculous, other times they're subtle, 0:03:29.440 --> 0:03:33.480 And sometimes only decades later do we realize that a 0:03:33.600 --> 0:03:37.280 drug meant to solve one problem created some new problem. 0:03:37.800 --> 0:03:42.200 So we end up with medications for anxiety that camp 0:03:42.360 --> 0:03:46.800 down fear, but they create dependence. We get painkillers that 0:03:47.320 --> 0:03:52.120 blunt suffering, but they cause addiction. We have sleep aids 0:03:52.200 --> 0:03:56.680 that knock us out but damage our normal sleep architecture. 0:03:57.040 --> 0:04:01.200 Even the most elegant drugs can rip through the system 0:04:01.280 --> 0:04:03.880 in ways that we never anticipated. Now. Part of the 0:04:04.000 --> 0:04:08.240 challenge is scale. A lot of side effects don't reveal 0:04:08.320 --> 0:04:12.320 themselves until thousands or millions of doses have been taken, 0:04:12.640 --> 0:04:15.280 and part of it is just an issue of humility. 0:04:15.520 --> 0:04:21.479 Our biology is staggeringly complex even today, prescribing a drug 0:04:21.520 --> 0:04:25.800 as something like sending out a sonar ping and hoping 0:04:25.839 --> 0:04:30.040 the echo tells us something useful about what's happening beneath 0:04:30.160 --> 0:04:34.960 the surface. So this raises deeper questions. Are drugs treating 0:04:35.040 --> 0:04:40.599 diseases or sometimes treating symptoms of the world we've built. 0:04:40.839 --> 0:04:45.320 If a pill can quiet hunger signals or reduce cravings 0:04:45.400 --> 0:04:48.800 or lift mood or dull pain. Does that mean the 0:04:48.880 --> 0:04:54.760 problem is solved or merely postponed? And what about responsibility? 0:04:54.800 --> 0:04:59.320 When nearly half the population struggles with obesity, or when 0:04:59.600 --> 0:05:04.560 anxinxiety and depression are among the leading causes of disability worldwide, 0:05:05.080 --> 0:05:09.360 is it meaningful to frame these as individual moral failures? 0:05:09.920 --> 0:05:15.240 Or are we forced to confront the interaction between biology 0:05:15.560 --> 0:05:20.880 and behavior and environment and forced to rethink what choice 0:05:21.400 --> 0:05:25.240 really means. So these questions sit right at the intersection 0:05:25.520 --> 0:05:29.360 of medicine and society. So to dig in on these topics, 0:05:29.400 --> 0:05:32.159 there's no one better to sit down with than science 0:05:32.279 --> 0:05:34.880 journalist Thomas Getz, who has just come out with a 0:05:34.960 --> 0:05:39.520 new podcast series called Drug Story. Every episode of Drug 0:05:39.560 --> 0:05:44.920 Story takes a single prescription drug like ozembic or xanax, 0:05:45.000 --> 0:05:48.800 or ambient or opioids, and uses that drug as a 0:05:48.960 --> 0:05:52.320 lens to tell a much larger story, a story about 0:05:52.360 --> 0:05:56.160 disease and biology, but also about markets and incentives and 0:05:56.279 --> 0:06:01.200 unintended consequences. Thomas gets is an award win journalist. He's 0:06:01.279 --> 0:06:04.480 the former executive editor at Wired and the author of 0:06:04.800 --> 0:06:09.240 The Decision Tree and The Remedy. He spent years reporting 0:06:09.279 --> 0:06:11.839 on medicine and science, and he has a special eye 0:06:11.880 --> 0:06:17.600 for connecting molecular mechanisms to human behavior and individual patients 0:06:17.640 --> 0:06:27.200 to systemic forces. So here's my conversation with Thomas Getz. So, Thomas, 0:06:27.240 --> 0:06:30.919 you've just come out with a podcast series called drug Story. 0:06:31.000 --> 0:06:31.960 Tell us about that. 0:06:32.240 --> 0:06:35.840 I spent the last ten twelve years on an unexpected 0:06:35.880 --> 0:06:40.719 journey deep into pharmacy. So my background is in journalism 0:06:40.800 --> 0:06:42.720 and I have a background in public health. But I 0:06:42.800 --> 0:06:46.600 kept on thinking about the way we use drugs in 0:06:46.600 --> 0:06:51.599 our society to really treat problems which are manifestations of 0:06:51.680 --> 0:06:55.040 much larger problems. So when you think about the major 0:06:55.320 --> 0:07:01.360 kind of maladies of the modern life, like the heart disease, ibetes, obesity, 0:07:01.560 --> 0:07:04.640 even things like depression or anxiety, a lot of these 0:07:04.680 --> 0:07:07.760 things are manifest because of the world we've built. But 0:07:07.760 --> 0:07:10.240 then the thing that we have, one of the things 0:07:10.240 --> 0:07:13.160 that we have to treat them are drugs. And so 0:07:13.200 --> 0:07:16.600 we have medications and we have prescriptions, and it works 0:07:17.080 --> 0:07:21.280 pretty well for some people, but it doesn't actually solve 0:07:21.360 --> 0:07:24.000 the root problems of what's going on. And so I thought, 0:07:24.160 --> 0:07:26.680 I thought the idea of the podcast is to use 0:07:27.240 --> 0:07:31.920 individual drugs to tell these larger stories about disease and 0:07:31.960 --> 0:07:36.120 society and economics and business, but really to focus on 0:07:36.160 --> 0:07:39.040 the drug as a as a kind of proxy or 0:07:39.120 --> 0:07:41.480 mcguffin to tell this larger story. 0:07:41.720 --> 0:07:43.560 So let's take an example of some of the drugs. 0:07:43.760 --> 0:07:47.080 You looked at the EpiPen for allergies, you look to 0:07:47.760 --> 0:07:53.200 ambient for insomnia, xanax for anxiety, at opiates for pain. 0:07:54.960 --> 0:07:56.760 What kind of through lines do you see when you 0:07:56.840 --> 0:07:58.800 when you examine these different stories. 0:07:58.800 --> 0:08:02.560 Right, Well, with that group you just did, all of 0:08:02.600 --> 0:08:07.040 those drugs, oddly have had pretty massive unintended consequences. 0:08:07.520 --> 0:08:09.480 So like EpiPen. 0:08:09.840 --> 0:08:13.360 You know, EpiPen treats anaphylaxis, which is an allergic reaction, 0:08:13.440 --> 0:08:16.600 a severe allergic reaction. But the reason that that kind 0:08:16.640 --> 0:08:20.160 of we had this upsurge in food allergies over the 0:08:20.240 --> 0:08:25.320 last twenty thirty years was actually because the official guidance 0:08:25.720 --> 0:08:30.720 on food and possible allergic foods was exactly backwards. For 0:08:30.760 --> 0:08:34.520 twenty years, the American Academy of Pediatrics was recommending that 0:08:34.679 --> 0:08:38.640 parents avoid exposing their kids to peanuts and milk and 0:08:38.760 --> 0:08:41.760 eggs early in life. Well, then that was under the 0:08:41.760 --> 0:08:44.080 precautionary principle, the idea that they should you know, people 0:08:44.120 --> 0:08:47.079 should do no harm and if something seems risky, then 0:08:47.120 --> 0:08:50.240 avoid it until the kids are a little older. 0:08:50.400 --> 0:08:52.360 Cow's milk, I assume, yeah, yeah, yeah, cow's milk. 0:08:52.440 --> 0:08:55.160 Yes. Well, turns out that was exactly wrong. So it 0:08:55.200 --> 0:08:58.679 turns out that early exposure is really useful and actually 0:08:59.240 --> 0:09:02.120 helps actate their body in the immune system to these 0:09:02.160 --> 0:09:05.480 possible allergens. And in fact, in countries where kids are 0:09:05.520 --> 0:09:08.160 exposed to things like peanuts from a very early age, 0:09:08.320 --> 0:09:11.400 there are basically no peanut allergies. So that was just 0:09:11.440 --> 0:09:16.119 this massive unintended consequences of well well minded, well intended 0:09:17.240 --> 0:09:20.720 guidance that that was just backwards. And so along comes 0:09:20.720 --> 0:09:23.240 the EpiPen and and it was perfectly timed to take 0:09:23.240 --> 0:09:27.120 advantage of this upsurge in food allergies. And along the 0:09:27.120 --> 0:09:29.640 way they raised the prices click click click, and made 0:09:29.679 --> 0:09:31.960 a lot of money and then had congressional hearings and 0:09:32.520 --> 0:09:34.800 it was it was there was a lot of outrage 0:09:34.800 --> 0:09:37.240 about the cost of drugs, which was really the EpiPen 0:09:37.400 --> 0:09:39.880 was case a. But when you look at these other 0:09:39.960 --> 0:09:44.720 drugs like xanax and ambient for instance, these were drugs 0:09:44.840 --> 0:09:47.360 that at the time when they first came out, they 0:09:47.360 --> 0:09:50.880 thought they were perfect pills. They thought they were magic, 0:09:51.000 --> 0:09:54.439 almost magic pills, and because they worked, because they worked 0:09:54.520 --> 0:09:58.440 really well, like ambient works pretty well to put people 0:09:58.520 --> 0:10:02.439 to sleep, and and xanax worked really well to eliminate 0:10:02.559 --> 0:10:04.200 somebody's anxiety really quickly. 0:10:04.400 --> 0:10:05.319 But it turns out that. 0:10:05.320 --> 0:10:08.679 These these same medications, because they work so well, they 0:10:08.720 --> 0:10:13.280 create different human behaviors, and so people take them too much. 0:10:13.360 --> 0:10:15.400 They tend to abuse them, they tend to get tolerant 0:10:15.440 --> 0:10:19.679 to them, and it's really hard to stop using them oftentimes. 0:10:20.040 --> 0:10:22.040 So those are great examples of kind. 0:10:21.880 --> 0:10:27.920 Of the the unintended results of using these medications in 0:10:29.000 --> 0:10:34.800 great amounts millions of people without enough kind of attention 0:10:34.920 --> 0:10:37.000 paid to what are the possible consequences. 0:10:37.280 --> 0:10:39.680 Yeah, our society is like a giant and amical system, 0:10:39.679 --> 0:10:41.160 and so when you push down over here, you get 0:10:41.160 --> 0:10:43.920 something else happening over here, and so on. Would we 0:10:44.400 --> 0:10:47.720 have been better off without these drugs, though presumably not, 0:10:48.000 --> 0:10:53.440 because if somebody has insomnia, or somebody has high anxiety 0:10:53.640 --> 0:10:56.240 or an allergic reaction, we still want to be able 0:10:56.240 --> 0:10:56.800 to help them. 0:10:56.840 --> 0:10:57.600 What's your take on that. 0:10:57.760 --> 0:11:02.600 Yeah, Yeah, totally. So, yes, these are useful medications. The 0:11:02.679 --> 0:11:07.920 trick is how to use them. So again, thinking about 0:11:07.960 --> 0:11:11.680 xanax or ambient, they're really at this point intended to 0:11:11.679 --> 0:11:14.760 be used for very short periods of time when something 0:11:14.840 --> 0:11:18.280 is acutely wrong. Right, so somebody is having a lot 0:11:18.320 --> 0:11:22.679 of trouble sleeping, then maybe an ambient is appropriate to 0:11:22.800 --> 0:11:26.600 use for a very short duration and then to remove 0:11:26.640 --> 0:11:30.480 it and come up with much more durable, sustainable solutions 0:11:30.520 --> 0:11:33.560 like not using your screen in bed and things like that, 0:11:34.040 --> 0:11:38.440 more behavioral solutions. The trouble is that patients get prescribe 0:11:38.480 --> 0:11:42.760 these drugs and they work, and so the patient reasonably 0:11:42.840 --> 0:11:45.280 it says, why can't I keep on taking these drugs? 0:11:45.679 --> 0:11:50.079 Where they're not necessarily cognizant of the dependencies or the 0:11:50.160 --> 0:11:53.760 talents that their body are acclimating to the drugs. So 0:11:54.240 --> 0:11:58.160 we have to think about these drugs not as the solution, 0:11:58.400 --> 0:12:02.320 but as part of a much order kind of program 0:12:02.679 --> 0:12:06.360 or treatment program. And one of the problems that we 0:12:06.400 --> 0:12:10.440 have in medicine is that a lot of doctors are 0:12:10.480 --> 0:12:14.600 just not trained or don't have the time to manage 0:12:14.920 --> 0:12:18.400 individual therapies closely enough. And it's just a matter of 0:12:18.679 --> 0:12:21.640 time and man hours and billing, and it's the complexity 0:12:21.679 --> 0:12:25.080 of our healthcare system. But what happens in reality is 0:12:25.080 --> 0:12:27.360 people get prescribed to drug, they leave the doctor's office, 0:12:27.480 --> 0:12:29.920 it works, and they just keep refilling it. And so 0:12:30.000 --> 0:12:33.400 for those drugs, those drugs that have potential abuse or 0:12:33.520 --> 0:12:36.280 dependency issues, those are really the ones that we need 0:12:36.280 --> 0:12:38.839 to work out or watch out for. And obviously opiates 0:12:38.880 --> 0:12:42.400 are a prime example of this. You know, they really 0:12:42.520 --> 0:12:47.600 should have only been prescribed for acute pain temporary short durations, 0:12:47.800 --> 0:12:51.160 but they were widely prescribed for even moderate chronic pain, 0:12:51.520 --> 0:12:54.360 and people took them for months, years, and we had 0:12:54.480 --> 0:12:56.040 an epidemic of addiction. 0:12:56.360 --> 0:12:59.040 And speaking of pain medications like opiates, where are we 0:12:59.080 --> 0:13:02.800 now with that now, How that opiates are considered persona 0:13:02.880 --> 0:13:05.520 non grata, what's the future of pain control? 0:13:05.880 --> 0:13:08.480 One of the things about opiates that was that was 0:13:08.600 --> 0:13:11.839 again kind of an undertended consequence, was that they were 0:13:11.880 --> 0:13:17.880 really widely prescribed. When pain experts started to recognize that 0:13:18.280 --> 0:13:22.520 and argue that pain should be acknowledged, should be a 0:13:23.520 --> 0:13:27.439 was worthy of treatment, because pain was really not considered 0:13:27.440 --> 0:13:30.360 and doctors were not treating patients for their pain, so 0:13:30.679 --> 0:13:33.320 they there was a program around the late nineties early 0:13:33.360 --> 0:13:36.960 two thousands called pain as the fifth vital sign, where 0:13:37.040 --> 0:13:41.160 they instructed doctors. They were recommended doctors ask people just 0:13:41.200 --> 0:13:45.120 like they took their blood pressure or their their breathing rate. 0:13:45.559 --> 0:13:47.840 They said, okay, a fifth vital sign would be ask 0:13:47.920 --> 0:13:50.800 your patients whether they're experiencing pain. So it was a 0:13:50.880 --> 0:13:53.320 zero to ten scale. Zero is no pain, ten is 0:13:53.480 --> 0:13:57.959 excruciating unbearable pain, and doctors started asking their patients about 0:13:57.960 --> 0:14:00.800 their pain level. That was one dull in terms of 0:14:00.800 --> 0:14:03.679 flushing out a problem that people a lot of people have. 0:14:03.760 --> 0:14:06.760 Twenty twenty five percent of Americans deal with chronic pain, 0:14:07.000 --> 0:14:10.600 so it's a massive issue. The problem, the unattended consequence 0:14:11.040 --> 0:14:13.960 was that once that was on the table, it became 0:14:14.000 --> 0:14:17.640 something that the physician was then obliged to treat. And 0:14:17.920 --> 0:14:20.920 different people had very different ways of rating their pain. 0:14:21.320 --> 0:14:23.680 So for me, what would be a two, could for 0:14:23.720 --> 0:14:26.320 you be a ten. The doctor was really in no 0:14:26.440 --> 0:14:30.240 way of understanding what the relative concern was. But the 0:14:30.960 --> 0:14:34.960 treatment at hand at the time was opioids, and specifically 0:14:35.000 --> 0:14:37.880 oxy content, which had just been approved as a supposedly 0:14:38.040 --> 0:14:41.560 safe version of an opioid. So it seemed like a 0:14:41.560 --> 0:14:46.800 great opportunity to use a so called safe drug to 0:14:46.920 --> 0:14:51.480 treat a newly cognizant condition. Well, it didn't work out 0:14:51.480 --> 0:14:54.280 that way. It turns out oxy content was highly addictive. 0:14:54.320 --> 0:14:59.400 People would abuse it rampantly. So opioids solved the problem, 0:14:59.440 --> 0:15:02.080 but they, as we've been saying, they created other problems. 0:15:02.360 --> 0:15:06.120 So now or pain therapy are they're trying to find 0:15:06.160 --> 0:15:09.760 new ways of dealing with again that very real problem 0:15:09.800 --> 0:15:12.000 for twenty twenty five percent of Americans. So there are 0:15:12.240 --> 0:15:14.920 new drugs, There are non opioid drugs. There's a new 0:15:14.960 --> 0:15:19.560 one called gernaviks, which was just approved last year twenty 0:15:19.600 --> 0:15:24.800 twenty five, by Vertex Pharmaceuticals. It's a non opioid peripheral 0:15:25.520 --> 0:15:28.720 nerve agent, so it doesn't work on the brain, doesn't 0:15:28.720 --> 0:15:32.400 work on the opioid receptors. They're very insistent and glad 0:15:32.520 --> 0:15:36.040 that it works on the peripheral nerve systems. The trick though, 0:15:36.120 --> 0:15:39.000 is that has only been approved for acute pain, not 0:15:39.440 --> 0:15:43.400 chronic pain. So people can use it for two weeks 0:15:43.480 --> 0:15:47.560 four weeks, but insurance will only cover it, will only 0:15:47.600 --> 0:15:50.160 pay for the drug for that amount of treatment. Now, 0:15:50.160 --> 0:15:53.240 I spoke for my podcast, I spoke to some patients 0:15:53.320 --> 0:15:55.960 who actually have found it very useful for their chronic pain, 0:15:56.360 --> 0:15:58.600 but their pain out of pocket, and that's one of 0:15:58.600 --> 0:16:00.840 the problems. And it's about a thousand dollars a month 0:16:00.880 --> 0:16:02.560 to pay out a pocket, which which is a lot 0:16:02.600 --> 0:16:06.200 of money. So the drug company is trying to get 0:16:06.200 --> 0:16:09.840 evidence that it works for chronic pain on a population level. 0:16:09.840 --> 0:16:12.280 They're trying to bring that to the FDA. That's a 0:16:12.320 --> 0:16:16.840 whole process that is ongoing. But we're still trying to 0:16:16.880 --> 0:16:21.040 find solutions to pain. One of the things that actually works. 0:16:21.040 --> 0:16:23.280 And again you know more about this than I, but 0:16:23.400 --> 0:16:26.440 cognitive behavioral therapy for a lot of these issues turns 0:16:26.440 --> 0:16:30.880 out to be a very effective long term solution. But 0:16:31.440 --> 0:16:34.920 the issues there are access to therapists, access treatment, so 0:16:35.320 --> 0:16:39.120 there are consequences or concerns onto a self. 0:16:39.480 --> 0:16:41.520 I mean, the good news is with apps and AI 0:16:41.680 --> 0:16:44.720 and so on, things like cognitive behavioral therapy can be 0:16:44.920 --> 0:16:49.320 addressed at scale now in new ways totally. Yet people 0:16:49.400 --> 0:16:52.960 still like in a sense taking pills. What's the attraction 0:16:53.200 --> 0:16:56.200 to saying, hey, here's a solution, I swallow this, I'm 0:16:56.200 --> 0:16:57.000 going to be fixed. 0:16:57.480 --> 0:17:00.240 Well, it seems like an easy fix, and one of 0:17:00.240 --> 0:17:02.760 the things I learned was it's only really in the 0:17:02.840 --> 0:17:06.160 last fifty seventy five years that we've had this kind 0:17:06.240 --> 0:17:10.120 of medicine cabinet of drugs like behind in most pharmacies 0:17:10.160 --> 0:17:12.520 there are about two or three thousand drugs behind the counter. 0:17:12.600 --> 0:17:14.959 A lot of those drugs have been only developed in 0:17:15.160 --> 0:17:16.000 recent decades. 0:17:16.600 --> 0:17:18.720 The big boom in the pharma. 0:17:18.480 --> 0:17:21.679 Industry was in the fifties, sixties, seventies, eighties, where we 0:17:21.720 --> 0:17:25.840 had these whole classes of drugs emerge. So they provided 0:17:26.880 --> 0:17:30.600 real answers or apparently provided real answers to all these 0:17:30.640 --> 0:17:37.320 problems heart disease, diabetes, you know, the ps, psychiatric concerns. 0:17:37.680 --> 0:17:40.680 So that's awesome, but on the other. 0:17:40.520 --> 0:17:44.840 Hand, we've only had a few years to understand what 0:17:45.000 --> 0:17:48.879 works best. And one of the things that has always 0:17:48.880 --> 0:17:52.680 surprised me is that the odds of any drug working 0:17:53.000 --> 0:17:57.560 for any individual are roughly a coin flip. It's roughly 0:17:57.560 --> 0:17:59.840 about fifty percent chance. So you go to something like 0:18:00.040 --> 0:18:03.879 an antidepressant and there's kind of a thirty percent chance 0:18:03.960 --> 0:18:06.080 than any given antidepressant is going to work for any 0:18:06.200 --> 0:18:06.840 given patient. 0:18:07.200 --> 0:18:10.280 So what that means is trial and error. 0:18:10.640 --> 0:18:14.280 So patients are kind of start a drug, they take 0:18:14.320 --> 0:18:16.320 it for a few weeks, they see if it works. 0:18:16.320 --> 0:18:18.160 If it doesn't, they go to a different drug. If 0:18:18.160 --> 0:18:20.320 that doesn't work, they go to a different drug. Well, 0:18:20.320 --> 0:18:23.240 on average, it can take a person seeking treatment for depression. 0:18:23.280 --> 0:18:25.680 It can take them six months or more to find 0:18:25.680 --> 0:18:27.760 something that works. We talk about that as a process, 0:18:27.960 --> 0:18:31.320 but it's not exactly a process for the patient's experience, right, 0:18:31.359 --> 0:18:35.520 it's a it's a kind of a trudging through darkness. 0:18:35.119 --> 0:18:38.639 It's a real struggle to get to something that works. 0:18:38.920 --> 0:18:43.280 And that's true not just for psychiatric conditions or chronic pain. 0:18:43.680 --> 0:18:45.800 It's also true for something like heart disease because you 0:18:45.840 --> 0:18:50.240 have other variables like side effects like diarrhea is probably 0:18:50.240 --> 0:18:54.280 the most common side effect to drugs. When you're taking chemicals, 0:18:54.280 --> 0:18:56.720 putting them into the body, your body reacts in some 0:18:56.760 --> 0:18:59.520 ways that are intended, some ways that are not intended. 0:18:59.680 --> 0:19:02.960 Sometimes you can tolerate those unintended consequences, sometimes you can't. 0:19:03.400 --> 0:19:06.400 So that all adds up into the recipe of does 0:19:06.480 --> 0:19:09.159 it work. It's not just a clinical sense, it's like 0:19:09.280 --> 0:19:13.480 does it work for you as a patient, And for 0:19:14.119 --> 0:19:17.880 most conditions, that is a process, and it's a messy one. 0:19:17.920 --> 0:19:20.800 And it's a muddy one, and it has a lot 0:19:20.840 --> 0:19:39.520 of frustration and anxiety and frustration to it. 0:19:39.520 --> 0:19:42.280 It seems to me the central issue is that biology 0:19:42.359 --> 0:19:45.760 is insanely complicated, right. I mean, we often talk about 0:19:45.760 --> 0:19:47.960 the brain is the most complex thing we've discovered in 0:19:48.000 --> 0:19:50.920 the known universe. And so what we're trying to do 0:19:51.040 --> 0:19:53.600 is say, look, here's a here's a molecule of a 0:19:53.640 --> 0:19:56.320 particular shape, and if you take a bunch of those in, 0:19:56.680 --> 0:19:59.520 they'll bind some receptor. And what we're going to hope 0:19:59.600 --> 0:20:04.080 is that that that fixes this whole system, whether that's depression, anxiety, insomnia, 0:20:04.119 --> 0:20:07.520 whatever it is. And it seems almost impossible that that 0:20:07.560 --> 0:20:10.399 will ever work. But sometimes not just things in the 0:20:10.480 --> 0:20:13.400 right direction, or let's say, for fifty percent of patients, 0:20:13.400 --> 0:20:17.320 as you mentioned. So, what is your take on how 0:20:17.400 --> 0:20:20.919 you see the drug industry nowadays? Having been doing this 0:20:21.000 --> 0:20:23.359 drug story for a while now, how. 0:20:23.200 --> 0:20:23.720 Are you seeing this? 0:20:23.800 --> 0:20:27.359 Do you see drugs as miracles of biology that they 0:20:27.400 --> 0:20:30.960 work sometimes or problems for society? 0:20:31.240 --> 0:20:35.800 You're exactly right, these are complicated systems. You've got biology 0:20:35.840 --> 0:20:39.600 and the brain, like the brain is even in these 0:20:39.640 --> 0:20:43.359 biological illnesses, the brain is still at play. Like just 0:20:43.400 --> 0:20:47.320 with allergies, there's this constant fear and concern about that 0:20:47.359 --> 0:20:50.120 people have before they take an EpiPen shot. People who 0:20:50.160 --> 0:20:53.399 have an EpiPen in their purse, they describe to me 0:20:53.440 --> 0:20:57.399 this whole thing about like is a reaction EpiPen worthy 0:20:57.760 --> 0:21:01.280 because they just aren't sure if they should waste that 0:21:01.320 --> 0:21:03.920 shot or take that shot which costs three hundred dollars 0:21:04.040 --> 0:21:06.879 or so. So there are all these psychological concerns that 0:21:06.920 --> 0:21:09.359 get wrapped up into the biological So that's the first thing. 0:21:09.600 --> 0:21:13.080 Now back to your question, like what about the drug industry. 0:21:13.359 --> 0:21:17.760 I think drugs are an amazing accomplishment of our society 0:21:17.800 --> 0:21:21.000 and of medicine and of clinical medicine and of public health. 0:21:21.119 --> 0:21:25.520 Right like, they save and treat thousands of people, millions 0:21:25.560 --> 0:21:28.639 of people every day in this country around the world. 0:21:28.720 --> 0:21:33.600 They save lives, full stop. Drugs are a benefit to society. 0:21:33.880 --> 0:21:37.520 The trouble comes when we expect drugs as you as 0:21:37.600 --> 0:21:39.680 we just were talking about, like you take the pill 0:21:39.880 --> 0:21:43.440 and it's going to fix the problem. That that isn't 0:21:43.440 --> 0:21:46.440 the way it works. On the one hand, biology isn't 0:21:46.440 --> 0:21:50.520 that simple, and two it isn't fixing the larger problems 0:21:50.520 --> 0:21:55.680 of these these deeper social conditions that oftentimes are creating 0:21:56.160 --> 0:22:01.600 the disease or the illness. So there's this great evolutionary 0:22:01.600 --> 0:22:05.320 biologist in at Harvard called Daniel Lieberman, you might know them. 0:22:06.520 --> 0:22:10.120 So he talks about these as mismatched diseases that we've 0:22:10.200 --> 0:22:12.960 put our body like we've designed a world that is 0:22:13.080 --> 0:22:17.320 very comfortable and accommodating, but it's not necessarily the world 0:22:17.359 --> 0:22:20.879 that our bodies evolve to inhabit. And so we a 0:22:20.880 --> 0:22:24.480 lot of these diseases, like heart disease or obesity, are 0:22:24.480 --> 0:22:27.960 the results of the context in which we live. And 0:22:28.000 --> 0:22:31.480 so the diseases we're getting, like like heart disease or obesity, 0:22:31.520 --> 0:22:35.800 are not the inevitable result of human life. They are 0:22:35.840 --> 0:22:39.520 the exact consequence of the world we've built, the food 0:22:39.560 --> 0:22:41.160 systems we've created. 0:22:41.359 --> 0:22:44.040 So this is a good segue into GLP one. Yeah, yeah, 0:22:44.080 --> 0:22:45.320 so let's talk about that, right. 0:22:45.359 --> 0:22:48.080 So glp ones are so I should say when I 0:22:48.160 --> 0:22:52.680 started the episode on GLP one, so ozempic. 0:22:52.960 --> 0:22:54.520 I was, by the way, for anyone who doesn't know, 0:22:54.600 --> 0:22:56.680 GLP one's glucagon like peptide one. 0:22:56.920 --> 0:22:58.440 And these are the drugs that people are taking for 0:22:58.480 --> 0:22:59.040 weight loss. 0:22:59.320 --> 0:23:02.280 Yes, and they they basically you'll describe it better than 0:23:02.280 --> 0:23:04.440 I will, but I'll describe it in simple terms. They 0:23:04.520 --> 0:23:08.160 basically interfere with the signal between your gut and your brain, 0:23:08.480 --> 0:23:10.640 and so they turn off your cravings. 0:23:11.200 --> 0:23:12.000 That's exactly right. 0:23:12.040 --> 0:23:14.240 These are normal hormones that you have in your gut 0:23:14.320 --> 0:23:16.760 that tell the brain, Okay, now you're full, go on, 0:23:16.880 --> 0:23:20.560 do the next thing. And the GLP one drugs are 0:23:21.040 --> 0:23:24.400 what are called agonists to these receptors. They mimic the 0:23:24.520 --> 0:23:27.080 action of these hormones so that they tell the brain, hey, 0:23:27.160 --> 0:23:28.040 no problem, you're full. 0:23:28.400 --> 0:23:30.360 A lot like you're a neuroscientists, you explain it better 0:23:30.359 --> 0:23:32.280 than I would. So the GLB ones what they do 0:23:32.560 --> 0:23:35.760 is they they because they interfere with that signal, they 0:23:35.800 --> 0:23:39.040 turn off what is called food noise in the brain. 0:23:39.119 --> 0:23:43.080 So they stop people from craving these foods that you know, 0:23:43.640 --> 0:23:45.160 eat more and more and more. 0:23:45.560 --> 0:23:47.560 And they have other benefits as well. 0:23:47.600 --> 0:23:50.440 But so what people feel like is just not hungry. 0:23:50.440 --> 0:23:52.040 I'm just not thinking about. 0:23:51.760 --> 0:23:55.760 Food, right, And so sometimes they so people who oftentimes 0:23:56.280 --> 0:24:00.320 had spent decades trying to just not eat one or 0:24:00.840 --> 0:24:04.119 find it easy to not eat one more or not 0:24:04.240 --> 0:24:08.439 at all, and so it's been extremely helpful for individuals 0:24:08.480 --> 0:24:12.680 for whom who have been struggling for years, for decades 0:24:12.880 --> 0:24:17.399 with being overweight, being obese, and the consequent health consequences 0:24:17.440 --> 0:24:22.240 of that like diabetes, joint pain, you know. 0:24:22.200 --> 0:24:24.960 Obstructive sleep, app now, all the things that come with obesity, 0:24:25.040 --> 0:24:25.600 that's right. 0:24:25.600 --> 0:24:27.760 Just being able to move, just being able to live 0:24:27.800 --> 0:24:29.919 a active life. 0:24:30.040 --> 0:24:33.080 And how many millions of people are on these GLP 0:24:33.160 --> 0:24:33.760 one drugs now? 0:24:33.760 --> 0:24:36.720 Well, so there are there are about forty percent of 0:24:36.760 --> 0:24:40.280 Americans ro obese, so that's that's more than one hundred 0:24:40.280 --> 0:24:45.600