Ep. 36 - When the Voice in Your Head Is the Loudest Thing in the Room

Dr. Steven Klein came to addiction medicine through an unusual convergence of paths. A physician and scientist triple board certified in addiction medicine, pediatrics, and medical genetics, he also carries lived experience in recovery that shapes everything about how he shows up for his patients. He speaks openly about his own relationship with substances, with food, and with the kind of internal noise that most people in active addiction know intimately. That noise, what he describes as a hierarchy of craving that drowns out everything else, is at the center of his clinical work.

Much of that work now centers on GLP-1 receptor agonists, medications most people associate with weight loss, that are showing remarkable promise in quieting the craving signal in people struggling with alcohol, opioids, and other substances. Steven describes it not as a cure but as a way to lift the needle off the record long enough to learn a new song. Recovery still has to be built. But these medications may be buying patients something that's always been in short supply, time. Pam and Steven also explore the genetics and epigenetics of addiction risk, why relapse is better understood as a neurobiologic stage than a moral failure, and what it means to finally have a tool that could shift care from reactive to preventative.

There is something quietly revolutionary happening at the intersection of science and compassion, and this conversation sits right in the middle of it.

Contact Pam Feinberg-Rivkin:
Facebook: @FeinbergCare
Instagram: @FeinbergCare
LinkedIn: Feinberg Consulting Inc
YouTube: @FeinbergConsulting8059 

Looking for a practical takeaway from this conversation?
Download our complimentary companion resource, Looking Beyond the Behavior, designed to help parents and caregivers shift from asking "What's wrong with my child?" to "What might my child be communicating?" The guide explores how looking at children's emotional, behavioral, and physical health through a holistic lens can open the door to greater understanding, connection, and support.

Contact Pam Feinberg-Rivkin:
Facebook: @FeinbergCare
Instagram: @FeinbergCare
LinkedIn: Feinberg Consulting Inc
YouTube: @FeinbergConsulting8059 

Transcript

0:00

Welcome to the Resilient Butterfly Podcast. My goal is to share inspiring stories of healing and recovery through many diverse approaches and models. Our guests bring incredible lived experiences, insights, andor professional expertise, each with their own unique path. While we highlight and celebrate these stories, our intention is to inform, inspire, and demonstrate resilience and creativity. This podcast does not endorse any one approach. We believe there is more than one way to heal, and we're here to showcase the resilience and possibilities that exist. Welcome back to Resilient Butterfly. I'm your host, Pam Feinberg-Griffkin, and today we will explore recovery through compassion, science, and lived experience. Today's guest stands at the intersection of addiction medicine, genetics, and recovery-informed care, is helping shift what we understand craving is itself. Dr. Stephen Klein is a physician scientist, and he mentioned his hair. He looks like a mad scientist, specializing in addiction medicine, triple board certified in addiction medicine, pediatrics, and medical genetics, with an MD, PhD in human genetics from UCLA. That's a lot. I am so excited. He currently practices at care and treatment centers where he works extensively with relapse vulnerable adults, young adults, and teens, and plays a key role in advancing the use of GLP1 receptor agonist to reduce cravings. Dr. Klein, thank you for coming. Thank you so much for having me. And there's this uh topic uh on GLP1 we'll get to because there's so many questions people have, and some are a little skeptical and others are excited. So um I really want to start with what originally drew you to medicine and eventually to addiction medicine. Absolutely. Thank you so much for asking with such a kind of broad question that can give you some interest and some and some insight into my history. What really drew me to medicine in the beginning was that my dad was a physician. So we always grew up talking about science. I'm one of three children. I'm the only one who went into medicine. So there's something that I have in common with my dad besides curly hair, um, which is that we think about kind of these uh abstract nature of disease and really how the human body and the human machine works. My dad was an endocrinologist and um really thought very hard about the ways that the endocrine hormones affect the heart and other parts of the body. So I think that intellectual curiosity first drew me to medicine. Um, I also had um some experiences growing up. I um am gay and I always kind of wondered why I was different than the people around me. I think honestly, that's what drew me to genetics. If medicine is in fact the study of how we're all the same, take 100,000 people and give them a medication and see how they react. I think genetics is the study of how we're all different. So, what are the mutations and different parts of our DNA that make us different? And studying that first in college and then in my PhD, I just found amazing. And I found that it allowed me to combine a career with things that I loved, which was working with children and then understanding complex molecular biology. And um, I really, really loved it for many, many, many years. Um, I was at the children's hospital of Philadelphia for six incredible years of training. Um, but academic medicine is difficult. And at that time, also I'm a person in long-term recovery. I was growing my sober network at the same time as growing my academic pedigree. And I realized there might be an opportunity to combine yet another part of my passion in life, which is watching people recover from drug and alcohol addictions, substance use disorders. And two years ago, I completely shifted my career path and joined the then trainees and now faculty at CAREN Treatment Centers, where I work with the young adults, like you said. I also think deeply about the molecular basis of disease and then get to watch that kind of come to come to fruition and watching the patients in front of me recover and come back to life. So I feel like I have the best job in the world. Um Yeah. And you have the enthusiasm for it as well, obviously, because if you have the best job, you um that goes hand in hand. I'm so excited. Um, studying human genetics and epigenetics shape how you understand addiction, risk, and relapse. First of all, um most everybody in the world knows human genetics, but epigenetics is something different that not everyone actually understands. So can you explain epigenetics versus genetics? Absolutely. So epig is just a prefix that means above. So it means above the genetic code, which is oversimplified. So there's a little bit more to it. So I'll give you the uh description and the understanding that I tell everybody, whether it's parents of a child who have a genetic condition or patients now who want to understand epigenetics and how it relates to their addiction. So in the world of genetics, the best analogy that I have is a library. So in our library, we have 23 bookcases, those are our chromosomes. On every bookcase, we have books, those are our genes. So in if we were to open a book, you were to see words. Those are our A's, T's, G's, and C's. So those are the genetic code that make up what you said. Most people have a basic understanding is human genetics. So when people think about genetic disease, they really think about a spelling mistake in one of those words or in one of those A's, T's, G's, and C's. Those are things that are readily passed on, and that's how all of the variation of human, the human condition is made, propagated, passed on, the driver of evolution and things like that. Interestingly, that's not the end of the story. So going back to our library, I can go through the library and stick little flags in the spines of the books. Those flags make it easier or harder for the librarian to find those books. That's our epigenetic code. So those flags can turn off and turn on genes without changing the words in the books or the genetic code themselves. It's a more adaptable, more plastic system than making a true mutation to the genetic code. So it's really a way that above the genetic code, we can alter our gene expression. So for instance, um in a family of, I have I have five siblings. In a family of five siblings, the epigenetics could be something during our our lifetime, that the five siblings, but the next lifetime, their epigenetics could be different, correct? Yeah, and each of you could have a separate experience. And that's what's really interesting. So if you let's just say for a second that you and your five siblings were identical twins, so you were uh, I don't know what we would call that. You are quad quadruplets plus one. Yeah. So there are five of you are genetics. Quinn tuplets. Perfect. If you were quintuplets, you would all have the genetic material that was exactly the same. So all of your libraries would read the same and the books would be the same. What's interesting is that your epigenetic code, the flags, could potentially be altered by your experience through your lives, and therefore your children and your children's children may inherit different epigenetic signatures based on what you've experienced. And that comes from a really interesting study that actually looked at grandchildren of people who survived the Holocaust. So there was an epigenetic signature because going through such terrible torture and starvation and things that really made the body adapt caused such a profound change in the epigenetics that it was actually inherited two generations later. So it's really a way that our experience changes our genetics. It's the way our kind of nature and nurture, if you will, come together. Right. Well, it's great explanation. Thank you for that. I've never heard it explained in a library with books. That's really interesting. You've spoken publicly about your own recovery. How does lived experience help you practice medicine today? I mean, lived experience for me is everything. Um, lived experience, I would say, as it relates to my recovery from drug and alcohol uh use disorders. And also from now, what I talk very publicly about too is my relationship with food. Like we just talked about, my background is in genetics and metabolism. I know a lot about the inner workings and the metabolism of the body and the way we use macromolecules and things like that. It didn't help me have any more control over what I was eating and then being in a somewhat of a conflicting relationship with my body image of my weight. In a similar way, I may understand all of the components of the neurobiology of addiction. But my lived experience tells me that this actually has to be something outside of the space between my two ears. I think that's where my lived experience really helps. When I meet a patient, I am really trying to help them have an experience where they start to be on that path where they realize that potentially the answer to drug and alcohol addiction is finding that solution outside of yourself. That's a pretty hard thing to explain if you've never been through it. Sure. So I think one, it's that experience with recovery. And also, it makes me deeply empathetic to the fact that addiction is a disease. I tell patients all the time in my office, sometimes when we're talking about medications or family members' reactions to medication, if you came into my office and I was an oncologist and I told you that the treatment for the life-threatening cancer that you had was to stay with us for 28 days, you probably would without blinking an eye. But unfortunately, in recovery, we face a lot of stigma. And in drug treatment, we face a lot of stigma, which makes these decisions more difficult. Patients are navigating multiple emotional and family systems, and we have to be sensitive to all of those. Luckily, my patients are the patient themselves, and sometimes I can help them navigate those systems with their families and other people. Was there a moment in your training when you realized that traditional addiction models fully were not fully explaining why you were witnessing what you were witnessing clinically? Um, I would say there were definitely times in my training where I just wish we had more. I wish we had more effective treatments that had a biological basis. So, in my opinion, there is a treatment for addiction. That treatment is recovery. Unfortunately, recovery is hard fought and nuanced and in some cases extremely expensive. And I don't mean that by treatment centers. I mean you need family buy-in, you need resources, you need time away from work. These things are intensive in people's lives. So I think recovery is the treatment and is the cure for addiction. What I was struck by early in my training was real and my own personal experiences, how profound cravings can be for drugs and alcohol, and also how pervasive and how suggestive the voice in your own head that talks to you about your cravings can be. And it was always my my dream, my my hope, and now my reality that we would have pharmacologic agents that could quiet the noise of that voice and give patients a leg up in that fight, especially in early recovery. In your perspective, is that why chronic relapse occurs, that that voice in someone's head that they cannot get rid of? Or what what is your perspective in chronic relapse? So I think relapse, to be to be completely honest, is just a part of addiction. Um so I think there's not a single person who has alcoholism or drug addiction that hasn't woken up multiple times in their path and said, today's the day I'm never gonna drink again, or today's the day I'm never gonna do drugs again, and flush the drugs down the toilet and threw the alcohol away only to drink that afternoon. When we talk about relapse now, it's really when people have tried, you know, recovery or been in treatment and then have a return to use event. But I think it's more nuanced than that. I think relapse or return to use, as we call it now, really just shows how pervasive the that voice is. Again, you can swear something off with or without a solemn oath that morning, only to return to it that afternoon. I don't I don't necessarily think of individuals being prone or not prone to return to use. I think of recovery as a staged neurobiologic transformation. And sometimes we're just meeting patients earlier in that transformation, and sometimes it's later. Sure. What patterns do you see neurologically or metabolically in relapse-prone patients? I wouldn't say that there are neurologic signals. So I'm someone who's very careful with words. So I think metabolic signals as far as things that we're measuring that have numbers attached to them. Um, I wouldn't say that that's something that we're necessarily at the point of doing right now. Um, I would say that there are definitely some trends in people who experience return to use and multiple kinds of treatment events. I think uh trauma is very pervasive. I think early childhood events are very pervasive and sometimes predictive. I think, you know, there are some maybe characteristics of people who um are predisposed some way to use alcohol or drugs problematically, people who are very sensitive, people who maybe are are different makeups, but I wouldn't say those are the types of things that I, as a scientist, kind of am quantifying, we're we're getting there. Um and actually, I think one of the things about GLP1s that's so amazing is once you have a really great medication, it allows you to start to understand the question a little bit more. And I think now that we're in a place where we can start looking at brain signals and a lot of of the neuro uh imaging approaches, that's what we're really leading the charge with at Karen Treatment Centers to understand what is the neurobiologic phenomenon of craving. How does that change during treatment? And how can we modulate that with pharmacotherapies? Sure. And why do you see patients do everything right? Quote. And what does that mean, every thing right? Because there's so many factors that people throw at someone in treatment, right? And still feel overpowered by these cravings. Is it is that the voice in their head? And is that related to that the chronic stress or whatever they've actually had in their life? Yeah, I mean, I think you raise a couple of interesting points there. Number one, what is everything right? So I think, you know, just because you're checking boxes, again, thinking about this staged neurobiologic approach, I think there's a lot of things that we recommend. So, you know, doing residential treatment for people with severe disease and engaging in therapy and using medications and doing all the different wraparound amazing clinical services. You know, I think that is part of starting this trajectory of change. I also don't necessarily view return to use as failure of that change. It actually could just be part of that path. I tend to think of recovery in anyone who's struggling with any type of disease or disorder of agency as really being on that path, somewhere on that trajectory. So I don't know when patients are going to finally get it and things are going to click and they get to that place where they can put down drugs and alcohol forever. I know what it's looked like for myself for the past nine years. Um, but you know, I think that's very personal and very different for everybody. And that's not necessarily how traditional medicine is practiced. So I think that's why we're at a really interesting inflection point and potentially changing point, which is we need to know what we're measuring. And again, going back to having these amazing medications now, maybe we can understand better how the brain is responding to treatment and to reduction in cravings and ability to uh resist return to use. But you know, I tell people all the time I needed every single drink and every single drug that I took on my journey to finally bring me to that point where I was ready to change. And everything that's happened from that point has been a result of that history. And that's something that I use again, going back to lived experience. That's something that I used with my patients almost every day. We can't change a single thing that's happened to us up until this point. Recovery acknowledges that we've gotten to this point and now informs us in taking the next step. So I view the whole system as an actually incredibly encouraging. I think anyone who's sitting in my office, anyone who's seeking care, anyone who's even thinking about seeking care can really be in a place where they're they're opened up to the idea that, you know, like they they have hope. They have hope that tomorrow can be a little bit different than today. And that's the world that I choose to live in and surround myself with people who are filled with hope and filled with a positive outlook for the future. Sure. How do you help families understand that craving craving is not a moral failure, but a brain-based signal? So many families take it on for themselves and shame and like really yeah. How do you help families? Family is really difficult, especially as someone who works with young people. I think every parent in the world wants their child to be healthy and happy. And I think at some point, as I come from a family where I'm not the only person who's been affected by drug and alcohol use. Um, and you know, I just think the family system is incredibly complicated. I think my role as a physician is to remind people that, in fact, I'm a doctor. I'm a doctor treating a disease. I'm not someone who treats moral ineptitude. I'm not someone who treats whims. I'm not someone who's here to kind of rewrite their structure, their value system, or their agency. Um, I also deeply honor the path and the pain that families have been on, and that, you know, no addict exists in a vacuum. No person with substance use disorder got there without touching anybody else's life. So I try as best as I can to hear the perspectives and the journeys of all of the parents, of all of the spouses, of all of the children of the patients that I have the honor to serve. But at the end of the day, I'm their doctor. So I kind of think about what's best for them and how can we work within the family and also leverage while also sometimes mitigating risks around the family and really maximizing outcomes for each individual patient. So we're going to get to GLP one because so many people are uh interested in this. Uh, when did you first notice that something biologically significant was happening with the use in addiction for GLP1? So, to be completely honest, again, this is a lived experience question for me because I'm a person on a GLP one. So the first time that I realized that something was happening in the realm of addiction was the first time that I took one. So I was a medical resident in the pandemic and I was in pediatrics at the children's hospital. They moved us around a little bit so we could cover the emergency room, and it was incredibly stressful. A lot of stress, a lot of not knowing what was going on, a lot of wondering if there was going to be masks or how the um the pandemic would affect children, especially. And at the same time, a lot of our coping skills were taken away. So gyms were closed, no dinner with friends, no being able to socialize as much. And uh at that time, I reverted to a coping skill that I had used more through childhood and early adolescence, which was food. And I put a lot of weight back on. At that time in my career, I was about four years sober from drugs and alcohol. So I put on all this weight. I wasn't really feeling great about myself. And then the pandemic uh kind of waned. And and my I met with my primary care doctor, and she put me on Mongiorno, which is now rebranded as Zepbound. And honestly, the first time that I took that medication, I would say in the first month, I had this kind of incredible response like, wow, this is the way life can be. I realized that I was addicted to food way before I was addicted to drugs or alcohol. I was always thinking about what I was going to be eating next. I was always thinking about the Chinese food I'd be ordering after a long shift. I was always thinking about dessert before appetizers had even come. Like I was just preoccupied with food. And all of a sudden, it became clear as day this is how other people exist and potentially what other people's experience is. They're not just overrun with these really loud cues to eat and overeat and seek food. And it was just a Amazing for me. It was a really transformative experience. Also, as a person in recovery, it allowed me to go a little bit deeper into some things that I wasn't necessarily applying my recovery principles to, namely my relationship to my body and my relationship with food. And it just allowed that to go much deeper and really for me to understand it, uh, largely because I was, I wasn't in it as much. And I think that's how when we started to get these signals that there was, there was really a benefit to people with alcohol use disorder and now other use disorders, it made so much sense to me. Going back to your question, like people can just be so overrun with these feelings. Addiction is truly a disorder of salience or hierarchy to the person suffering with the use disorder. Their cravings are number one, two, and three on their hierarchy list. So I think that turning down a volume is really amazing. So the first time I experienced that was with my my own experience. And now it's been amplified, you know, hundreds of times with the experience of my patients. So you say turning down the volume, and I've heard others say that too, that the this chatter that they hear. Neurologically, what's really happening? So, really, it's a it's a it's a reconfiguration of salience. So salience is a very important topic. So salience is the ability for us to kind of hone in on one thing. So, for example, you have lovely headphones on, but if you were sitting in a room right now, you could focus in on my voice and assign it higher salience and maybe tune out a fan or someone talking in the room next door or something like that. That's giving higher salience to things. It's actually one of the things that makes us kind of exquisitely human. Um, so it's really hard when salience is disrupted. A great example of when salience is disrupted is people affected with autism spectrum disorders. So when everything is one volume or everything that touches your skin is one feeling, it can be very disintegrating and very, very hard for us to kind of drown out and be able to focus on what we need to focus on. So I think about that as salience attribution is huge in addiction. Again, when you're having cravings for things, if that's the loudest voice, that salience, which is all part of what's called the mesolimbic system, is really what's dysregulated. And that's something that we we've tried. But honestly, anyone who's worked on the front lines of addiction can attest to it. It's a very, very nimble and major adversary for us. And can you describe why GLP1 is an adjunct of therapy versus standalone care for addiction? Sure. So going back to kind of an earlier point, I think there is definitely a treatment for addiction, and that treatment is recovery. I think about adjuncts because really what we're doing is turning down the noise so that other noises can come through. So really the analogy for this that I use all the time is addiction is like there's a record playing in your mind. That record always ends in using drugs or drinking. What these medications do is they lift the needle off that record long enough that I can teach you another song. And I think that teaching of another song is really important. So for the person affected with drugs and alcohol, from my own experience, drugs and alcohol, drug and alcohol use disorders, from my own experience, every coping skill involves substances. If I'm happy, I drink. If I'm sad, I drink. If I'm excited, drink, this just kind of goes on and on. What's amazing about recovery is it's learning there's other ways to cope with feelings. When you have major cravings as well as no coping skills, it's really, really hard. And coping skills take time. That's something that in general I refer to as recovery capital. That capital takes a long time to acquire and then to allow to grow. And I believe these medications are buying patients precious time. So there were there are some people that actually say that it can um potentially reduce motivation. Is that something that you can speak upon? It's not something that I've seen personally in my own experience. It doesn't look like it. Um it's not something that I hear from my patients. I think it's a really interesting idea. And it gets to a really interesting point, which is desire and reward is why we do everything. I tell people all the time, reward is not a glitch in the system, it's the entire system. Our reward pathway, that mesolimbic system, resides in our brain stem. If you're evolution and you want to protect something really important, you put it in the brainstem. That's where our centers for drop for breathing uh automatically are. That's where a lot of our autonomic centers reside. And that's where our reward center is largely based. So reward is why we do so much. So if you really knock down reward, you could think about not wanting to pursue a career, not wanting to pursue a mate, not wanting to pursue seeking shelter, finding warmth. Again, these are not things that I see in my patients, but maybe that's because they have cravings that are so loud. Turning down the volume of those doesn't necessarily get to the baseline volume. I don't prescribe GLP1s to patients who don't have substance use disorders. But again, if this was something that was really happening, I think we would hear much more about it. This year alone, somewhere between 10 and 12% of Americans will be on a GLP one. If people were strongly unmotivated and, you know, having trouble getting up out of bed and getting into, you know, their daily routines, I think we would know. And and, you know, just to kind of round that that part of it out, I think, you know, there's something really frustrating about doing things that don't align with your value systems. Um, for me, that's the the restoration of agency. So I want you to make decisions that you feel good about. And I think that in itself can be motivating. So if drinking is the thing that you keep turning back to, that can be really self-defeating. If I can empower patients to be on a recovery journey, I think that in of itself can again motivate them to make positive change in their lives. Is uh their families to ask a lot of these questions. Is this replacing one substance with another? Will people need this forever? And is recovery still recovery if medication is involved? Yeah, that's a question that I love to answer because I think it really kind of brings something to light about the way that we treat different diseases differently. So we need to start with the idea that addiction is a disease. And as a disease, it's a chronic brain disease. So I think just by that reframing, to me, it's by no kind of stretch of the imagination that we may need chronic brain medications. So let's look at other examples of diseases that have medications. Diabetes. What was that? Diabetes? Diabetes, great example. So when your doctor, when you have diabetes, starts you on insulin, the conversation is not when do I get off of this? When your doctor starts you on a statin for lowering cardiovascular risk, it's almost assumed that that will be for the rest of your life. When you're started on something for hypertension, that's a long-term medication. But these things aren't as related to the human condition as something like desire, something like willpower, something like obesity. So let's start again with obesity first. We've tried that other method, the method of if you're obese, it's your fault and it's because you're lazy and you eat too much. What we're now seeing with these medications that people have regained agency and we're finally starting to see the obesity curves plateau and maybe even downtrend for the first time. It's my hope that that's where we get with GLP1s and addiction. Do I think that medic this medication is for the rest of someone's life? To be completely honest with you, I don't know. I think there's definitely a world where patients can eventually come off the medications. I think of it as a constant calculus with that recovery capital. So if you've bought yourself enough time to learn new coping skills, build community, build the forces around you that support you in recovery, then I think there's a world where you come off the medication. And even if the cravings do return, you have the ability to deal with them. But that's a chapter of this book that's yet to be written. But I don't think it should stop us from helping the patients in front of us right now. Because to be completely frank, it doesn't stop us with other medications. Sure. Who is not a candidate for GLP1? Great question. So we screen everybody at care and treatment centers for a few things. There's a few cancers that family history or um personal history would make someone not a candidate. They're pretty rare, but they do have potentially mutations in them that the GLP1s could be drivers of tumor growth. Those are medullary thyroid carcinoma, and then something that's a little bit of a mouthful, but something called multiple endocrine neoplasia syndrome type two. So those are two cancers that we screen everybody for. In addition to those, we ask for a personal history of pancreatitis, a personal history of gastroparesis, a history of any type of eating disorder, and then uh pregnancy, desire for pregnancy, or breastfeeding. So those are things that none of those, I would say, are hard exclusionary criteria, but they have to have a conversation. So pancreatitis is one of my favorites. There's a suspected uh warning associated with GLP1s, because there's these case studies of very severe, sometimes necrotizing pancreatitis, which can be very, very severe in a medical emergency. What's really interesting about the patients that I have the honor of serving is that drinking also causes pancreatitis. So if someone tells me they've had pancreatitis three times, every time after a severe binge of alcohol, I have to weigh that. So if I have a medication in one hand that can decrease their drinking, and I kind of think that their pancreatitis is caused by the alcohol, then it's a conversation. Um, sometimes I have patients acknowledge that there's a risk if they've had pancreatitis, um, and then we do it very slowly. We might not ever increase the dose. So we stay at a very low dose. For the gastroparesis, um, I've actually never had a patient kind of um spontaneously screen out because of that. That's when the stomach stops moving food forward. These medications delay gastric emptying, so we wouldn't want to exacerbate that. Restrictive type eating disorders is something that I'm very um keenly aware of. So I would never want someone with a history of anorexia to be triggered into a relapse or a return to restricting binge eating disorders. I think there's a real potential use case there. And then pregnancy, we just don't have great data. Most OBGYNs, and I think the current recommendations is a washout period and then trying to become pregnant, not using them during active pregnancy. How long has GLP1s been used for addiction now? So the that's an evolving story. So I would say uh I what's interesting is that some of the best data comes from retrospective use. So somewhat I I guess accidentally, there was just a great paper that came out of um the University of Pittsburgh that made the statement that one in 10 Americans have obesity and alcohol use disorder. So during the lifetime of GLP1s, especially coming in vogue for weight loss, many, many people have been prescribed GLP1s who have also had alcohol use disorder or some type of substance use disorder. Your question kind of reaches an interesting point of the discussion, which is where's the kind of state of the evidence? So we have lots of retrospective evidence. The most recent published in March of 2026 that looked at 600,000 U.S. veterans that showed a nearly 20% decrease in the diagnosis of alcohol use disorder, cocaine use disorder, opioid use disorder, nicotine use in all patients who are prescribed GLP1s for either obesity or type 2 diabetes. So the retrospective evidence is very robust. The place where we're catching up is prospective evidence. So randomized control trials. There's really two, one was in 2025, Hendershot et al. One was more recently. That's when we randomized patients to either get a GLP1 or a placebo. The signals in those studies are very robust, but we're still collecting that data now. So I used a lot of words to say we don't necessarily know when it started because alcohol use disorder is so pervasive. Patients who have type 2 diabetes and obesity were likely prescribed these medications for as really as long as they've been around. As far as being used for a primary indication, I would say we're leading that charge at CAREN Treatment Centers. We're one of the only treatment centers that has a GLP1 program under our treatment center kind of roof and that enrolls patients on a on a daily basis. We believe that the data is very compelling and that the benefits far outweigh the risks. And the patient stories and the experience that we're having is only reinforcing that. Are you doing work with GLP1s only in residential or as an outpatient at CAREN? When patients leave, the prescription can follow them. Got it. So they start. But they're not started outpatient. At Cairn, yes. Everyone is started in residential treatment and then it follows them into the outpatient setting. Got it. Got it. We don't have a pathway yet for patients to come in from outpatient and be prescribed GLP1s. When do you think that this may be more widely used? I think the next big step is going to be a few of the amazing clinical trials that are being run by uh NIDA, the National Institute of Drug Addiction, and other government agencies. There they should be coming out with data in the next six to eight months. So a few really strong clinical trials will lead to FDA approval. Once the FDA acknowledges that these medications are can be used for this as a primary indication, I think that it will open up much more widespread usage, especially because that will make a path forward for reimbursement from insurance companies and then make them more accessible. And I think that'll be the major next step in this journey, is acknowledgement. Even after that, we know, you know, for example, there are great medications that are FDA approved right now for alcohol use disorder and especially for opioid use disorder. Unfortunately, because of some of the conversation earlier, there's stigma around those medications from one of the questions you asked. Is it replacing one medication with another? Is recovery still the same? For some reason, we're we're we get into a lot of um ethical minutiae when it becomes to this, and there will always be barriers. Why I love the GLP1 conversation right now is because it's bringing obesity and addiction and close proximity and making us as a society rethink both of those. It's actually really hard to have a BMI of 40 if you can't walk into a restaurant and order 2,000 calories in one appetizer. It's also more likely that you're going to be an addict or someone who struggles with alcohol use disorder or substance use disorder. If you live in a society that sold our dopamine signaling to the highest bidder for the last three generations. So I think as a society, we're having a moment where we can take a step back and say, this isn't the fault of the people, this isn't the fault of the patient, this is a system problem. Let's change the system and let's start helping people on a societal level. Yeah. As um, can you talk about the dose and monitoring and integration with therapy at uh Kieran or as as someone leaves? Yeah, so the dosing, it's actually great. And from my experience and also what's coming out in the literature, there seem to be three dosing uh areas, three dosing ranges. And luckily, the first is addiction. So craving suppression seems to happen at the lowest doses. In the middle, we have type 2 diabetes, and at the highest end, we have obesity. So I think the real monitoring that has to go on is titrating dose with weight loss. So I practice medicine in the United States. A lot of the patients that I meet are in the FDA approved range for weight loss, which is a BMI above 30. Even BMIs 27, 28, and 29 are people who come into my office and say I wouldn't mind losing five to 10 pounds. The story gets a little more interesting with monitoring when we get below BMI 27, especially below BMI 25. Those are people who probably don't have too much weight to lose. And that was really uh something that we wanted to monitor very, very closely. What we find is at the lowest end, using the the GLP1 agent which we use, which is semaglutide, which is the active ingredient in Ozempic and Wagovi, uh, really that there is a possibility to be on a low dose without losing significant weight. And that's been something that's been really transformative for the patients that we have in that in that arena that are low, I would say normal or even low normal BMI. And as you continue to show promise for GLP1s, how is this going to affect with early intervention, reducing shame after relapse and families who feel out of options? Yeah, I love that question. Um, so I think there's a real there's a real opportunity here to truly practice preventative medicine in a way that maybe we haven't before. So addiction care right now is very reactive. So most of the addiction services that we have are for people who already have gotten to the point where they identify with capital kind of A addiction and they have substance use disorder, which by the DSM 5 we would characterize as severe. I think what's amazing about the accessibility of these medications in a perfect world where they're affordable and accessible is that we could potentially identify people who don't, who don't yet have that kind of identity of themselves and just want to decrease their drinking a little bit. And maybe we can take problem drinkers and divert them from ever having substance use disorder. I think that's the type of medicine I'm most excited about participating in. I also think that we have a real opportunity to shift the narrative as it relates to families and as it relates to society at large. For example, Oprah was on the cover of People magazine for the first time ever in her very public fight with her own weight. She's now able to control her weight with a GLP1. I think that really sets the stage for an interesting conversation in that Oprah has enough money that she could hire someone to exercise every single one of her digits and extremities independently. If she can't control her weight, who can? And I think that's really the conversation that we have to be having, which is what is it to have agency? What is it to be able to make decisions in a system that's truly rigged against us? I mean, we are bombarded with dopamine signals now from the time we wake up, roll over, and look at our phones to the time we go to sleep. So these dopamine signals and disrupting them and pirating them has consequence. And I think, again, for the people who are under my care in a treatment center, they may be the loudest of that signal. But I actually think that most of us are struggling with something that we don't want to do as much as we do it. And I think these medications offer us a way to start that conversation. Sure. Well, this is really, really exciting. I uh it's having some breakthrough for people in that have chronically relapsed or haven't even tried yet because um they can't even get to that point. And as you say, we we when we see people, the families are very desperate. And um they have to be intervened on, and sometimes we have to then ask a lawyer to marchman act them down here in Florida to get them legally into treatment to save their lives. And this is um really profound. So I appreciate all of this information, and I would love to follow up maybe in a year and see where every everything is. And can you tell the listeners where you can be found at Care and Treatment Centers and about care and treatment? Yeah, absolutely. So I can be found in Karen Treatment Centers in Pennsylvania. However, Karen Treatment Centers is also in Florida and a number of other states. Um, we can be found on the internet. It's Karen with a C, C-A-R-O-N. Uh, I'm on their website. They can reach out to me directly. I'm also on Instagram and on TikTok and on LinkedIn. I'm very accessible, very vocal about this movement in society and decreasing the stigma around addiction. Karen offers incredible world-class wraparound clinical services as well as cutting-edge medical interventions such as GLP1s, and really is leading the field in neurointerventions as well at both campuses. So if you're out there and you're struggling and you need help, please reach out to me. I can get you in touch with the right people at Karen or find Karen's website. We have an incredible team of people who are just waiting to meet you, hear your story, and figure out how we can help you. In addition, Feinberg Consulting will help the family gather the person that needs help to be able to help the family unite and be able to get them into treatment. And we can be reached at feinbergcare.com at 248-538-5425. And we work closely with Kieran and other treatment centers across the country. Very pleased that Kieran is really stepping into some really beautiful work that they're doing right now. And this is my first time meeting you, and I'm so excited, really. Um, thank you so much for coming on. Thank you so much for having me in the amazing attention and nuance you're giving to this, which is a complicated subject, but something that uh I think is really exciting and really will help and affect a lot of people. Thank you. Thank you for joining the conversation today. If you are seeking help for yourself or a loved one, please reach out to our Feinberg Consulting Team at 248-538-5425. That's 248-538-5425. And check out our website at feinbergcare.com. I'm grateful for our guests and all who have joined us today. Make sure you follow us on Apple, Spotify, or anywhere you listen to podcasts.