Dr. Adi Jaffe - Addiction expert, bestselling author, and founder of IGNTD

I live in an area that has a huge problem with addiction. There are literally hundreds of people sitting on a main street on any given day, and dozens of overdoses daily.

People in my area seem to be suffering from "addiction fatigue" and are struggling to still have empathy for those suffering from addiction. What do you feel is the best way to deal with "addiction fatigue" amongst other members of a community?

Wow. Great Question. I'd love to know more specific about the area, etc.

My guess is that this comes along with some stress and struggle specific to the region and that perhaps the "fatigue" is also a reaction to the impact of that stress AND the judgement regarding the users reliance on drugs for dealing with the pain and struggle (versus those who feel like they have to hold their own and take up the slack)...

Am I right at all?

Yes somewhat. I'm in Vancouver in Canada, which has a pretty long history of addiction issues.

The problem is that anyone who works in the downtown eastside area (paramedics, police, volunteers) seem to get to a point where they are just so fatigued of seeing the same self-destructive behaviour day in day out.

I've known many people who work in jobs directly with those suffering from addiction, and their empathy just seems to be at an end. It's something I struggle with too and do not know what the best approach is.

Yes... Like medics in a war-torn region. It is sad and difficult to work in an environment that doesn't seem to change no matter how much effort you exert. 🙏

What are some small daily bases changes one can make to distance themselves from certain addictive behaviours? (ie eating junkfood)

This is a GREAT question and I have many thoughts, but I'll start with an overarching principle - DO NOT try to eliminate bad habits. Instead, either replace them (or crowd them out) with habits you'd like to take on instead OR identify the role they play (what they help with) and neutralize their power by actually addressing the underlying issues!

You can do both of these in parallel!

I was about to ask about Habit swapping (bad for okay, okay for good, good for better, & 'finally' swap better for best).. Thanks for beating me to it.

I would even look at the habits as more or less helpful rather than "bad" or good." We'd be amazed how that perspective can change over time and how some "bad" things were simply necessary at certain points in our lives.

Excellent solution. My buddy has a drinking problem that I'm trying to help him get past. I bring him out for a long run at 8pm a few days a week (you can't buy alcohol after 10pm in my country). It seems to be working very well.

That's SO great and so antithetical to the silly idea that your friend is sick. He just needs some life restructuring!

You talk a lot about harm reduction. How do you feel about AA and their lifelong sobriety approach?

I'm a big supporter of "whatever works," so I think AA is great for the people for whom it works. The problem is that, to some extent due to its length of existence and its religious origins and connections, it's been seen as "THE" approach for addiction... and this is where things fall apart.

Overall success in AA is very small (5%-15% is the estimate range for success among all those who try/enter) and the vast majority of people (over 95%) will simply not meet long-term, let alone lifelong, sobriety goals. So, if our hope is to actually help people and not to shame/judge/relegate them to failure, we need to support additional and alternative approaches that have either similar/better success rates OR that succeed for different groups of people who are unhelped by AA.

There is absolutely no way of knowing how "successful" 12 Step programs are for many different reasons. Number one is it's an anonymous program. Two is that the idea of "success" is impossible to quantify. I will be honest and say that I AM someone who got sober in AA. I also work in addiction and I am familiar with and certified in multiple other addiction recovery programs. Here's what I have seen in myself and hundreds of other addicts: the reason for success in one person versus another is entirely elusive. That's why there is the idea of a "Higher Power" which is NOT RELIGIOUS. Yes, the 12 Steps were formed by religious people. Because it was the 1930s and it was a majority Christian country and culture. Just look at our government. But in no way is it forcing people to be religious. As I said, the idea of the Higher Power relates the honest truth that we don't have control over everything. Recovery doesn't happen for everyone and we don't know why and most likely never will. I support all forms of recovery and the "Whatever Works" approach as well. But I need to make it clear that the statistics for success in 12 Step programs are meaningless. Would I be considered "unsuccessful" in AA because I've relapsed? That's not fair to anyone or any recovery program. The fact is the vast majority of people trying to get sober do relapse; often many times. What I have seen is that the vast majority of people who eventually get long term sobriety ARE involved in the 12 Steps. That is my personal life experience data.

AA groups use Christian prayers exclusively and the word god is repeated hundreds of times in the text, so religion is intimately connected there. And research always uses anonymous members and there have been literally hundreds of studies assessing AA efficacy - the findings are simple (and easy to understand): AA works great for people who are committed to it and stick with it and terribly for those who do not. The only issue is that we send people there who are not interested and it destroys the entire operation (but grew AA to mammoth proportions). The outcome measure for AA seems pretty clear - long-term abstinence and if we start actually listening to people and giving them choice in the approach they get to pursue we may identify helpful factors in determining fit. But as of now, that is a very hard thing to study and the most recent and largest study to try found about the same success rate for all available interventions (but very few identifying factors that predicted success).

I do not at all deny the religious undertones (or overtones!) of AA. It absolutely was based off of Christian concepts and principles. But if you look at all religions around the world, they're based on the same ideas too. I also absolutely agree it works for people who stick to it....clearly it would not work for people who don't, and that's the point I'm trying to make. You can't say it doesn't work for people if you're basing that on the people it didn't work for.

I'm saying that the evidence tells us we should stop sending people to AA (even AA says that in the book). And if AA wants to alter the religious overtones, it's really easy to edit the book... By keeping it bible-like they're choosing to continue the religious narrative... IMO

I agree, I have an issue with the legal system forcing people to go to AA. But it's not as easy to change the entire Big Book, although they are making a lot of progress on it. It takes an entire international consensus to do that. I think it's much easier to show people what the message is than it is to change the text. But as I said, they have made changes over time.

I saw somewhere that people who are forced into rehab or aa actually have the same success rate as people who choose to go. I don't remember where exactly I read that tho

Mandated treatment shows success on par with seller selected treatment, which is to say neither are incredibly successful but sending people helps as often.

Guys he’s saying that because he’s peddling a competing platform to AA. AA is better than no treatment and there doesn’t seem to be concrete data that it is less effective than any other method. So yeah he’s going to paint it as ineffective because of religious origins and offer an “alternative.” Redditors always complain that we should focus on treatment for people with mental issues and substance abuse problems, and then bitches about one of the few treatment platforms that has been effective for an extended period of time.

Data suggests otherwise and almost all of it produced by people with no competing interest. But beliefs are what they are, so you can choose to trust or not.

What's your evidence base behind what you offer? How does it align with MAT for opioid use disorders, protective medications like disulfiram for alcohol ise disorder, and access to BBV testing etc? What's your role in reducing both fatal and non-fatal overdose risk?

We had a slew of research when I ran a treatment center a few years back (you can look up some posters and such we presented) and data collection is ongoing for the new platform that uses many of the same principles.

I am a supporter of MAT and all harm-reduction approaches and think that we first and foremost have to reduce the risk of death if we're to have any chance at creating lasting change.

Since I work almost exclusively online now, acute interventions are nearly impossible and so my only role in reducing overdose risk is through mitigation (education, advocacy, etc.) and helping those who struggle head off their risk and reduce potential damage.

I hope that makes sense.

Surely its more important to work as part of a multidisciplinary service than providing a branded package of care (ie case working, recovery communities, MAT, BBV testing, naloxone, housing, social work, psychiatry, psychology)? Supporting is fine, but really the actions are more important. And why the branding anyway? Doesn't that perpetuate an ongoing belief system around recovery rather one based on scientific merit (though im not saying it should be exclusively one or the other)?

Of course the people who need the most help are the most chaotic and vulnerable people such as those that are homeless and using drugs by injecting. Given that this cohort are the priority group from a public health perspective and from a purely compassionate aspect, how do you support them?

Also what kind of interventions do you do around ARBD, including the challenges around capacity to make informed decisions on their recovery?

Love these questions. I saw a HUGE gap in the unserved population that is simply not receiving any professional help for their struggles and decided to focus there. The branding is more around the platform for providing the service than around the approach. My hope is to greatly reduce the barriers to entry and then use technology to match people with the services that can best benefit them. To your second point, I hope to scale what we do to provide Medicare, Medicaid and Veterans Benefits recipients for little or no money. Have to build the infrastructure and evidence base to get there, but I believe that's the way to intelligently serve those least served (with tie ins to adjunct supportive services in their respective communities). When it comes to brain damage (alcohol or otherwise), we don't have anything built in per se. I love the potential for neurofeedback here but again, interventions that truly address these needs require substantial oversight and can be expensive and we don't operate there.

You'll have obviously worked out that I'm an addiction psychiatrist, albeit in the NHS in Scotland/UK. In addictions circles, American provision is considered a laughing stock compared to Europe, so its a wee bit reassuring that there's at least someone who takes a more pragmatic harm reduction approach with some modicum of evidence based medicine and a degree of consideration for our most discriminated/stigmatised/traumatised individuals. Easier said than done if there's massive barriers to accessing healthcare in the first place, but that's obviously not your fault.

Good luck in your endeavours and by all means contact me if you want a sense of how things work in Europe's largest drug service. Hope you get some interesting questions that promote robust discussion.

Thank you. And you should know that many of us here consider it a joke as well... even if it's the black humor kind... And thank you!

Over the last few decades the thinking behind addition has shifted and it is now commonly being classified as a disease. And yet many experts are still hesitant to call it that because it doesn’t fit the characteristics that a lot of diseases have. What are your thoughts on the general consensus that addition is a disease?

I don't think addiction is a disease per se, though it looks like it sometimes. I call it a syndrome because what we see is a collection of symptoms that may have very different underlying causes yet present the same. It's hard to define a disease only by its symptoms... diseases usually have a common pathway that is somehow disturbed and Dopamine is the closest thing to that in addiction but it's just not specific enough IMO.

Thank you for the response, I’m inclined to agree. It doesn’t fit the scientific characteristics of a disease but is definitely an affliction. I think also it’s hard because people feel like if it’s not a disease then it’s necessarily their fault or their control - what is the right way to treat addition so that you’re not necessarily calling it a disease but you’re also not blaming or shaming the addict?

Simple - help people identify THEIR unique contributing criteria without judgement and then help them identify tools to address those needs. Simple but not necessarily easy to carry out :)

I get a bunch of benefits from smoking pot, but there are drawbacks that I don't want. Do you have any suggestions for how to be more moderate in my drug use?

I do - I think it's important to identify the role cannabis is playing in your life. What is pot helping you with? Once you figure that out (it can take some time and there are ways to get help in doing this), you can set about addressing those needs through other channels. Additionally, there may be ways to reduce the unintended consequences through other interventions, though that can sometimes create a slippery slope of overcompensation.

At IGNTD, we follow 3 principles - Honest Exploration (why is this happening), Radical Acceptance (our F-Shame approach to help come to terms and reduce shame and become ready to change) and Individualized Transformation where you actually create the change through a variety of tools.

It sounds like you may be in the HE phase and looking for the reasons why pot is important :)

CBD- get the benefits without the psychosis-related effects (I’m not a psychologist or expert in anything, but I have plenty of experience in the pots)

I'm also a big fan of the concept of abstinence sampling, which I know Adi talks about a lot in his podcast. Taking a break from the substance, even if you don't see it as a serious problem or want to quit long term, can help you figure out what is missing in your life and improve your long-term relationship with the substance.

This is a wonderful idea - abstinence sampling is a powerful tool for understanding oneself without long-term commitment (since we're all a bit commitment phobic).

My thoughts are energetic when I smoke pot. I feel alive and I feel justified optimism for my different goals and areas of my life. CBD has never done that for me. Should I get some better CBD, or does it tend to just have a calming effect?

You may be able to counter some of the less desirable effect of the pot with higher CBD concentrations or adjunct CBD as well.

What are your thoughts on the medications currently in the market for reducing alcohol cravings (i.e. naltrexone, acamprosate, topiramate, baclofen, etc.)? Do you know of anything new or in development that is promising/interesting?

I am a big supporter of those medications, especially as an initial path to reduction so that a person can sample abstinence (or at least reduced use) and get more involved in addressing any potential underlying struggles.
Ketamine, MDMA, psilocybin etc. are somewhat emerging treatments and I haven't heard of any great candidates for prescription-based medications being tested for alcohol currently. I know people have been playing with Dopamine blockade and/or reinforcement but I haven't heard of any promising results... Anything that directly addressed GABA is likely to be habit forming long-term and therefore a bit less desirable but potentially still helpful.

I'm not him I just had an MD prescribe me naltrexone for the sinclair method. I've really been looking for anything that says it doesn't work as good as its claimed to but I haven't found any proof it doesn't work at least 70% of cases. There are some rehabs that say shit like it doesn't work if you don't take it, like no shit.

I've seen it be a MIRACLE for about a third of people and a moderate success for another third. GOOD LUCK!!! And yes, you have to take it haha!

2020 was a record year for overdoses in the United States, yet our addiction treatment industry is massive. How do we reconcile this? What are we doing wrong?

It's actually very easy (though sad) to reconcile - The addiction industry has been failing for decades with the costs being hundreds of thousands of human lives. It relies on a relatively primary unhelpful approach (AA, because it's free so treatment centers save money) and resists change while blaming those who struggle for failure.

We need to modernize the ENTIRE industry so that people get the care THEY personally need without judgement and have more choice and autonomy in the process (not to mention transparency). If we can do that (that's our goal at IGNTD), we will not only achieve better outcomes and save lives but we will also help create a population less dependent on substance use to address underlying issues.

Overdoses have been doubling every decade or so since we've been measuring them and our current approaches have failed to stem the tide. We need to move from a powerlessness, acute treatment approach (rehabs and such) to an empowerment and community based set of principles.

Thanks for doing this AMA! Feel free to skip around these questions or not answer any at all.

Does the IGNTD method work better for certain addictions over others?

How have your personal experiences with drugs and addiction informed your treatment strategies?

Is there a single best anecdote/analogy/statistic that you think would work best for getting someone to question traditional addiction treatment methods?

What are some other areas of mental health that you think your emphasis on combatting shame and non-judgmental support could also be helpful outside of addiction?

Given your experience with the criminal justice system, what are some ways that you think our justice system could do a better job of promoting better mental health in our incarcerated populations?

Thanks again!

1. Does the IGNTD method work better for certain addictions over others?

I can say that 70% of our users are with us for alcohol primarily. Sex addiction and meth are next up (probably because they're part of my story and people relate). In general, we're a great fit for people experiencing deep shame about their struggles and willing to dive deep to address any underlying causes.

1. How have your personal experiences with drugs and addiction informed your treatment strategies?

Yes. They primarily informed my desire to help people who feel underserved (or damaged) by the traditional methods employed in the U.S. My specific recovery journey doesn't need to fit anyone else's, but the fact that traditional approaches simply didn't do it for me showed me others are also looking for alternatives.

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1. Is there a single best anecdote/analogy/statistic that you think would work best for getting someone to question traditional addiction treatment methods?

Certainly - 90% of people who need addiction help do not even engage with traditional treatment and 90% of those who do fail. That means our current approach only helps 1% of those who need it and the results are clear - more and more people dying every year.

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1. What are some other areas of mental health that you think your emphasis on combatting shame and non-judgmental support could also be helpful outside of addiction?

Fortunately we've made strides in many areas over the last few decades but there is o no doubt that stigma still exists. My guess is that MH around employment and education currently suffer the most from stigmatization.

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1. Given your experience with the criminal justice system, what are some ways that you think our justice system could do a better job of promoting better mental health in our incarcerated populations?

OOH, so many options here. It has to start with staff and CJ management not looking at people as damaged, hopeless, morally corrupt bodies. Honestly, there are people doing much better work within the CJ system and it typically requires VERY deep interventions that are centered around empathy and true compassion... Not that easy to do and there are almost NO resources available.

What is mh?

Mental Health!

My father struggled with alcoholism for ~30 years, through multiple, near countless rehab efforts and programs, yet continues to drink. Popular media likes to always portray characters that beat their addictions, but I’ve witnessed the exact opposite. Is there a point where a person can get where treatments, and programs simply don’t work?

I'm so sorry for your father's struggles. Unfortunately I find that many times people who struggle with the traditional approach are simply redirected to it over and over and over and end up being frustrated or outright feel like hopeless failures. Since at least 80% of what's offered it based on the religious-disease-morality approach, it's hard to find alternatives.

Has your father ever connected with something that felt like a fit for him? Has he expressed hating the traditional approach but been told "take it or leave it?" Has he expressed that he wishes he could get a handle on his life?

Those are important signals...

Hi Dr. Jaffe! Right now I'm sitting at two years clean from my D(s)OC but I'm starting to struggle with urges to use again. Do you have any general tips or coping mechanisms for long term maintenance? I feel like I'm almost back at day one, my usual distractions are becoming less effective and I'm worried about intrusive thoughts of using becoming more frequent and intense.

Great question and you probably have a sense of my answer - The things that work for you shouldn't be distractions (those just cover up your pain) but should be inspirational and serve to heal those underlying reasons why you are craving relief.

I use the analogy of getting a bathroom pass back in junior high - remember there were classes where you always had to go to the bathroom and some where you never did? It sounds like life currently feels like a class that makes you want to escape to the bathroom and you need to make it into a class where you are glued to your seat having a blast.

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Hope that wasn't too simplistic, but you get the point!

Do you know about sexual addiction?

Personally (yes) or professionally (yes)?

In your field I'm wondering sexual addiction is a link to abuse or trauma? I think I'm addicted because I crave attention from men.

There is a pretty common link between all addiction struggles and trauma and yes, a particular one when it comes to sex addiction. Have you experienced such trauma in your past?

I was emotionally abused being told I'm ugly and dumb all my life. I use sex as reassurance that I'm beautiful and gorgeous.

I'm so sorry. You already know that the answer is within you and not outside, but the logic of it doesn't always change the internal need. I would try some embodied approaches like EMDR or somatic experiencing or breathwork for that more body-centered help!

I quit going to therapy due to judgment.

I hear that often

What is your primary outcome measure to define "success," and have you published any of your findings in peer reviewed journals?

Wonderful question - we wrote up some of our previous data from Alternatives (an outpatient treatment center I cofounded back in the day) for presentation in conferences but never wrote it up fully.

My main outcome measure has to do with Quality Of Life (QOL) improvements, which we measure using a number of instruments but primarily the IGNTD Wheel of Life.

Collecting data currently in order to present and publish more on all of this!

If I have multiple bad vices I am trying to quit. Ciggerettes, alcohol, porn, is it better to try to stop everything at once or work on one at a time?

What a great question. It's best to work on parallel tracks - identify and go HARD after those things that are causing pressure and stress and leading to more use AND fill your life with as many habits and rituals that are helpful as you can!

Is the name a acronym? I'm having trouble understanding what it means.

It just stands for - Ignited (but with most vowels removed). We've come to create an acronym for it - Inspiration, Gratitude, Necessity, Transparency and Drive :)

It’s a cool name!

Thank you!

What do you consider the main drivers of addiction on a societal level? What do you think we can do as a society to be less vulnerable to addiction overall?

I focus much of my work on shame, but in my book The Abstinence Myth I discuss 4 overall factors - Biology, Psychology, Environment and Spirituality. Society affects them all, but stigma, marginalization, oppressive regulations and psychological stressors are certainly high up on the list. This obviously differs by cultural and economic factors, but we don't do very well with acceptance of differences in many western cultures and in the U.S. in particular we still rely on puritanical standards to a large extent. This can leave many feeling like they are living on the margins of their own society.

Alienation seems to be the common theme, in all its biological, psychological, social, spiritual, etc. forms. I get the sense that so much of what influences our behavior in society is enforced through (the threat of) alienation, including shame in communities and deprivation of our biological needs in economies.

I would tend to agree... Alienation is tantamount to death (evolutionarily anyway).

Is there a method of quantifying the addictiveness of different substances? For instance, a unit of measure to compare the addictiveness of cocaine vs heroin vs meth vs caffeine vs gambling vs food etc.

I don't know of any specific statistic or metric for this unfortunately...

I see you have touched on racial inequalities and injustices as well. If this program were to actually work, why wouldn't it be offered to anyone and everyone? The costs of the program immediately exclude poverty-stricken communities and unfortunately minority groups as well. I appreciate your desire to stray from the norm and try new things, programs like AA are free and accessible to everyone. If it works and it will help humanity, make it free. Don't line your pockets and limit its access to certain groups. Especially the groups of people who historically have had the most options for recovery. Offer it to minority and poor communities who's only option for recovery has been jails and prisons.

I always wonder when people suggest this - how do you actually expect me to make it free? It’s cost upwards of $100,000 to produce the materials and keep it going for 3 years... if we receive no funds, who is going to keep it going? And just to be clear, AA collects upwards of $10m every single year and pays their board enormous sums of money... there are entire stores selling AA merchandise for actual money (books, chips, and other merchandise) too. Are you asking them all to just give the stuff away?

I promise you this - if everyone stopped paying per the 7th tradition in meetings the program would die... like it or not, it costs money to maintain things... if you have an alternative source of funding, I am ALL ears.

Sounds like you need money to market this program. I attend multiple AA meetings in inner cities that collect less than $5 every meeting. They would easily continue to meet without any funds. They collect upwards of $10m every year but they have never charged a single cent from anyone. If the program you offer works I have no doubt individuals would give donations in return. In the age of internet making this free would be so easy. Regardless, I am interested in my first questions. You have hours of audio of you talking about privilege, racial injustices, etc. How do you then offer a program that costs an exorbitant amount of money that would not be available to poor communities? The communities that need it most. White people go to rehab, black people go to jail --> White people use IGNTD (and talk about racial injustices, privilege), black people go to jail.

Unfortunately you’re simply wrong. We actually have wonderful variability in our user-base. And at a cost as low as less than $1 per day I don’t believe we’ve priced anyone out. Again, if you have alternative funding sources, I’m happy to hear it. Until then, feel free to attend your free meetings and not pay.