Speaker 1: Today we're going to talk about the fascinating world of
Speaker 1: prescription drugs and their intersection with culture and society. And
Speaker 1: for that we're going to be joined by science journalist
Speaker 1: Thomas Getz. Medications are some of the most consequential advancements
Speaker 1: of modern life, but their stories are often quite nuanced
Speaker 1: and complicated. What if some of our most common diseases
Speaker 1: are design flaws of modern life? In other words, we
Speaker 1: always need to be asking when we're treating biological illnesses
Speaker 1: and when we're medicating our way around the world that
Speaker 1: we've built. Also, does it matter if we are fixing
Speaker 1: a root cause versus just circumventing it. If a pill
Speaker 1: can quiet hunger or pain or anxiety, is that cheating?
Speaker 1: Do cures ever create the next crisis? So today we're
Speaker 1: going to talk about the larger stories of social ills
Speaker 1: and public health. Welcome to enter cosmos with me David Eagleman.
Speaker 1: I'm a neuroscientist and author at Stanford and in these
Speaker 1: episodes we sail deeply into our three pound universe to
Speaker 1: better understand the world around us. Generally, when we think
Speaker 1: about medicine, we picture a simple story, which is a
Speaker 1: disease appears science identifies the cause and a drug fixes
Speaker 1: the problem. But biology is sufficiently complicated that it rarely
Speaker 1: cooperates with stories that are that your body is trying
Speaker 1: to regulate hunger and mood and pain and sleep and anxiety.
Speaker 1: It balances internal signals against the outside world. But the
Speaker 1: fact is that world has changed faster than our biology
Speaker 1: ever could, and we now live in environments saturated with
Speaker 1: calories and stimulation and stress and chemical shortcuts, and much
Speaker 1: of the world that we've built is designed explicitly to
Speaker 1: capture our attention and to override satiety and to make
Speaker 1: us feel better fast. So it's no surprise that many
Speaker 1: of the most common conditions of modern life, obesity, anxiety, insomnia,
Speaker 1: chronic pain, heart disease, are what scientists sometimes call mismatched diseases.
Speaker 1: In other words, we are ancient biological systems operating in
Speaker 1: a world that we weren't really designed for, and when
Speaker 1: those systems strain, we reach for medications. Now, prescription drugs
Speaker 1: are fascinating from a biology perspective because they are in
Speaker 1: a sense controlled perturbations. You stick some molecules into the bloodstream,
Speaker 1: and those cross barriers and binder receptors and nudge the
Speaker 1: activity in some circuits, and then we watch what happens.
Speaker 1: Sometimes the effects are kind of miraculous, other times they're subtle,
Speaker 1: And sometimes only decades later do we realize that a
Speaker 1: drug meant to solve one problem created some new problem.
Speaker 1: So we end up with medications for anxiety that camp
Speaker 1: down fear, but they create dependence. We get painkillers that
Speaker 1: blunt suffering, but they cause addiction. We have sleep aids
Speaker 1: that knock us out but damage our normal sleep architecture.
Speaker 1: Even the most elegant drugs can rip through the system
Speaker 1: in ways that we never anticipated. Now. Part of the
Speaker 1: challenge is scale. A lot of side effects don't reveal
Speaker 1: themselves until thousands or millions of doses have been taken,
Speaker 1: and part of it is just an issue of humility.
Speaker 1: Our biology is staggeringly complex even today, prescribing a drug
Speaker 1: as something like sending out a sonar ping and hoping
Speaker 1: the echo tells us something useful about what's happening beneath
Speaker 1: the surface. So this raises deeper questions. Are drugs treating
Speaker 1: diseases or sometimes treating symptoms of the world we've built.
Speaker 1: If a pill can quiet hunger signals or reduce cravings
Speaker 1: or lift mood or dull pain. Does that mean the
Speaker 1: problem is solved or merely postponed? And what about responsibility?
Speaker 1: When nearly half the population struggles with obesity, or when
Speaker 1: anxinxiety and depression are among the leading causes of disability worldwide,
Speaker 1: is it meaningful to frame these as individual moral failures?
Speaker 1: Or are we forced to confront the interaction between biology
Speaker 1: and behavior and environment and forced to rethink what choice
Speaker 1: really means. So these questions sit right at the intersection
Speaker 1: of medicine and society. So to dig in on these topics,
Speaker 1: there's no one better to sit down with than science
Speaker 1: journalist Thomas Getz, who has just come out with a
Speaker 1: new podcast series called Drug Story. Every episode of Drug
Speaker 1: Story takes a single prescription drug like ozembic or xanax,
Speaker 1: or ambient or opioids, and uses that drug as a
Speaker 1: lens to tell a much larger story, a story about
Speaker 1: disease and biology, but also about markets and incentives and
Speaker 1: unintended consequences. Thomas gets is an award win journalist. He's
Speaker 1: the former executive editor at Wired and the author of
Speaker 1: The Decision Tree and The Remedy. He spent years reporting
Speaker 1: on medicine and science, and he has a special eye
Speaker 1: for connecting molecular mechanisms to human behavior and individual patients
Speaker 1: to systemic forces. So here's my conversation with Thomas Getz. So, Thomas,
Speaker 1: you've just come out with a podcast series called drug Story.
Speaker 2: Tell us about that.
Speaker 3: I spent the last ten twelve years on an unexpected
Speaker 3: journey deep into pharmacy. So my background is in journalism
Speaker 3: and I have a background in public health. But I
Speaker 3: kept on thinking about the way we use drugs in
Speaker 3: our society to really treat problems which are manifestations of
Speaker 3: much larger problems. So when you think about the major
Speaker 3: kind of maladies of the modern life, like the heart disease, ibetes, obesity,
Speaker 3: even things like depression or anxiety, a lot of these
Speaker 3: things are manifest because of the world we've built. But
Speaker 3: then the thing that we have, one of the things
Speaker 3: that we have to treat them are drugs. And so
Speaker 3: we have medications and we have prescriptions, and it works
Speaker 3: pretty well for some people, but it doesn't actually solve
Speaker 3: the root problems of what's going on. And so I thought,
Speaker 3: I thought the idea of the podcast is to use
Speaker 3: individual drugs to tell these larger stories about disease and
Speaker 3: society and economics and business, but really to focus on
Speaker 3: the drug as a as a kind of proxy or
Speaker 3: mcguffin to tell this larger story.
Speaker 2: So let's take an example of some of the drugs.
Speaker 1: You looked at the EpiPen for allergies, you look to
Speaker 1: ambient for insomnia, xanax for anxiety, at opiates for pain.
Speaker 1: What kind of through lines do you see when you
Speaker 1: when you examine these different stories.
Speaker 3: Right, Well, with that group you just did, all of
Speaker 3: those drugs, oddly have had pretty massive unintended consequences.
Speaker 2: So like EpiPen.
Speaker 3: You know, EpiPen treats anaphylaxis, which is an allergic reaction,
Speaker 3: a severe allergic reaction. But the reason that that kind
Speaker 3: of we had this upsurge in food allergies over the
Speaker 3: last twenty thirty years was actually because the official guidance
Speaker 3: on food and possible allergic foods was exactly backwards. For
Speaker 3: twenty years, the American Academy of Pediatrics was recommending that
Speaker 3: parents avoid exposing their kids to peanuts and milk and
Speaker 3: eggs early in life. Well, then that was under the
Speaker 3: precautionary principle, the idea that they should you know, people
Speaker 3: should do no harm and if something seems risky, then
Speaker 3: avoid it until the kids are a little older.
Speaker 2: Cow's milk, I assume, yeah, yeah, yeah, cow's milk.
Speaker 3: Yes. Well, turns out that was exactly wrong. So it
Speaker 3: turns out that early exposure is really useful and actually
Speaker 3: helps actate their body in the immune system to these
Speaker 3: possible allergens. And in fact, in countries where kids are
Speaker 3: exposed to things like peanuts from a very early age,
Speaker 3: there are basically no peanut allergies. So that was just
Speaker 3: this massive unintended consequences of well well minded, well intended
Speaker 3: guidance that that was just backwards. And so along comes
Speaker 3: the EpiPen and and it was perfectly timed to take
Speaker 3: advantage of this upsurge in food allergies. And along the
Speaker 3: way they raised the prices click click click, and made
Speaker 3: a lot of money and then had congressional hearings and
Speaker 3: it was it was there was a lot of outrage
Speaker 3: about the cost of drugs, which was really the EpiPen
Speaker 3: was case a. But when you look at these other
Speaker 3: drugs like xanax and ambient for instance, these were drugs
Speaker 3: that at the time when they first came out, they
Speaker 3: thought they were perfect pills. They thought they were magic,
Speaker 3: almost magic pills, and because they worked, because they worked
Speaker 3: really well, like ambient works pretty well to put people
Speaker 3: to sleep, and and xanax worked really well to eliminate
Speaker 3: somebody's anxiety really quickly.
Speaker 2: But it turns out that.
Speaker 3: These these same medications, because they work so well, they
Speaker 3: create different human behaviors, and so people take them too much.
Speaker 3: They tend to abuse them, they tend to get tolerant
Speaker 3: to them, and it's really hard to stop using them oftentimes.
Speaker 2: So those are great examples of kind.
Speaker 3: Of the the unintended results of using these medications in
Speaker 3: great amounts millions of people without enough kind of attention
Speaker 3: paid to what are the possible consequences.
Speaker 1: Yeah, our society is like a giant and amical system,
Speaker 1: and so when you push down over here, you get
Speaker 1: something else happening over here, and so on. Would we
Speaker 1: have been better off without these drugs, though presumably not,
Speaker 1: because if somebody has insomnia, or somebody has high anxiety
Speaker 1: or an allergic reaction, we still want to be able
Speaker 1: to help them.
Speaker 2: What's your take on that.
Speaker 3: Yeah, Yeah, totally. So, yes, these are useful medications. The
Speaker 3: trick is how to use them. So again, thinking about
Speaker 3: xanax or ambient, they're really at this point intended to
Speaker 3: be used for very short periods of time when something
Speaker 3: is acutely wrong. Right, so somebody is having a lot
Speaker 3: of trouble sleeping, then maybe an ambient is appropriate to
Speaker 3: use for a very short duration and then to remove
Speaker 3: it and come up with much more durable, sustainable solutions
Speaker 3: like not using your screen in bed and things like that,
Speaker 3: more behavioral solutions. The trouble is that patients get prescribe
Speaker 3: these drugs and they work, and so the patient reasonably
Speaker 3: it says, why can't I keep on taking these drugs?
Speaker 3: Where they're not necessarily cognizant of the dependencies or the
Speaker 3: talents that their body are acclimating to the drugs. So
Speaker 3: we have to think about these drugs not as the solution,
Speaker 3: but as part of a much order kind of program
Speaker 3: or treatment program. And one of the problems that we
Speaker 3: have in medicine is that a lot of doctors are
Speaker 3: just not trained or don't have the time to manage
Speaker 3: individual therapies closely enough. And it's just a matter of
Speaker 3: time and man hours and billing, and it's the complexity
Speaker 3: of our healthcare system. But what happens in reality is
Speaker 3: people get prescribed to drug, they leave the doctor's office,
Speaker 3: it works, and they just keep refilling it. And so
Speaker 3: for those drugs, those drugs that have potential abuse or
Speaker 3: dependency issues, those are really the ones that we need
Speaker 3: to work out or watch out for. And obviously opiates
Speaker 3: are a prime example of this. You know, they really
Speaker 3: should have only been prescribed for acute pain temporary short durations,
Speaker 3: but they were widely prescribed for even moderate chronic pain,
Speaker 3: and people took them for months, years, and we had
Speaker 3: an epidemic of addiction.
Speaker 1: And speaking of pain medications like opiates, where are we
Speaker 1: now with that now, How that opiates are considered persona
Speaker 1: non grata, what's the future of pain control?
Speaker 3: One of the things about opiates that was that was
Speaker 3: again kind of an undertended consequence, was that they were
Speaker 3: really widely prescribed. When pain experts started to recognize that
Speaker 3: and argue that pain should be acknowledged, should be a
Speaker 3: was worthy of treatment, because pain was really not considered
Speaker 3: and doctors were not treating patients for their pain, so
Speaker 3: they there was a program around the late nineties early
Speaker 3: two thousands called pain as the fifth vital sign, where
Speaker 3: they instructed doctors. They were recommended doctors ask people just
Speaker 3: like they took their blood pressure or their their breathing rate.
Speaker 3: They said, okay, a fifth vital sign would be ask
Speaker 3: your patients whether they're experiencing pain. So it was a
Speaker 3: zero to ten scale. Zero is no pain, ten is
Speaker 3: excruciating unbearable pain, and doctors started asking their patients about
Speaker 3: their pain level. That was one dull in terms of
Speaker 3: flushing out a problem that people a lot of people have.
Speaker 3: Twenty twenty five percent of Americans deal with chronic pain,
Speaker 3: so it's a massive issue. The problem, the unattended consequence
Speaker 3: was that once that was on the table, it became
Speaker 3: something that the physician was then obliged to treat. And
Speaker 3: different people had very different ways of rating their pain.
Speaker 3: So for me, what would be a two, could for
Speaker 3: you be a ten. The doctor was really in no
Speaker 3: way of understanding what the relative concern was. But the
Speaker 3: treatment at hand at the time was opioids, and specifically
Speaker 3: oxy content, which had just been approved as a supposedly
Speaker 3: safe version of an opioid. So it seemed like a
Speaker 3: great opportunity to use a so called safe drug to
Speaker 3: treat a newly cognizant condition. Well, it didn't work out
Speaker 3: that way. It turns out oxy content was highly addictive.
Speaker 3: People would abuse it rampantly. So opioids solved the problem,
Speaker 3: but they, as we've been saying, they created other problems.
Speaker 3: So now or pain therapy are they're trying to find
Speaker 3: new ways of dealing with again that very real problem
Speaker 3: for twenty twenty five percent of Americans. So there are
Speaker 3: new drugs, There are non opioid drugs. There's a new
Speaker 3: one called gernaviks, which was just approved last year twenty
Speaker 3: twenty five, by Vertex Pharmaceuticals. It's a non opioid peripheral
Speaker 3: nerve agent, so it doesn't work on the brain, doesn't
Speaker 3: work on the opioid receptors. They're very insistent and glad
Speaker 3: that it works on the peripheral nerve systems. The trick though,
Speaker 3: is that has only been approved for acute pain, not
Speaker 3: chronic pain. So people can use it for two weeks
Speaker 3: four weeks, but insurance will only cover it, will only
Speaker 3: pay for the drug for that amount of treatment. Now,
Speaker 3: I spoke for my podcast, I spoke to some patients
Speaker 3: who actually have found it very useful for their chronic pain,
Speaker 3: but their pain out of pocket, and that's one of
Speaker 3: the problems. And it's about a thousand dollars a month
Speaker 3: to pay out a pocket, which which is a lot
Speaker 3: of money. So the drug company is trying to get
Speaker 3: evidence that it works for chronic pain on a population level.
Speaker 3: They're trying to bring that to the FDA. That's a
Speaker 3: whole process that is ongoing. But we're still trying to
Speaker 3: find solutions to pain. One of the things that actually works.
Speaker 3: And again you know more about this than I, but
Speaker 3: cognitive behavioral therapy for a lot of these issues turns
Speaker 3: out to be a very effective long term solution. But
Speaker 3: the issues there are access to therapists, access treatment, so
Speaker 3: there are consequences or concerns onto a self.
Speaker 1: I mean, the good news is with apps and AI
Speaker 1: and so on, things like cognitive behavioral therapy can be
Speaker 1: addressed at scale now in new ways totally. Yet people
Speaker 1: still like in a sense taking pills. What's the attraction
Speaker 1: to saying, hey, here's a solution, I swallow this, I'm
Speaker 1: going to be fixed.
Speaker 3: Well, it seems like an easy fix, and one of
Speaker 3: the things I learned was it's only really in the
Speaker 3: last fifty seventy five years that we've had this kind
Speaker 3: of medicine cabinet of drugs like behind in most pharmacies
Speaker 3: there are about two or three thousand drugs behind the counter.
Speaker 3: A lot of those drugs have been only developed in
Speaker 3: recent decades.
Speaker 2: The big boom in the pharma.
Speaker 3: Industry was in the fifties, sixties, seventies, eighties, where we
Speaker 3: had these whole classes of drugs emerge. So they provided
Speaker 3: real answers or apparently provided real answers to all these
Speaker 3: problems heart disease, diabetes, you know, the ps, psychiatric concerns.
Speaker 2: So that's awesome, but on the other.
Speaker 3: Hand, we've only had a few years to understand what
Speaker 3: works best. And one of the things that has always
Speaker 3: surprised me is that the odds of any drug working
Speaker 3: for any individual are roughly a coin flip. It's roughly
Speaker 3: about fifty percent chance. So you go to something like
Speaker 3: an antidepressant and there's kind of a thirty percent chance
Speaker 3: than any given antidepressant is going to work for any
Speaker 3: given patient.
Speaker 2: So what that means is trial and error.
Speaker 3: So patients are kind of start a drug, they take
Speaker 3: it for a few weeks, they see if it works.
Speaker 3: If it doesn't, they go to a different drug. If
Speaker 3: that doesn't work, they go to a different drug. Well,
Speaker 3: on average, it can take a person seeking treatment for depression.
Speaker 3: It can take them six months or more to find
Speaker 3: something that works. We talk about that as a process,
Speaker 3: but it's not exactly a process for the patient's experience, right,
Speaker 3: it's a it's a kind of a trudging through darkness.
Speaker 3: It's a real struggle to get to something that works.
Speaker 3: And that's true not just for psychiatric conditions or chronic pain.
Speaker 3: It's also true for something like heart disease because you
Speaker 3: have other variables like side effects like diarrhea is probably
Speaker 3: the most common side effect to drugs. When you're taking chemicals,
Speaker 3: putting them into the body, your body reacts in some
Speaker 3: ways that are intended, some ways that are not intended.
Speaker 3: Sometimes you can tolerate those unintended consequences, sometimes you can't.
Speaker 3: So that all adds up into the recipe of does
Speaker 3: it work. It's not just a clinical sense, it's like
Speaker 3: does it work for you as a patient, And for
Speaker 3: most conditions, that is a process, and it's a messy one.
Speaker 3: And it's a muddy one, and it has a lot
Speaker 3: of frustration and anxiety and frustration to it.
Speaker 1: It seems to me the central issue is that biology
Speaker 1: is insanely complicated, right. I mean, we often talk about
Speaker 1: the brain is the most complex thing we've discovered in
Speaker 1: the known universe. And so what we're trying to do
Speaker 1: is say, look, here's a here's a molecule of a
Speaker 1: particular shape, and if you take a bunch of those in,
Speaker 1: they'll bind some receptor. And what we're going to hope
Speaker 1: is that that that fixes this whole system, whether that's depression, anxiety, insomnia,
Speaker 1: whatever it is. And it seems almost impossible that that
Speaker 1: will ever work. But sometimes not just things in the
Speaker 1: right direction, or let's say, for fifty percent of patients,
Speaker 1: as you mentioned. So, what is your take on how
Speaker 1: you see the drug industry nowadays? Having been doing this
Speaker 1: drug story for a while now, how.
Speaker 2: Are you seeing this?
Speaker 1: Do you see drugs as miracles of biology that they
Speaker 1: work sometimes or problems for society?
Speaker 3: You're exactly right, these are complicated systems. You've got biology
Speaker 3: and the brain, like the brain is even in these
Speaker 3: biological illnesses, the brain is still at play. Like just
Speaker 3: with allergies, there's this constant fear and concern about that
Speaker 3: people have before they take an EpiPen shot. People who
Speaker 3: have an EpiPen in their purse, they describe to me
Speaker 3: this whole thing about like is a reaction EpiPen worthy
Speaker 3: because they just aren't sure if they should waste that
Speaker 3: shot or take that shot which costs three hundred dollars
Speaker 3: or so. So there are all these psychological concerns that
Speaker 3: get wrapped up into the biological So that's the first thing.
Speaker 3: Now back to your question, like what about the drug industry.
Speaker 3: I think drugs are an amazing accomplishment of our society
Speaker 3: and of medicine and of clinical medicine and of public health.
Speaker 3: Right like, they save and treat thousands of people, millions
Speaker 3: of people every day in this country around the world.
Speaker 3: They save lives, full stop. Drugs are a benefit to society.
Speaker 3: The trouble comes when we expect drugs as you as
Speaker 3: we just were talking about, like you take the pill
Speaker 3: and it's going to fix the problem. That that isn't
Speaker 3: the way it works. On the one hand, biology isn't
Speaker 3: that simple, and two it isn't fixing the larger problems
Speaker 3: of these these deeper social conditions that oftentimes are creating
Speaker 3: the disease or the illness. So there's this great evolutionary
Speaker 3: biologist in at Harvard called Daniel Lieberman, you might know them.
Speaker 3: So he talks about these as mismatched diseases that we've
Speaker 3: put our body like we've designed a world that is
Speaker 3: very comfortable and accommodating, but it's not necessarily the world
Speaker 3: that our bodies evolve to inhabit. And so we a
Speaker 3: lot of these diseases, like heart disease or obesity, are
Speaker 3: the results of the context in which we live. And
Speaker 3: so the diseases we're getting, like like heart disease or obesity,
Speaker 3: are not the inevitable result of human life. They are
Speaker 3: the exact consequence of the world we've built, the food
Speaker 3: systems we've created.
Speaker 1: So this is a good segue into GLP one. Yeah, yeah,
Speaker 1: so let's talk about that, right.
Speaker 3: So glp ones are so I should say when I
Speaker 3: started the episode on GLP one, so ozempic.
Speaker 1: I was, by the way, for anyone who doesn't know,
Speaker 1: GLP one's glucagon like peptide one.
Speaker 2: And these are the drugs that people are taking for
Speaker 2: weight loss.
Speaker 3: Yes, and they they basically you'll describe it better than
Speaker 3: I will, but I'll describe it in simple terms. They
Speaker 3: basically interfere with the signal between your gut and your brain,
Speaker 3: and so they turn off your cravings.
Speaker 2: That's exactly right.
Speaker 1: These are normal hormones that you have in your gut
Speaker 1: that tell the brain, Okay, now you're full, go on,
Speaker 1: do the next thing. And the GLP one drugs are
Speaker 1: what are called agonists to these receptors. They mimic the
Speaker 1: action of these hormones so that they tell the brain, hey,
Speaker 1: no problem, you're full.
Speaker 3: A lot like you're a neuroscientists, you explain it better
Speaker 3: than I would. So the GLB ones what they do
Speaker 3: is they they because they interfere with that signal, they
Speaker 3: turn off what is called food noise in the brain.
Speaker 3: So they stop people from craving these foods that you know,
Speaker 3: eat more and more and more.
Speaker 2: And they have other benefits as well.
Speaker 1: But so what people feel like is just not hungry.
Speaker 1: I'm just not thinking about.
Speaker 3: Food, right, And so sometimes they so people who oftentimes
Speaker 3: had spent decades trying to just not eat one or
Speaker 3: find it easy to not eat one more or not
Speaker 3: at all, and so it's been extremely helpful for individuals
Speaker 3: for whom who have been struggling for years, for decades
Speaker 3: with being overweight, being obese, and the consequent health consequences
Speaker 3: of that like diabetes, joint pain, you know.
Speaker 1: Obstructive sleep, app now, all the things that come with obesity,
Speaker 1: that's right.
Speaker 3: Just being able to move, just being able to live
Speaker 3: a active life.
Speaker 2: And how many millions of people are on these GLP
Speaker 2: one drugs now?
Speaker 3: Well, so there are there are about forty percent of
Speaker 3: Americans ro obese, so that's that's more than one hundred
Speaker 3: million people. And so far about ten percent of Americans
Speaker 3: have taken a GLP one so that's that's thirty million people.
Speaker 1: And when you say have taken, once you start, you
Speaker 1: really have to continue, right, so you are taking people for.
Speaker 3: Most people, but there is there is a it is
Speaker 3: possible or for some I should say this, some people
Speaker 3: do have success in tight trading, in backing off where
Speaker 3: they reach their target weight and they're able to then
Speaker 3: kind of maintain behavioral fixes that that don't make them
Speaker 3: depend on the drugs. But yeah, for most people, they're
Speaker 3: going to be taking the GLP one for the rest
Speaker 3: of their life now, that there's nothing bad about that.
Speaker 2: There's no shame in that.
Speaker 3: If you are prescribed as statin, you will take your
Speaker 3: statin for the rest of your life. If you have
Speaker 3: a high bloodressure medication, you're you'll be taking that for
Speaker 3: the rest of your life.
Speaker 2: Blood thinners rest of your life. Yeah, exactly.
Speaker 3: So it's not that that is that is one of
Speaker 3: the things that we wait one of the ways we
Speaker 3: use medicine. But the thing about golp ones is it's
Speaker 3: very much an individual treatment, right it is. It is
Speaker 3: one person changing the way they eat and it solves
Speaker 3: the problem for them. When you're talking about a population
Speaker 3: wide problem like obesity, again forty percent of Americans being obese,
Speaker 3: soon to be fifty percent, you're looking at really huge
Speaker 3: social issues that when you are prescribing things like glp ones,
Speaker 3: which at present are very expensive drugs, it just becomes
Speaker 3: a really difficult proposition to think about, Okay, well, how
Speaker 3: are we as a society going to afford that, and
Speaker 3: are there other changes that we could be making that
Speaker 3: would be given the amount of money that we would
Speaker 3: be spending, which is something like one point five trillion dollars.
Speaker 3: If you put everyone everyone in America who's obese on
Speaker 3: a GLP one at full price, it would be one
Speaker 3: and a half trillion dollars.
Speaker 2: So that's a lot of money.
Speaker 3: We could do a lot of things with one and
Speaker 3: a half trillion dollars, including change some of the food
Speaker 3: systems that we have. So you just have to think
Speaker 3: about the kind of trade offs and costs.
Speaker 1: So specifically, what you're thinking about is you feel like
Speaker 1: food manufacturers have done things to optimize food for consumption,
Speaker 1: to make them salty and sugary and fatty and small
Speaker 1: and tasty and so on, So you can keep going
Speaker 1: with it.
Speaker 2: This is what you're addressing. Yeah, well there's I mean,
Speaker 2: they have been doing that.
Speaker 1: Right and so and so the point you're addressing here
Speaker 1: is that not only could we be addressing this with
Speaker 1: drugs with JLP ones, but also doing something about the
Speaker 1: food industry. I do have a question, though, what would
Speaker 1: you How would you actually legislate that, because what they're
Speaker 1: doing is making food so that people will buy that
Speaker 1: food and enjoy that food, and you can't exactly legislate
Speaker 1: to say, hey, don't make it as tasty as you have.
Speaker 3: Right, So I'm not saying that you have to legislate it.
Speaker 3: I'm not saying that it requires government intervention. It could,
Speaker 3: but it doesn't require that. I think one of the
Speaker 3: things that's interesting that we're seeing is that when people
Speaker 3: take these GLP ones and the food noise turns off,
Speaker 3: they independently change what they decide to eat. They eat
Speaker 3: more vegetables, right, They don't eat the stuff that is
Speaker 3: full of sugar, fat and salt that is on the
Speaker 3: shelvesult processed foods, and so what you end up seeing
Speaker 3: is that the food companies themselves are trying to anticipate
Speaker 3: new products and develop new products that are in fact
Speaker 3: more healthy, more appealing to the millions of people who
Speaker 3: are taking glp ones. So that is a market based solution, right,
Speaker 3: People's people are changing their behavior and the industry is
Speaker 3: trying to change in turn. That would be wonderful if
Speaker 3: food companies develop healthier, less quote unquote less addictive foods
Speaker 3: that that people would want to buy and and that
Speaker 3: don't don't end up, you know, manifesting in in excess
Speaker 3: body fat and obesity.
Speaker 2: So so some of that is.
Speaker 3: Market based, but there is possibly a role for you know,
Speaker 3: the FDA, the f and FDA stands for food. Food
Speaker 3: labeling is something that they governed. They can control kind
Speaker 3: of claims of being healthy, they can control claims of
Speaker 3: good for you, things like that. So there are ways
Speaker 3: that that regulatory arms can be brought to bear.
Speaker 1: Yeah, and it makes sense because when people are on
Speaker 1: GLP ones and they start eating more healthy foods, more
Speaker 1: salubrious foods, it's because they know that they should be
Speaker 1: doing it, and they no longer have the pull of
Speaker 1: this tempting sugar, salt fat thing over there, so they're
Speaker 1: able to just think through the problem and make the
Speaker 1: right choice. And so making sure the labeling is correct
Speaker 1: so that something doesn't erroneously say falsely say hey this
Speaker 1: is healthy for you allows people to make good decisions
Speaker 1: use the rationality there.
Speaker 3: But I have a question for you, and I'm actually curious,
Speaker 3: what do you make of the idea that foods are
Speaker 3: addictive or might be addictive, that some foods could be addictive.
Speaker 2: Do you think that's true that other I do think
Speaker 2: it's true.
Speaker 1: What's interesting is people sometimes use the word designed there
Speaker 1: as in the companies designed the food. But there's also
Speaker 1: a sense in which it's just evolved. It's a natural
Speaker 1: evolution that you know, people gravitate towards things with more
Speaker 1: salt and fat and sugar and so on, and they
Speaker 1: like these things. So we've always had, you know, junkie
Speaker 1: food like this, and we just have more and more
Speaker 1: of it. So this leads to this interesting question that
Speaker 1: you post in your podcast, which is does it seem
Speaker 1: like it's cheating to take GLP ones? So, first of all,
Speaker 1: what have you seen in your interviews in your research
Speaker 1: do people feel like, hey, this is cheating to take
Speaker 1: this drug and lose weight that way as opposed to
Speaker 1: doing the hard work of going to the gym and
Speaker 1: resisting and using willpower.
Speaker 3: So that is the debate that is that has been
Speaker 3: the debate in part around GLP ones. That has also
Speaker 3: been the debate around obesity itself for decades, that this
Speaker 3: was something that individuals should just you know, take control
Speaker 3: of their own free will, live better, exercise more, lose
Speaker 3: the weight. It's not that easy, and it hasn't worked
Speaker 3: that way because that argument has been made for decades
Speaker 3: and the obesity rate has been climbing every year, so
Speaker 3: there's larger systems at play. Part of the problem I
Speaker 3: think with that debate is that one the foods actually
Speaker 3: are manipulating our brains in ways that are maybe outside
Speaker 3: of our personal control, that they are addictive in some sense,
Speaker 3: some of these foods. The other concern is that this
Speaker 3: debate around cheating is one where we are blaming people.
Speaker 3: There's still this kind of this notion of blame and
Speaker 3: responsibility for obesity in particular, which we don't necessarily have.
Speaker 3: There's a lot of stigma to obesity that we don't
Speaker 3: have with other diseases, even something like high cholesterol. It's
Speaker 3: just often behavioral based. It doesn't appear you don't look
Speaker 3: when you have high cholesterol. It doesn't really look like
Speaker 3: you do. So there's not as it's not as easy
Speaker 3: to attribute stigma. But it's also a particularly American problem
Speaker 3: or American argument about individual responsibility. Other countries, other cultures
Speaker 3: do not have as strong a history of individualism and
Speaker 3: individual responsibility, where there's two edges to the sword that
Speaker 3: you are both have the freedom to pursue your own interests,
Speaker 3: but also you have to be in control and suffer
Speaker 3: the consequences of your decisions and choices. That is a
Speaker 3: very American way of looking at individual choices, and again
Speaker 3: Europe other societies do not have as strong a strain
Speaker 3: of individualism. They have much more of a commonality or
Speaker 3: communal notion of health and responsibility, and so they don't
Speaker 3: kind of have this culture of blame, which is problem
Speaker 3: again uniquely American one.
Speaker 1: So this is interesting because it all comes down to
Speaker 1: this question of whether obesity is a choice. Right, you're
Speaker 1: saying with the double edged sword, you know, you have
Speaker 1: all those freedom to do things, but also you're responsible
Speaker 1: for your choices. But this is really the heart of
Speaker 1: the issue is biologically there's a huge amount of variation
Speaker 1: on any axis that you measure, and some of these
Speaker 1: axes have to do with, for example, how much food
Speaker 1: noise one has, how saated one can be when one eats,
Speaker 1: and so on. There are genetic differences, there are you know,
Speaker 1: childhood differences and so on. All these things add up
Speaker 1: to people being quite different from one another. So the
Speaker 1: question here is about choice, because this doesn't take weigh
Speaker 1: somebody's choice, but it does bound it. And this is
Speaker 1: I think the important part to recognize with all this
Speaker 1: is that we all make choices and we're all bound.
Speaker 1: We're fenced in by our biology, and sometimes we're fenced
Speaker 1: in differently so the answer is both, we're you know,
Speaker 1: we're making decisions, but we don't come to the table equally.
Speaker 2: But I totally agree with that.
Speaker 3: I would also say we're fenced in by our society
Speaker 3: and culture and by industry. So in the nineteen eighties,
Speaker 3: Nabisco and Craft, that two of the largest food companies
Speaker 3: in the world, were bought by big tobacco companies, and
Speaker 3: big tobacco brought all the science and engineering and marketing
Speaker 3: that they had learned in cigarettes to food, and so
Speaker 3: they started to create snack foods that were even better,
Speaker 3: even more irresistible. Now you might say, like that's just
Speaker 3: good business, that was just smart, you know, of their markets,
Speaker 3: but there was a recent study that actually showed that
Speaker 3: the food products that were sold by those companies when
Speaker 3: they were owned by big tobacco were actually eighty percent
Speaker 3: higher in salt, sugar, and fat than products that were
Speaker 3: owned by non tobacco companies. So they were actually engineered
Speaker 3: to be very high in those ingredients because people like them.
Speaker 3: As you say, because that's what people are choosing. But
Speaker 3: at what point does that notion of choice and choosing
Speaker 3: certain products just because they taste better, just because we
Speaker 3: crave them. At what point does that stop being an
Speaker 3: individual decision and start being something that you know. There
Speaker 3: are larger structures and forces at work. There's marketing in
Speaker 3: terms of the grocery stores, and we're what's being put
Speaker 3: at light level, that's paid for, that's placement. There's the
Speaker 3: commercials that were being told these foods are irresistible and
Speaker 3: that's a good thing. So those are all the contexts
Speaker 3: that I think also surround these ideas of individual choice
Speaker 3: that have a great deal of influence and have had
Speaker 3: a great deal of invisible influence on our diets and
Speaker 3: on our behavior in the past decades.
Speaker 1: Absolutely right, And I think the way we can put
Speaker 1: this together is to think about the fence lines around
Speaker 1: your own behavior, given your biology, in the context of
Speaker 1: the world that you're in. Some people will just have
Speaker 1: the capacity to watch it Rito's commercial and resist and
Speaker 1: not pick them up. And other people will watch it
Speaker 1: and they have so much food noise from that, and
Speaker 1: they have so much craving, and they're influenced by the
Speaker 1: marketing and so on, and they go for it. The
Speaker 1: question is, given your genetics and your experience, what is
Speaker 1: your capacity to resist and make good choices in the
Speaker 1: context that you're in.
Speaker 3: Yeah, and it does have I mean there are socioeconomic
Speaker 3: variables here too. Wealthier people have more opportunity and more agency.
Speaker 3: One of your former colleagues, Albert Bendora, talks about self efficacy,
Speaker 3: the ability to form our own make our own choices,
Speaker 3: the confidence that we have to guide our own paths.
Speaker 3: That is something that that wealthy people have much more
Speaker 3: of than people who are not wealthy.
Speaker 2: They they you know, more.
Speaker 3: Stresses in life. So those are all those are all
Speaker 3: issues as well.
Speaker 2: Just before we go off GLP ones.
Speaker 1: And my question is there are all these other consequences
Speaker 1: that they're having that are extraordinary, like people are giving
Speaker 1: up smoking and gambling and other sorts of things.
Speaker 2: What's your take on this?
Speaker 3: Well, it makes sense right again, you're the neuroscientist. I'm not,
Speaker 3: but they seem to this. They seem to be things
Speaker 3: that are also affected by these pathways. So substance abuse, drinking,
Speaker 3: drinking alcohol to access. Uh, these are all behaviors that
Speaker 3: where we're hitting our pleasure centers, we're hitting our dopamine
Speaker 3: receptors whatever it is they work on our brain and
Speaker 3: GOLP ones somehow turn it off, and it's I think
Speaker 3: where they're just starting to do clinical trials in these areas.
Speaker 3: It's extremely promising. It's extremely hopeful for human health much
Speaker 3: more broadly. And remember, we're getting much stronger, better, more
Speaker 3: effective GLP ones in the pipeline. We're going to start
Speaker 3: having oral GLP one's pills. Right now it's injections. So
Speaker 3: once we get to pills and that are going to
Speaker 3: be more efficacious at fixing or addressing some of those behaviors,
Speaker 3: some of those issues. I think the doors are wide
Speaker 3: open to how these drugs are going to help us
Speaker 3: in the years ahead.
Speaker 1: Now, by the way, you made a very interesting calculation
Speaker 1: in your podcast, which is that it would cost, as
Speaker 1: you mentioned earlier, one point five trillion to get let's
Speaker 1: just say we're talking about ABCD to get everyone with
Speaker 1: ob city in America on these trucks. But what you
Speaker 1: calculated is why this might actually make sense to spend
Speaker 1: that money.
Speaker 3: Yeah, well that's with the caveat that's full list price.
Speaker 3: So you know they're talks about doing deals with the
Speaker 3: drug companies to lower those prices. But roughly that had
Speaker 3: one point five trillion dollars.
Speaker 2: If it were that ye, why would it be worth it.
Speaker 3: Yeah, So the reason it's worth it, I think is
Speaker 3: because we spend hundreds of billions of dollars. We spend
Speaker 3: five trillion dollars on healthcare in this country every year, right,
Speaker 3: more than any other nation on Earth. And out of
Speaker 3: that five trillion, we spend hundreds of billions of dollars
Speaker 3: on obesity. We spend hundreds of hundreds of billions of
Speaker 3: dollars on diabetes, hundreds of billions of dollars on heart disease.
Speaker 2: So if we're.
Speaker 3: Addressing obesity, which is upstream from all of these other conditions, well,
Speaker 3: we would be chipping away at the amount we're expending
Speaker 3: on those issues, right, So there it wouldn't be kind
Speaker 3: of erasing them altogether, but we would spend far less
Speaker 3: on diabetes if we had far fewer people go from
Speaker 3: obesity into diabetes. That's one point, But the other issue
Speaker 3: is really I think goes to kind of quality of
Speaker 3: life and quality of health span, Like how do we
Speaker 3: help people have the best possible life that they can,
Speaker 3: the best possible health they can before they get sick.
Speaker 3: And that's one of the things that's so promising about
Speaker 3: these GLP ones is they're really good at prevention, and
Speaker 3: so if we can if we can help people pay
Speaker 3: that one point five trillion dollars to give people better
Speaker 3: lives instead of waiting for them to get sick and
Speaker 3: go in the hospital and you know, surgery and all
Speaker 3: these other things that we spend that five trillion dollars on.
Speaker 3: That's that's probably a good argument to spend that money.
Speaker 1: That was my interview with Thomas Getz. Thomas's podcast Drug
Speaker 1: Story dives into many topics that we didn't touch on here,
Speaker 1: like lipiitour and heart does ease, or zoloft and depression,
Speaker 1: or xanax and anxiety, or ambient and insomnia and so on.
Speaker 1: So I just want to summarize by hitting three issues first.
Speaker 1: From the point of view of biology, every drug is
Speaker 1: a hypothesis.
Speaker 2: It is a guess.
Speaker 1: It's a carefully engineered intervention into a system that we
Speaker 1: only partially understand. We identify a receptor or a pathway
Speaker 1: or a circuit, and we nudget. Sometimes the result is great,
Speaker 1: you get meaningful relief. Other times the effects are delayed,
Speaker 1: or they're indirect, or they're only visible years later, when
Speaker 1: millions of bodies have already been changed. The fact is
Speaker 1: that even with all the massive progress in biology, we
Speaker 1: still don't have predictable outcomes, and we're not going to
Speaker 1: for as far as we can squint into the future,
Speaker 1: We're always working to scratch out insight to a vast
Speaker 1: dynamical system that is shaped by evolution and development and experience.
Speaker 1: So when we intervene chemically, we always want to act
Speaker 1: on a single system, but we essentially never can. Instead,
Speaker 1: all we can do is perturb a system that's going
Speaker 1: to adapt and compensate, and that often surprises us. For
Speaker 1: the most part, medicine just can't tackle the complexity of
Speaker 1: everything happening under the hood, at least not yet. Medicine
Speaker 1: can't simulate the entirety of your biology, at least not yet,
Speaker 1: and certainly can't simulate your biology decades into the future
Speaker 1: to see what the long term effects of drugs are
Speaker 1: or aren't. When you're dealing with exceedingly complex systems like
Speaker 1: the human body, it's just impossible to have certainty. And
Speaker 1: that's exactly why so many of the drugs on the
Speaker 1: market come with complicated stories that stretch beyond the biology.
Speaker 2: Into societal issues.
Speaker 1: The second thing I want to point out is the
Speaker 1: question that is always there about the distinction between normal
Speaker 1: human experiences and medical conditions. If you have grief after
Speaker 1: you lose a parent, or sadness after some hardship, or
Speaker 1: anxiety in stressful moments, those shouldn't be thought of as diseases.
Speaker 1: Those are just appropriate human responses to life. They become
Speaker 1: medical diagnoses when they persist without a clear cause, when
Speaker 1: they become chronic, when they start to impair your daily functioning,
Speaker 1: like we see with clinical depression or anxiety disorders or
Speaker 1: chronic pain. In those cases we can say, okay, the
Speaker 1: issue is not just a specific event or injury, but
Speaker 1: an ongoing physiological state, and treating it medically can both
Speaker 1: be appropriate and life changing. And modern medicine has made
Speaker 1: unbelievably great progress in addressing these conditions with drugs as
Speaker 1: part of broader treatment approaches. But the boundary between normal
Speaker 1: human suffering and diagnosable disease, that boundary is subjective sometimes
Speaker 1: and it's always blurry, and that raises really difficult questions
Speaker 1: about when treatment is warranted and how society decides which
Speaker 1: conditions justify large scale medical intervention. And these are questions
Speaker 1: for which there are no simple or definitive answers. Finally,
Speaker 1: I want to highlight Thomas's view that many of the
Speaker 1: conditions we now medicate, things like obesity and anxiety and
Speaker 1: pain and insomnia, these are signals, their messages from nervous
Speaker 1: systems doing their best to regulate themselves in a world
Speaker 1: that often pushes them out of equilibrium. Drugs can help,
Speaker 1: sometimes they help enormously, but they also reveal the limits
Speaker 1: of a purely pharmacological solution. They remind us that biology
Speaker 1: and culture are never cleanly separable, and that treating downstream
Speaker 1: symptoms without addressing upstream causes is only going to take
Speaker 1: us so far. So we're probably never going to find
Speaker 1: the perfect molecules that finally fix everything. But perhaps we'll
Speaker 1: get better at integration drugs alongside changes that we're able
Speaker 1: to make in our environment and our behavior, in our
Speaker 1: policy and our technology, we'll get better at pairing molecules
Speaker 1: with psychology and neuroscience and social design. So to my mind,
Speaker 1: one of the most important things about understanding prescription drugs
Speaker 1: is resisting simple stories, and Thomas does a good job
Speaker 1: with that. Prescription drugs have changed the world for the better,
Speaker 1: and also their stories can be complicated. So what we
Speaker 1: can do is keep researching. We can build bigger and
Speaker 1: bigger simulations with the help of massive computational models.
Speaker 2: We can leverage AI to understand those models.
Speaker 1: We can measure carefully, we can watch for unintended consequences.
Speaker 2: And that's what science does.
Speaker 1: It just keeps getting better, such that in one hundred
Speaker 1: years from now, when some future broadcaster makes Drug Story two,
Speaker 1: the interplay between our drugs, our bodies, and the world
Speaker 1: we've built will hopefully be much more straightforward. Go to
Speaker 1: eagleman dot com slash podcast for more information and to
Speaker 1: find further readings. Join the weekly discussions on my substack,
Speaker 1: and check out and subscribe to Inner Cosmos on YouTube
Speaker 1: for videos of each episode and to leave comments Until
Speaker 1: next time. I'm David Eagleman, and this is Inner Cosmos.