Is Addiction a Brain Disease? With Dr. Mark Gold, MD

Montare Media presents Season 2, episode 23 of the Discover U Podcast with JD Kalmenson:  Is Addiction a Brain Disease? With Dr. Mark Gold, MD

Learn More about Montare Behavioral Health: https://montarebehavioralhealth.com/about/digital-library/

JD Kalmenson’s interviews Dr. Mark Gold, MD to understand the history of chemical dependency, and process addictions, seen through the lens of a prominent researcher and medical doctor. Dr. Gold gives the audience an idea of how difficult it was to get proper treatment for any kind of addiction within the hospital system as far back as the 1970’s, and how his work transformed our understanding of addiction from a lack of will power to a brain disease. Discussion of various effective treatments follows. 

Over his 25-year career at the University of Florida, Dr. Mark Gold has been a Professor of Neuroscience, a physician-scientist at UF McKnight Brain Institute, and a university bench-to-bedside leader. He became UF Distinguished Professor, Eminent Scholar & Chairman of the Department of Psychiatry. He was the Founder of the Division of Addiction Medicine & Florida's Recovery Center, UF Psychiatric Hospital, and outpatient centers from Gainesville to Vero Beach. His theories have changed the field, stimulated research, and led to new treatments. With his mentor Herb Kleber, Gold helped change addiction psychiatry to disease management, including evidence-based care that evaluates & treats co-occurring disorders. Gold's work proved that cocaine caused a relative dopamine deficiency along with anhedonia, and pioneered the study of second-hand tobacco, cannabis, and opium smoke. Gold and Kelly Brownell co-chaired the historic Yale Conference on Food and hedonic overeating. This work has led to collaborative research on the drug-like effects of some food and the use of anti-addiction medications in obesity. Since his retirement, Gold has continued his work as a researcher, mentor, and inventor. He is on the Board of Directors of various education, intervention, and prevention organizations, including CADCA and DEAEF. And he has received numerous Lifetime Achievement awards for his pioneering work.

Host Kalmenson is the CEO/Founder of Renewal Health Group, a family of addiction treatment centers, and Montare Behavioral Health, a comprehensive brand of mental health treatment facilities in Southern California. Kalmenson is a Yale Chabad Scholar, a skilled facilitator, teacher, counselor, and speaker, who has provided chaplain services to prisons, local groups and remote villages throughout the world. His diverse experience as a rabbi, chaplain, and CEO has inspired his passion and deep understanding of the necessity for effective mental health treatment and long-term sobriety.

Follow JD at JDKalmenson.com

Transcript

JD Kalmenson:
Welcome to another episode of Discover U, our podcast exploring innovative and effective solutions to issues in behavioral health. I'm JD Kalmenson, CEO of Montare Behavioral Health, a family of dynamic treatment centers in Southern California. I am so honored and excited to introduce you to our wonderful, incredible guest today, Dr. Mark Gold. Dr. Gold is a true pioneer and leader in so many areas of medicine, and we are absolutely thrilled to have him here to share some of his insights in the field of addiction medicine with you. Just a brief summary of the long list of accomplishments. Over his 25-year career at the University of Florida, Dr. Mark Gold has been a professor of neuroscience, a physician scientist at UF McKnight Brain Institute and a university bench to bedside leader. He became UF distinguished professor, eminent scholar and chairman of the Department of Psychiatry, and he is the founder of the Division of Addiction Medicine and Florida Recovery Center, UF Psychiatric, Psychiatric hospital and outpatient centers from Gainesville to Vero Beach to Vero Beach. His theories have changed the field, stimulated research and led to new treatments. With his mentor, Herb Cleaver. Dr. Gold helped change addiction psychiatry to disease management, including evidence-based care that evaluates and treats co-occurring disorders.

JD Kalmenson:

Welcome Mark. So happy to have you with us today.

Dr. Mark Gold:

It's good to see you look great.

JD Kalmenson:

Thank you. Thank you. And you don't look too shabby either. Maybe we all thank you so Yes. And maybe we all age with such grace and dignity and it's

Dr. Mark Gold:

Good to have been a friend.

JD Kalmenson:

Yes, yes. So, wow. You've started your work in addiction medicine decades ago when addiction was seen by many as a moral deficit. Can you talk about the progress that you've seen in understanding addictions as a brain disease and the phases that you've been instrumental in that development?

Dr. Mark Gold:

So JD, that's a really great question. And the first part of it is how nice it is for someone like you that's doing the real work right now, helping people to ask an older person what it was like in 1971, in 72, in 75. So, I mean, I could pick a point in time. So I'll pick 1975. 1975, I'm in the Yale University Hospital Emergency Department. I'm giving Naloxone or Narcan to people who've overdosed. And after they wake up, I call the general hospital unit and they say, Dr. Gold, that's great that you saved this person. And it's great that we have the medication Naloxone, but we don't accept drug addicts in this hospital. So where do we take them? They said, well outside, maybe a church basement, maybe Herb Cleaver has a storefront clinic. So, we would physically take them out of the emergency room after being rescued and try to get them seen in a community-based treatment. This happened to us again in alcohol. You'd say, well, maybe they didn't want people who'd used needles or injected heroin in ‘75. Nope. Same for alcohol. You could have alcoholic hepatitis and not be acceptable for admission to the internal medicine service. So really it was more than stigma. Not only was there no discipline of addiction medicine, no training program, no fellowship, but honestly, anyone who had any sort of substance use disorder or substance induced problem was left to fend for themselves.

JD Kalmenson:

And that was really the result of the way society viewed it. It wasn't a behavioral health issue. It was seen as a disciplinary moral deficit of sorts as just a problem of willpower. Is that right?

Dr. Mark Gold:

Yeah. It was seen as an embarrassment in that why can't these people hold their alcohol?

JD Kalmenson:

Just get it together,

Dr. Mark Gold: 

I tried to understand where in the brain drugs went, what happened in the brain when they went there and then tried to figure out strategies to undo it. In the process I became part of the answer, how do we know that addiction is a disease of the brain? Now, addictions other sorts of things too, but how do we know that? A lot of that was based on our own work? So I'd say the pivotal, I mean, here I'm a beginning doctor and I'm in the emergency department and I'm learning about this.

I don't like it. I went to Woodstock. I was a, helped people who had bad trips and had problems. 

And I actually went from there to a laboratory and did rodent and other experiments to understand what happened in an overdose, what happened in a person who took opioids and developed an addiction, what happened in withdrawal, and then tried to develop treatments to undo it. So my first big accomplishment in the field that led to an understanding of opioid action, opioid dependence, opioid withdrawal, the mechanism and how to reverse it was done in 1978. And then I moved on to cocaine after that. So I've been like, I went from one drug to another to another, because socio culturally Drug epidemics don't ever stay still. I mean,

JD Kalmenson:

Yeah. Why is that? 

Dr. Mark Gold:

The greatest thinker in this was a researcher, believe it or not, a psych addiction psychiatrist, now deceased. His name is David Musto, M U S T O. And he wrote a classic called The American Disease. And in it, he said that it's more generational forgetting. So the current generation, for example, has forgotten that cannabis could cause psychosis, and that even if it doubles the schizophrenia rate from a half a percent to 1%, that's a lot of misery. Or that you follow me?  Or that intravenous drug use, intravenous opioid use is ipso facto dangerous. People forgot that. And now they, we've added fentanyl to the mix, but even that hasn't stopped people from injecting themselves with street opioids. So, I think his point was a good one. 

 he also said that opioid epidemics end with stimulant epidemics. And if you look at the data closely, you'll see that the current opioid epidemic is horrific. And we haven't had anything anywhere like it in terms of deaths. But behind it are sneaking in methamphetamine deaths and cocaine deaths, methamphetamine use, and cocaine use. So it does appear that that's going to now supersede the opioid crisis. 

JD Kalmenson:

I mean, the disease itself, it's ever evolving and it's always progressive. Yesterday's high won't give you your fix for today. So that's an amazing sort of evolution that you were witness and actually a part of. And at what point would you say it's the eighties and the nineties where it starts being approached as the disease with neuro-scientific implications? And then there's the advent of the innovation of medication assisted treatment, which I'd love to hear your insights on how that evolved. And today it's probably, I'd say the number one method. Of course, you have the AA, the 12-step program, and a lot of the therapeutic interventions. But as far as the highest success rates, it's probably with MAT. 

Dr. Mark Gold:

Yeah. So I think Herb Cleaver and I got the ball rolling on that in ‘75. Cause we used Naloxone. People forget, but it was rarely used in emergency settings for overdose reversal. It was used at that time as part of the anesthesiologist bag of tricks. If they gave people too much opioid in a surgery, they'd use it to reverse it. But when we started emergency room, they were in these kind of vials, and I still have scars on my fingers from opening the vials and cutting myself and trying to rescue people. And they came, anyway. So we started with naloxone. Then there was a longer acting naloxone called Naltrexone, which was developed interestingly enough by the same scientist at Rockefeller University. He invented Naloxone and Naltrexone, both of which were invented for use in endocrinology. It wasn't invented for opioid use disorder or reversal. And that naltrexone then we used as an alternative to methadone. So we had overdose reversal with naloxone. We had M A T with methadone, we had longer term antagonist, M A T like Naltrexone. All of that was pretty much in place in the mid seventies. 

JD Kalmenson: 

Just to those who are listening who are not familiar with the function and what sort of healing agents or helpful agents these medications possess. So if you could just give us a brief…. 

Dr. Mark Gold:

MATs work. They work as part of a treatment program. You can't just replace the drug. It's not like these people have an opioid deficiency syndrome and you just give them the opioid and they're cured. They have a lot of life problems to work out. And without that, they'll relapse as soon as the MAT stops. That's real. There's very strong data that shows that. 

JD Kalmenson:

You mentioned that medication assisted treatment really is most potent and its efficacy is largely tied to a co-occurring treatment. A regular traditional sort of treatment model where the client is actively engaging therapeutically whether with a group or individually with a therapist and a doctor and not just relying on the medications. When combined, combining both treatment and medication assisted treatment together and especially cuz the medication assisted treatment really allows for a certain calmness and a certain ability to be focused and not be so distracted by the deficiency or by the temptation and the urge of the disease. What's the success rates that we're seeing when you combine both of them together and you have a longer model, let's say 90 days, six months? 

Dr. Mark Gold:

So there's a difference between the data reported in the FDA trials and what's reported by people in their own programs. And there's a lot of selection differences. And there also is the difference as to what you might consider a success. So let me just try to break that out. If success is you are taking the M A T, then at six months, you know, should expect 60 to 80% of the clients to be taking their MAT, 

 Then you have the next thing like overdose. So that's another outcome measure. It's clear if you're on any of these MATs, your risk of overdose is markedly decreased, again in that kind of range, 60 to 80%. If you say getting a job, it's different. If you say returning to the person you were before, different. And so that is really where your programs have had a special focus, which is that the person who's just thinking about drugs, just using drugs and ignoring their family and ignoring their community and not doing the things that they did before that brought them pleasure. To return them to the person that they were before all of this bad learning does not mean replacing their drug. That means giving them a chance to grow spiritually, emotionally, and develop a sense of community and also a giving nature, which is very different than a taking nature that so often defines addiction.

JD Kalmenson:

That's right. That's exactly right. I mean, when you talk about the idea of flow of people experiencing their greatest moments of ecstasy, elevation, and transcendence when they're connected to something larger than themselves. And that experience not only gives that surge and that real adrenaline of sorts, but it also allows us to get out of our head as it were. And that's a very healthy space to be and not being so self-absorbed that all the slightest ruffling of feathers is enough to do us in. So medication assisted treatment, obviously the data really backs it as having so much more efficacious results in, and I love how you broke that down, especially in the overdose department and in many others. What do you say to the AA criticism that you're replacing one drug with another drug and that how can one really become better when they're constantly, so to speak, during that entire treatment episode, they are using some type of a mind-altering substance. 

Dr. Mark Gold:

Since 1975, I'm a proponent of M A T, I'm an MAT first guy. And even when I wouldn't use Methadone I'd use Naltrexone or injectable Naltrexone plus safety. The first rule is don't do harm. And by telling someone that they shouldn't do this or that, we do expose them to risks and we shouldn't be naive to those risks. And for opioid use disorder, the risk is death. For cocaine use disorder, now that fentanyl is in the drug supply, the risk is death. But keep in mind, both fentanyl and methamphetamine, we have really no MATs. So if we didn't have a drug treatment infrastructure that could treat people without MATs, we'd really be lost right now. And how about the fastest growing substance use disorder in under 21 year olds, the number one cause of going to addiction medicine experts for evaluation under 21 is cannabis use disorder. And again, no MAT. So in a big tent model I like Methadone, I like Naloxone, I like Naltrexone, I like Suboxone. I'm a proponent of science and evidence, evidence-based treatment. But keep in mind, we have lots of people with these other substance use disorders and we wanna help them too. We wanna help them stay alive and prosper. 

JD Kalmenson:

That's right. No, that makes a lot of sense. And you know, alluded to something that is of particular interest to me, and I still think that it's an under-researched area within addiction medicine. The identifying the unique pathway and causation that leads somebody to end up becoming dependent on mind altering substances is not emphasized enough. In other words, there's many different pathways that lead somebody to addiction. And invariably, when somebody's addicted, there's going to be an issue in and of itself across the board, there's going to be a trauma, there's going to be a breakdown of functionality in virtually every area of their life that that's going to induce trauma, that's going to create a lot of mental health issues. But the pathway that led them to this state of a fierce to begin with is something that is so profound. And I believe if we have enough data amassed and accumulated, we would be able to hone in on the unique specific intervention that has a much stronger effectiveness for that specific pathway and causation. 

So, really taking a lot of the source origin and where this came from, the color and the context, and making it a part of the master treatment plan as well as a part of the aftercare plan. That's pretty largely absent because right now the field is dominated by symptom-based diagnosis. And just as an example, if somebody is struggling with unresolved mental health, then obviously the primary thrust of their master treatment plan has to deal with that trauma or to deal with that bipolar to deal with the PTSD or whatever it is that on the mental health side that they were not treating. But if somebody comes from very loving and nurturing family and has no discernible in your face mental health diagnosis, but just always struggled from a feeling of emptiness, a void, a vacuum, and you know, you can call it a certain spiritual deficiency, they need a hyper injection of meaning and purpose and they need to be engaged with being a very kind person for their baseline equilibrium to be okay, then we know that's a direction that they're gonna have to focus on in the treatment plan and on a long term basis when they leave treatment.

And so really tying these factors to the statistics and the research, I don't seen that being talked about enough.

Dr. Mark Gold:

No, you're right. I think in other parts of medicine that I work in, personalized medicine has been the big difference. That's basically what you're talking about. And that's right. In oncology we tend to personalize it based on the host, what genes you have and then the mutation in the cancer. So with those facts small numbers of people can be cured rather than just treated with general anti-cancer treatments. And you've seen people have cures, like Jimmy Carter had a tumor that could be recognized and it went to his brain and everybody was sure he was dying and turned out the mutation was one for which there was a personalized treatment and that cured him. So someday that will happen. There'll be people who have a very high susceptibility to opioids. It could be based on metabolism of genetic. Some people can drink a lot of coffee and nothing happens. It could be based on other factors. I think there's going to be differences in the pleasure systems, you this from talking to people and psychiatrist know this, some people wake up in the morning, they're happy, some people wake up in the morning, they're miserable, some people are miserable as the day goes on, some people are happy as the day goes on, there's a wide variation and we take none of the host factors into consideration in addiction. 

JD Kalmenson:

So I wanna ask you a question that anybody who is not personally exposed to addiction doesn't have a family member struggling with addiction, they're probably gonna have this question in one way or another. Folks on the outside look at addiction like a compulsion that compromises people's free will. And that's largely the result of your work and other scientists who have categorized it as a brain disease. How much free will can a person have even when they're addicted? So many wanna get better and you have to find themselves not being able to get better because they have the disease. So how do you get out? How do you free yourself from these shackles? 

Dr. Mark Gold:

No one knows. It's a rabbinical question.

JD Kalmenson:

<laugh>.

Dr. Mark Gold:

I mean Nora Volkow, the head of NIDA, actually wrote a paper once on addiction and free will, which is interesting because it's not one of her highly read or referenced papers. I'd look at it like this. It is really hard to not eat. So once you induce a new primary drive, it is really the way out on the bell curve exception that can go on a hunger strike. We spend many years never having sex, then we have sex and then we spend many years having sex. It's again, very, very difficult to conceptualize not eating, not drinking, not having sex. It's possible. But if drugs induce a primary drive state, at some point in time they demand to be considered and take over your consciousness like starvation and drive your behavior like starvation. So in a way, the MAT theory and practice is based on taking that off the table. So you don't have that drive state anymore. And you can then do the other psychological and psychiatric work. Some states have involuntary commitment for addiction and the basis of their statutes is often it's involuntary. After a certain period of time, the person is hopelessly dependent and does not have free will. I haven't been on the, you lose free will side, but do empathize with how difficult it must be to be able to say no to a drive that takes over every waking moment.

JD Kalmenson:

Yeah, I mean the law has clearly taken a stance. The fact that we criminalize possession of drugs. It is a very clear stance that we're holding folks accountable and telling them that regardless of how hard this might be for you, you do have free will. Otherwise, it would be part of the insanity plea group.

Dr. Mark Gold:

Yeah, I mean it's we're gonna have a lot of experiments, sadly in other countries. Of course, China's capital punishment, often for drug use they have in the past had even surgical approaches, neurosurgical approaches for addiction and opioid use disorder. Russia is not far behind other countries. So there will be other countries to look at. And it, it's ironic, and maybe not, I mean you are more of a philosopher than me, but the source countries for fentanyl are often countries that have

JD Kalmenson:

The strictest laws.

Dr. Mark Gold:

Extreme punishments. Yeah,

JD Kalmenson:

Extreme. That's why they're shipping it out. Yeah. They can't do…

Dr. Mark Gold:

Maybe it's a weapon, maybe they do see it as a weapon against us, but I can't put myself in those people's heads.

JD Kalmenson:

That's right. No, it's difficult. And like you said earlier, the most important thing is to be empathetic. And regardless of how much free will they do or they don't have and how it looks on a pie graph the reality is that it is severely compromised. And for that we have to really have incredible compassion and empathy and not judgment. On the data side, would you say that there are certain age brackets that are more vulnerable and susceptible to addiction?

Dr. Mark Gold:

Definitely. So the brain is not fully even gyrified, meaning those little wrinkles on the top until 21 for women and 25 if ever for men. So the brain doesn't develop very fast. And if you add drugs in there and they do interact with the brain's primary reinforcement pleasure areas, the chances that be they become insinuated into what's normal or be confused as part of an adolescent brain development. I suspect that we're gonna find that teen age of onset volume of use, duration of use during the time of brain development is a different disease than use when you're 45. That starts when you're 45. You know, you’ve looked at the recent educational test scores and you can see just how fragile the young people are. 

JD Kalmenson: 

That's very interesting. As far as addictions go, a process addiction seems to be very different than the other types. Can you give us a little bit of an overview on that? 

Dr. Mark Gold:

This is a really hot area and I've worked on speeding as an addiction or at least stimulating in young people, gaming and gambling as an addiction. Gambling's the only one that's in the DSM right now. And food. And our work on food started with sugar at Princeton. And my colleagues Bart Hubble, Nicole Lavena, and I think it's pretty clear that sugar and high fructose corn syrups have addictive like interactions with the brain and maybe high density foods as well. So the way that these things are defined is that their behaviors or food stuffs that mimic drug reinforcement, and cause continued compulsive use on the basis of access to just think about slot machines and so forth. But the area has real experts, Mark Potenza, there are big experts out there that are studying this. And right now, the DSM has paused at gambling, but sex is being considered sexual compulsivity. 

JD Kalmenson:

You mean paused that gambling as in that they haven't continued to include anything else

Dr. Mark Gold:

as process,

JD Kalmenson:

But it still is considered an addiction gambling according to the DSM. 

Dr. Mark Gold:

Yeah. Yes.

JD Kalmenson:

So why do you think that they're stalling? 

Dr. Mark Gold:

I present, I got the chance to present sugar and I don't know, I'm not on these. You have to be in the crowd I'm just a researcher. I end up, the researchers are the ones that throw a bunch of things on the wall,

JD Kalmenson:

Right

Dr. Mark Gold:

But I suspect they were just waiting to see how it turned out, having gambling included. And now that it turned out well, that gambling's been corroborated by most experts, that there's age of onset is actually a gateway drug theory of gambling based on teenage gambling and lottery that Mark Potenza studied longitudinally. So there's so many similarities now. So I just suspect that the DSM committee will expand that now that gambling hasn't hurt them. Maybe the next one is gaming, right? Because people do game to death. 

JD Kalmenson: 

This has profound implications for the average person because if the DSM characterizes a certain activity with the potential to become addicted to that activity and to subsequently go to treatment, then the entire healthcare portion of the process, the solution to the problem will be covered by insurance, by government, by private insurance, et cetera. It'll become a healthcare issue as opposed to you're on your own and figure it out. So the DSMs decision has wide ranging implications. 

Dr. Mark Gold:

I agree. And again, I'm always on the side of don't blame the patients and until we get there,

JD Kalmenson:

Yes,

Dr. Mark Gold:

We see it in obesity right now, we blame the obese patients. They live in areas without farm to table, without fresh food options with only high density food options. And they tend to stimulate their own taking like a drug.

JD Kalmenson:

That's right.

Dr. Mark Gold:

So honestly, you can't go wrong. If I were to give you one piece of advice from working in the field for the last 51 years. My first study was on amphetamine and memory. But it would be that you'll never go wrong if you just take your time, look at the data and don't blame the patient.

JD Kalmenson:

That's right. I mean, just to finish on the topic of a process addiction, and then I have one final question cuz I know we're running out of time and I could spend all day with you. You're a walking library an incredible resources resource on this entire field at large. But as far as process addiction, vis-a-vis regular chemical dependency. So chemical dependency you pioneered with others, medication assisted treatment. So we know that there is a really powerful tool at your disposal to help you deal with the withdrawals to help you deal with the yearning and the craving for that while you're getting treatment. When it comes to process addiction, gaming or gambling you don't have medication assisted treatment.

Dr. Mark Gold:

We will.

JD Kalmenson:

Oh, please tell us about that.

Dr. Mark Gold:

No, I just think we will. So one of my colleagues is who has been working to defend the high density manufactured food as an addiction has started at Michigan, detoxifying people giving less and less and less and watching withdrawal. For gambling Mark Potenza has three or four candidate medications that they've been pioneering. So I think once you really, if you can, it's kind of what happened in depression until we realized that depression was just not feeling sad. When we could identify a small group of people with depression, we could really evolve in the treatment side. And just the idea that you could show like TMS is better than antidepressants is just proof that we can actually diagnose reversible depression. Depression, that's a brain disease. I think we are not far from that for some of the process addictions. And I think gambling is gonna be treated just like other addictions may be more like alcohol dependence with a combination of 12 step and a medication.

JD Kalmenson:

I just hope we can catch up before the diseases before addiction continues to evolve and continues to progress. I just hope we can make some head way. This has been so insightful. 

JD Kalmenson:

You are an incredible mentor to so many, and it's inspiring from when we had a dinner together. You're just one of those beacons of light that I'm very fortunate to have met. And I wanna thank you so much for joining us today on the Discover U Podcast. We appreciate you taking the time and really sharing the wisdom that you've accumulated over 50 years. How awesome and amazing is that. 

Dr. Mark Gold:

Well, I want to thank you because I tend to make friends and never let go. And so I'm glad you don't mind me like reaching out to you every once in a while.

JD Kalmenson: 

Oh, I love that. I love that. Thank you. And I hope you, our audience, enjoy today's episode of Discover U as much as I did. And at Montare, we want you to know that you're never alone in your journey. To find out more about our innovative treatment programs, find us at montarebh.com and you can listen to this podcast, this episode on iTunes, Spotify, or wherever you get your podcasts. And I wanna wish all of you fantastic health and a productive and fun day. See you next time.