January 19, 2026 • 47 mins
Medications are among the most important advancements of science, but their social consequences are often complex. What if some of our most common diseases are design flaws of modern life? Does it matter if we're fixing a root cause rather than just circumventing it? If a pill can quiet hunger, pain, or anxiety, is that "cheating"? Today we talk about the fascinating world of prescription drugs with science journalist Thomas Goetz.
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Speaker 1 (00:05):
Today we're going to talk about the fascinating world of
prescription drugs and their intersection with culture and society. And
for that we're going to be joined by science journalist
Thomas Getz. Medications are some of the most consequential advancements
of modern life, but their stories are often quite nuanced
(00:26):
and complicated. What if some of our most common diseases
are design flaws of modern life? In other words, we
always need to be asking when we're treating biological illnesses
and when we're medicating our way around the world that
we've built. Also, does it matter if we are fixing
(00:47):
a root cause versus just circumventing it. If a pill
can quiet hunger or pain or anxiety, is that cheating?
Do cures ever create the next crisis? So today we're
going to talk about the larger stories of social ills
and public health. Welcome to enter cosmos with me David Eagleman.
(01:14):
I'm a neuroscientist and author at Stanford and in these
episodes we sail deeply into our three pound universe to
better understand the world around us. Generally, when we think
(01:42):
about medicine, we picture a simple story, which is a
disease appears science identifies the cause and a drug fixes
the problem. But biology is sufficiently complicated that it rarely
cooperates with stories that are that your body is trying
to regulate hunger and mood and pain and sleep and anxiety.
(02:07):
It balances internal signals against the outside world. But the
fact is that world has changed faster than our biology
ever could, and we now live in environments saturated with
calories and stimulation and stress and chemical shortcuts, and much
of the world that we've built is designed explicitly to
(02:31):
capture our attention and to override satiety and to make
us feel better fast. So it's no surprise that many
of the most common conditions of modern life, obesity, anxiety, insomnia,
chronic pain, heart disease, are what scientists sometimes call mismatched diseases.
(02:52):
In other words, we are ancient biological systems operating in
a world that we weren't really designed for, and when
those systems strain, we reach for medications. Now, prescription drugs
are fascinating from a biology perspective because they are in
a sense controlled perturbations. You stick some molecules into the bloodstream,
(03:16):
and those cross barriers and binder receptors and nudge the
activity in some circuits, and then we watch what happens.
Sometimes the effects are kind of miraculous, other times they're subtle,
And sometimes only decades later do we realize that a
drug meant to solve one problem created some new problem.
(03:37):
So we end up with medications for anxiety that camp
down fear, but they create dependence. We get painkillers that
blunt suffering, but they cause addiction. We have sleep aids
that knock us out but damage our normal sleep architecture.
Even the most elegant drugs can rip through the system
(04:01):
in ways that we never anticipated. Now. Part of the
challenge is scale. A lot of side effects don't reveal
themselves until thousands or millions of doses have been taken,
and part of it is just an issue of humility.
Our biology is staggeringly complex even today, prescribing a drug
(04:21):
as something like sending out a sonar ping and hoping
the echo tells us something useful about what's happening beneath
the surface. So this raises deeper questions. Are drugs treating
diseases or sometimes treating symptoms of the world we've built.
If a pill can quiet hunger signals or reduce cravings
(04:45):
or lift mood or dull pain. Does that mean the
problem is solved or merely postponed? And what about responsibility?
When nearly half the population struggles with obesity, or when
anxinxiety and depression are among the leading causes of disability worldwide,
is it meaningful to frame these as individual moral failures?
(05:09):
Or are we forced to confront the interaction between biology
and behavior and environment and forced to rethink what choice
really means. So these questions sit right at the intersection
of medicine and society. So to dig in on these topics,
there's no one better to sit down with than science
(05:32):
journalist Thomas Getz, who has just come out with a
new podcast series called Drug Story. Every episode of Drug
Story takes a single prescription drug like ozembic or xanax,
or ambient or opioids, and uses that drug as a
lens to tell a much larger story, a story about
(05:52):
disease and biology, but also about markets and incentives and
unintended consequences. Thomas gets is an award win journalist. He's
the former executive editor at Wired and the author of
The Decision Tree and The Remedy. He spent years reporting
on medicine and science, and he has a special eye
for connecting molecular mechanisms to human behavior and individual patients
(06:17):
to systemic forces. So here's my conversation with Thomas Getz. So, Thomas,
you've just come out with a podcast series called drug Story.
Speaker 2 (06:31):
Tell us about that.
Speaker 3 (06:32):
I spent the last ten twelve years on an unexpected
journey deep into pharmacy. So my background is in journalism
and I have a background in public health. But I
kept on thinking about the way we use drugs in
our society to really treat problems which are manifestations of
much larger problems. So when you think about the major
(06:55):
kind of maladies of the modern life, like the heart disease, ibetes, obesity,
even things like depression or anxiety, a lot of these
things are manifest because of the world we've built. But
then the thing that we have, one of the things
that we have to treat them are drugs. And so
we have medications and we have prescriptions, and it works
(07:17):
pretty well for some people, but it doesn't actually solve
the root problems of what's going on. And so I thought,
I thought the idea of the podcast is to use
individual drugs to tell these larger stories about disease and
society and economics and business, but really to focus on
the drug as a as a kind of proxy or
(07:39):
mcguffin to tell this larger story.
Speaker 2 (07:41):
So let's take an example of some of the drugs.
Speaker 1 (07:43):
You looked at the EpiPen for allergies, you look to
ambient for insomnia, xanax for anxiety, at opiates for pain.
What kind of through lines do you see when you
when you examine these different stories.
Speaker 3 (07:58):
Right, Well, with that group you just did, all of
those drugs, oddly have had pretty massive unintended consequences.
Speaker 2 (08:07):
So like EpiPen.
Speaker 3 (08:09):
You know, EpiPen treats anaphylaxis, which is an allergic reaction,
a severe allergic reaction. But the reason that that kind
of we had this upsurge in food allergies over the
last twenty thirty years was actually because the official guidance
on food and possible allergic foods was exactly backwards. For
(08:30):
twenty years, the American Academy of Pediatrics was recommending that
parents avoid exposing their kids to peanuts and milk and
eggs early in life. Well, then that was under the
precautionary principle, the idea that they should you know, people
should do no harm and if something seems risky, then
avoid it until the kids are a little older.
Speaker 2 (08:50):
Cow's milk, I assume, yeah, yeah, yeah, cow's milk.
Speaker 3 (08:52):
Yes. Well, turns out that was exactly wrong. So it
turns out that early exposure is really useful and actually
helps actate their body in the immune system to these
possible allergens. And in fact, in countries where kids are
exposed to things like peanuts from a very early age,
there are basically no peanut allergies. So that was just
this massive unintended consequences of well well minded, well intended
(09:17):
guidance that that was just backwards. And so along comes
the EpiPen and and it was perfectly timed to take
advantage of this upsurge in food allergies. And along the
way they raised the prices click click click, and made
a lot of money and then had congressional hearings and
it was it was there was a lot of outrage
about the cost of drugs, which was really the EpiPen
(09:37):
was case a. But when you look at these other
drugs like xanax and ambient for instance, these were drugs
that at the time when they first came out, they
thought they were perfect pills. They thought they were magic,
almost magic pills, and because they worked, because they worked
really well, like ambient works pretty well to put people
(09:58):
to sleep, and and xanax worked really well to eliminate
somebody's anxiety really quickly.
Speaker 2 (10:04):
But it turns out that.
Speaker 3 (10:05):
These these same medications, because they work so well, they
create different human behaviors, and so people take them too much.
They tend to abuse them, they tend to get tolerant
to them, and it's really hard to stop using them oftentimes.
Speaker 2 (10:20):
So those are great examples of kind.
Speaker 3 (10:21):
Of the the unintended results of using these medications in
great amounts millions of people without enough kind of attention
paid to what are the possible consequences.
Speaker 1 (10:37):
Yeah, our society is like a giant and amical system,
and so when you push down over here, you get
something else happening over here, and so on. Would we
have been better off without these drugs, though presumably not,
because if somebody has insomnia, or somebody has high anxiety
or an allergic reaction, we still want to be able
to help them.
Speaker 2 (10:56):
What's your take on that.
Speaker 3 (10:57):
Yeah, Yeah, totally. So, yes, these are useful medications. The
trick is how to use them. So again, thinking about
xanax or ambient, they're really at this point intended to
be used for very short periods of time when something
is acutely wrong. Right, so somebody is having a lot
(11:18):
of trouble sleeping, then maybe an ambient is appropriate to
use for a very short duration and then to remove
it and come up with much more durable, sustainable solutions
like not using your screen in bed and things like that,
more behavioral solutions. The trouble is that patients get prescribe
(11:38):
these drugs and they work, and so the patient reasonably
it says, why can't I keep on taking these drugs?
Where they're not necessarily cognizant of the dependencies or the
talents that their body are acclimating to the drugs. So
we have to think about these drugs not as the solution,
but as part of a much order kind of program
(12:02):
or treatment program. And one of the problems that we
have in medicine is that a lot of doctors are
just not trained or don't have the time to manage
individual therapies closely enough. And it's just a matter of
time and man hours and billing, and it's the complexity
of our healthcare system. But what happens in reality is
(12:25):
people get prescribed to drug, they leave the doctor's office,
it works, and they just keep refilling it. And so
for those drugs, those drugs that have potential abuse or
dependency issues, those are really the ones that we need
to work out or watch out for. And obviously opiates
are a prime example of this. You know, they really
should have only been prescribed for acute pain temporary short durations,
(12:47):
but they were widely prescribed for even moderate chronic pain,
and people took them for months, years, and we had
an epidemic of addiction.
Speaker 1 (12:56):
And speaking of pain medications like opiates, where are we
now with that now, How that opiates are considered persona
non grata, what's the future of pain control?
Speaker 3 (13:05):
One of the things about opiates that was that was
again kind of an undertended consequence, was that they were
really widely prescribed. When pain experts started to recognize that
and argue that pain should be acknowledged, should be a
was worthy of treatment, because pain was really not considered
(13:27):
and doctors were not treating patients for their pain, so
they there was a program around the late nineties early
two thousands called pain as the fifth vital sign, where
they instructed doctors. They were recommended doctors ask people just
like they took their blood pressure or their their breathing rate.
They said, okay, a fifth vital sign would be ask
(13:47):
your patients whether they're experiencing pain. So it was a
zero to ten scale. Zero is no pain, ten is
excruciating unbearable pain, and doctors started asking their patients about
their pain level. That was one dull in terms of
flushing out a problem that people a lot of people have.
Twenty twenty five percent of Americans deal with chronic pain,
so it's a massive issue. The problem, the unattended consequence
(14:11):
was that once that was on the table, it became
something that the physician was then obliged to treat. And
different people had very different ways of rating their pain.
So for me, what would be a two, could for
you be a ten. The doctor was really in no
way of understanding what the relative concern was. But the
treatment at hand at the time was opioids, and specifically
(14:35):
oxy content, which had just been approved as a supposedly
safe version of an opioid. So it seemed like a
great opportunity to use a so called safe drug to
treat a newly cognizant condition. Well, it didn't work out
that way. It turns out oxy content was highly addictive.
People would abuse it rampantly. So opioids solved the problem,
(14:59):
but they, as we've been saying, they created other problems.
So now or pain therapy are they're trying to find
new ways of dealing with again that very real problem
for twenty twenty five percent of Americans. So there are
new drugs, There are non opioid drugs. There's a new
one called gernaviks, which was just approved last year twenty
(15:19):
twenty five, by Vertex Pharmaceuticals. It's a non opioid peripheral
nerve agent, so it doesn't work on the brain, doesn't
work on the opioid receptors. They're very insistent and glad
that it works on the peripheral nerve systems. The trick though,
is that has only been approved for acute pain, not
chronic pain. So people can use it for two weeks
(15:43):
four weeks, but insurance will only cover it, will only
pay for the drug for that amount of treatment. Now,
I spoke for my podcast, I spoke to some patients
who actually have found it very useful for their chronic pain,
but their pain out of pocket, and that's one of
the problems. And it's about a thousand dollars a month
to pay out a pocket, which which is a lot
of money. So the drug company is trying to get
(16:06):
evidence that it works for chronic pain on a population level.
They're trying to bring that to the FDA. That's a
whole process that is ongoing. But we're still trying to
find solutions to pain. One of the things that actually works.
And again you know more about this than I, but
cognitive behavioral therapy for a lot of these issues turns
(16:26):
out to be a very effective long term solution. But
the issues there are access to therapists, access treatment, so
there are consequences or concerns onto a self.
Speaker 1 (16:39):
I mean, the good news is with apps and AI
and so on, things like cognitive behavioral therapy can be
addressed at scale now in new ways totally. Yet people
still like in a sense taking pills. What's the attraction
to saying, hey, here's a solution, I swallow this, I'm
going to be fixed.
Speaker 3 (16:57):
Well, it seems like an easy fix, and one of
the things I learned was it's only really in the
last fifty seventy five years that we've had this kind
of medicine cabinet of drugs like behind in most pharmacies
there are about two or three thousand drugs behind the counter.
A lot of those drugs have been only developed in
recent decades.
Speaker 2 (17:16):
The big boom in the pharma.
Speaker 3 (17:18):
Industry was in the fifties, sixties, seventies, eighties, where we
had these whole classes of drugs emerge. So they provided
real answers or apparently provided real answers to all these
problems heart disease, diabetes, you know, the ps, psychiatric concerns.
Speaker 2 (17:37):
So that's awesome, but on the other.
Speaker 3 (17:40):
Hand, we've only had a few years to understand what
works best. And one of the things that has always
surprised me is that the odds of any drug working
for any individual are roughly a coin flip. It's roughly
about fifty percent chance. So you go to something like
an antidepressant and there's kind of a thirty percent chance
(18:03):
than any given antidepressant is going to work for any
given patient.
Speaker 2 (18:07):
So what that means is trial and error.
Speaker 3 (18:10):
So patients are kind of start a drug, they take
it for a few weeks, they see if it works.
If it doesn't, they go to a different drug. If
that doesn't work, they go to a different drug. Well,
on average, it can take a person seeking treatment for depression.
It can take them six months or more to find
something that works. We talk about that as a process,
but it's not exactly a process for the patient's experience, right,
(18:31):
it's a it's a kind of a trudging through darkness.
It's a real struggle to get to something that works.
And that's true not just for psychiatric conditions or chronic pain.
It's also true for something like heart disease because you
have other variables like side effects like diarrhea is probably
the most common side effect to drugs. When you're taking chemicals,
(18:54):
putting them into the body, your body reacts in some
ways that are intended, some ways that are not intended.
Sometimes you can tolerate those unintended consequences, sometimes you can't.
So that all adds up into the recipe of does
it work. It's not just a clinical sense, it's like
does it work for you as a patient, And for
most conditions, that is a process, and it's a messy one.
(19:17):
And it's a muddy one, and it has a lot
of frustration and anxiety and frustration to it.
Speaker 1 (19:39):
It seems to me the central issue is that biology
is insanely complicated, right. I mean, we often talk about
the brain is the most complex thing we've discovered in
the known universe. And so what we're trying to do
is say, look, here's a here's a molecule of a
particular shape, and if you take a bunch of those in,
they'll bind some receptor. And what we're going to hope
(19:59):
is that that that fixes this whole system, whether that's depression, anxiety, insomnia,
whatever it is. And it seems almost impossible that that
will ever work. But sometimes not just things in the
right direction, or let's say, for fifty percent of patients,
as you mentioned. So, what is your take on how
you see the drug industry nowadays? Having been doing this
(20:21):
drug story for a while now, how.
Speaker 2 (20:23):
Are you seeing this?
Speaker 1 (20:23):
Do you see drugs as miracles of biology that they
work sometimes or problems for society?
Speaker 3 (20:31):
You're exactly right, these are complicated systems. You've got biology
and the brain, like the brain is even in these
biological illnesses, the brain is still at play. Like just
with allergies, there's this constant fear and concern about that
people have before they take an EpiPen shot. People who
have an EpiPen in their purse, they describe to me
(20:53):
this whole thing about like is a reaction EpiPen worthy
because they just aren't sure if they should waste that
shot or take that shot which costs three hundred dollars
or so. So there are all these psychological concerns that
get wrapped up into the biological So that's the first thing.
Now back to your question, like what about the drug industry.
I think drugs are an amazing accomplishment of our society
(21:17):
and of medicine and of clinical medicine and of public health.
Right like, they save and treat thousands of people, millions
of people every day in this country around the world.
They save lives, full stop. Drugs are a benefit to society.
The trouble comes when we expect drugs as you as
we just were talking about, like you take the pill
(21:39):
and it's going to fix the problem. That that isn't
the way it works. On the one hand, biology isn't
that simple, and two it isn't fixing the larger problems
of these these deeper social conditions that oftentimes are creating
the disease or the illness. So there's this great evolutionary
(22:01):
biologist in at Harvard called Daniel Lieberman, you might know them.
So he talks about these as mismatched diseases that we've
put our body like we've designed a world that is
very comfortable and accommodating, but it's not necessarily the world
that our bodies evolve to inhabit. And so we a
lot of these diseases, like heart disease or obesity, are
(22:24):
the results of the context in which we live. And
so the diseases we're getting, like like heart disease or obesity,
are not the inevitable result of human life. They are
the exact consequence of the world we've built, the food
systems we've created.
Speaker 1 (22:41):
So this is a good segue into GLP one. Yeah, yeah,
so let's talk about that, right.
Speaker 3 (22:45):
So glp ones are so I should say when I
started the episode on GLP one, so ozempic.
Speaker 1 (22:52):
I was, by the way, for anyone who doesn't know,
GLP one's glucagon like peptide one.
Speaker 2 (22:56):
And these are the drugs that people are taking for
weight loss.
Speaker 3 (22:59):
Yes, and they they basically you'll describe it better than
I will, but I'll describe it in simple terms. They
basically interfere with the signal between your gut and your brain,
and so they turn off your cravings.
Speaker 2 (23:11):
That's exactly right.
Speaker 1 (23:12):
These are normal hormones that you have in your gut
that tell the brain, Okay, now you're full, go on,
do the next thing. And the GLP one drugs are
what are called agonists to these receptors. They mimic the
action of these hormones so that they tell the brain, hey,
no problem, you're full.
Speaker 3 (23:28):
A lot like you're a neuroscientists, you explain it better
than I would. So the GLB ones what they do
is they they because they interfere with that signal, they
turn off what is called food noise in the brain.
So they stop people from craving these foods that you know,
eat more and more and more.
Speaker 2 (23:45):
And they have other benefits as well.
Speaker 1 (23:47):
But so what people feel like is just not hungry.
I'm just not thinking about.
Speaker 3 (23:51):
Food, right, And so sometimes they so people who oftentimes
had spent decades trying to just not eat one or
find it easy to not eat one more or not
at all, and so it's been extremely helpful for individuals
for whom who have been struggling for years, for decades
(24:12):
with being overweight, being obese, and the consequent health consequences
of that like diabetes, joint pain, you know.
Speaker 1 (24:22):
Obstructive sleep, app now, all the things that come with obesity,
that's right.
Speaker 3 (24:25):
Just being able to move, just being able to live
a active life.
Speaker 2 (24:30):
And how many millions of people are on these GLP
one drugs now?
Speaker 3 (24:33):
Well, so there are there are about forty percent of
Americans ro obese, so that's that's more than one hundred
million people. And so far about ten percent of Americans
have taken a GLP one so that's that's thirty million people.
Speaker 1 (24:50):
And when you say have taken, once you start, you
really have to continue, right, so you are taking people for.
Speaker 3 (24:56):
Most people, but there is there is a it is
possible or for some I should say this, some people
do have success in tight trading, in backing off where
they reach their target weight and they're able to then
kind of maintain behavioral fixes that that don't make them
depend on the drugs. But yeah, for most people, they're
going to be taking the GLP one for the rest
(25:17):
of their life now, that there's nothing bad about that.
Speaker 2 (25:20):
There's no shame in that.
Speaker 3 (25:21):
If you are prescribed as statin, you will take your
statin for the rest of your life. If you have
a high bloodressure medication, you're you'll be taking that for
the rest of your life.
Speaker 2 (25:28):
Blood thinners rest of your life. Yeah, exactly.
Speaker 3 (25:30):
So it's not that that is that is one of
the things that we wait one of the ways we
use medicine. But the thing about golp ones is it's
very much an individual treatment, right it is. It is
one person changing the way they eat and it solves
the problem for them. When you're talking about a population
wide problem like obesity, again forty percent of Americans being obese,
(25:53):
soon to be fifty percent, you're looking at really huge
social issues that when you are prescribing things like glp ones,
which at present are very expensive drugs, it just becomes
a really difficult proposition to think about, Okay, well, how
are we as a society going to afford that, and
(26:13):
are there other changes that we could be making that
would be given the amount of money that we would
be spending, which is something like one point five trillion dollars.
If you put everyone everyone in America who's obese on
a GLP one at full price, it would be one
and a half trillion dollars.
Speaker 2 (26:30):
So that's a lot of money.
Speaker 3 (26:32):
We could do a lot of things with one and
a half trillion dollars, including change some of the food
systems that we have. So you just have to think
about the kind of trade offs and costs.
Speaker 1 (26:42):
So specifically, what you're thinking about is you feel like
food manufacturers have done things to optimize food for consumption,
to make them salty and sugary and fatty and small
and tasty and so on, So you can keep going
with it.
Speaker 2 (26:59):
This is what you're addressing. Yeah, well there's I mean,
they have been doing that.
Speaker 1 (27:03):
Right and so and so the point you're addressing here
is that not only could we be addressing this with
drugs with JLP ones, but also doing something about the
food industry. I do have a question, though, what would
you How would you actually legislate that, because what they're
doing is making food so that people will buy that
food and enjoy that food, and you can't exactly legislate
(27:24):
to say, hey, don't make it as tasty as you have.
Speaker 3 (27:28):
Right, So I'm not saying that you have to legislate it.
I'm not saying that it requires government intervention. It could,
but it doesn't require that. I think one of the
things that's interesting that we're seeing is that when people
take these GLP ones and the food noise turns off,
they independently change what they decide to eat. They eat
(27:51):
more vegetables, right, They don't eat the stuff that is
full of sugar, fat and salt that is on the
shelvesult processed foods, and so what you end up seeing
is that the food companies themselves are trying to anticipate
new products and develop new products that are in fact
(28:12):
more healthy, more appealing to the millions of people who
are taking glp ones. So that is a market based solution, right,
People's people are changing their behavior and the industry is
trying to change in turn. That would be wonderful if
food companies develop healthier, less quote unquote less addictive foods
(28:35):
that that people would want to buy and and that
don't don't end up, you know, manifesting in in excess
body fat and obesity.
Speaker 2 (28:45):
So so some of that is.
Speaker 3 (28:47):
Market based, but there is possibly a role for you know,
the FDA, the f and FDA stands for food. Food
labeling is something that they governed. They can control kind
of claims of being healthy, they can control claims of
good for you, things like that. So there are ways
that that regulatory arms can be brought to bear.
Speaker 1 (29:09):
Yeah, and it makes sense because when people are on
GLP ones and they start eating more healthy foods, more
salubrious foods, it's because they know that they should be
doing it, and they no longer have the pull of
this tempting sugar, salt fat thing over there, so they're
able to just think through the problem and make the
right choice. And so making sure the labeling is correct
(29:31):
so that something doesn't erroneously say falsely say hey this
is healthy for you allows people to make good decisions
use the rationality there.
Speaker 3 (29:40):
But I have a question for you, and I'm actually curious,
what do you make of the idea that foods are
addictive or might be addictive, that some foods could be addictive.
Speaker 2 (29:52):
Do you think that's true that other I do think
it's true.
Speaker 1 (29:56):
What's interesting is people sometimes use the word designed there
as in the companies designed the food. But there's also
a sense in which it's just evolved. It's a natural
evolution that you know, people gravitate towards things with more
salt and fat and sugar and so on, and they
like these things. So we've always had, you know, junkie
(30:17):
food like this, and we just have more and more
of it. So this leads to this interesting question that
you post in your podcast, which is does it seem
like it's cheating to take GLP ones? So, first of all,
what have you seen in your interviews in your research
do people feel like, hey, this is cheating to take
(30:37):
this drug and lose weight that way as opposed to
doing the hard work of going to the gym and
resisting and using willpower.
Speaker 3 (30:45):
So that is the debate that is that has been
the debate in part around GLP ones. That has also
been the debate around obesity itself for decades, that this
was something that individuals should just you know, take control
of their own free will, live better, exercise more, lose
the weight. It's not that easy, and it hasn't worked
(31:05):
that way because that argument has been made for decades
and the obesity rate has been climbing every year, so
there's larger systems at play. Part of the problem I
think with that debate is that one the foods actually
are manipulating our brains in ways that are maybe outside
of our personal control, that they are addictive in some sense,
(31:27):
some of these foods. The other concern is that this
debate around cheating is one where we are blaming people.
There's still this kind of this notion of blame and
responsibility for obesity in particular, which we don't necessarily have.
There's a lot of stigma to obesity that we don't
(31:50):
have with other diseases, even something like high cholesterol. It's
just often behavioral based. It doesn't appear you don't look
when you have high cholesterol. It doesn't really look like
you do. So there's not as it's not as easy
to attribute stigma. But it's also a particularly American problem
or American argument about individual responsibility. Other countries, other cultures
(32:14):
do not have as strong a history of individualism and
individual responsibility, where there's two edges to the sword that
you are both have the freedom to pursue your own interests,
but also you have to be in control and suffer
the consequences of your decisions and choices. That is a
(32:37):
very American way of looking at individual choices, and again
Europe other societies do not have as strong a strain
of individualism. They have much more of a commonality or
communal notion of health and responsibility, and so they don't
kind of have this culture of blame, which is problem
(33:01):
again uniquely American one.
Speaker 1 (33:17):
So this is interesting because it all comes down to
this question of whether obesity is a choice. Right, you're
saying with the double edged sword, you know, you have
all those freedom to do things, but also you're responsible
for your choices. But this is really the heart of
the issue is biologically there's a huge amount of variation
on any axis that you measure, and some of these
(33:39):
axes have to do with, for example, how much food
noise one has, how saated one can be when one eats,
and so on. There are genetic differences, there are you know,
childhood differences and so on. All these things add up
to people being quite different from one another. So the
question here is about choice, because this doesn't take weigh
(34:00):
somebody's choice, but it does bound it. And this is
I think the important part to recognize with all this
is that we all make choices and we're all bound.
We're fenced in by our biology, and sometimes we're fenced
in differently so the answer is both, we're you know,
we're making decisions, but we don't come to the table equally.
Speaker 2 (34:22):
But I totally agree with that.
Speaker 3 (34:24):
I would also say we're fenced in by our society
and culture and by industry. So in the nineteen eighties,
Nabisco and Craft, that two of the largest food companies
in the world, were bought by big tobacco companies, and
big tobacco brought all the science and engineering and marketing
that they had learned in cigarettes to food, and so
(34:47):
they started to create snack foods that were even better,
even more irresistible. Now you might say, like that's just
good business, that was just smart, you know, of their markets,
but there was a recent study that actually showed that
the food products that were sold by those companies when
(35:10):
they were owned by big tobacco were actually eighty percent
higher in salt, sugar, and fat than products that were
owned by non tobacco companies. So they were actually engineered
to be very high in those ingredients because people like them.
(35:31):
As you say, because that's what people are choosing. But
at what point does that notion of choice and choosing
certain products just because they taste better, just because we
crave them. At what point does that stop being an
individual decision and start being something that you know. There
are larger structures and forces at work. There's marketing in
(35:52):
terms of the grocery stores, and we're what's being put
at light level, that's paid for, that's placement. There's the
commercials that were being told these foods are irresistible and
that's a good thing. So those are all the contexts
that I think also surround these ideas of individual choice
that have a great deal of influence and have had
(36:13):
a great deal of invisible influence on our diets and
on our behavior in the past decades.
Speaker 1 (36:20):
Absolutely right, And I think the way we can put
this together is to think about the fence lines around
your own behavior, given your biology, in the context of
the world that you're in. Some people will just have
the capacity to watch it Rito's commercial and resist and
not pick them up. And other people will watch it
and they have so much food noise from that, and
they have so much craving, and they're influenced by the
(36:42):
marketing and so on, and they go for it. The
question is, given your genetics and your experience, what is
your capacity to resist and make good choices in the
context that you're in.
Speaker 3 (36:55):
Yeah, and it does have I mean there are socioeconomic
variables here too. Wealthier people have more opportunity and more agency.
One of your former colleagues, Albert Bendora, talks about self efficacy,
the ability to form our own make our own choices,
the confidence that we have to guide our own paths.
(37:16):
That is something that that wealthy people have much more
of than people who are not wealthy.
Speaker 2 (37:21):
They they you know, more.
Speaker 3 (37:22):
Stresses in life. So those are all those are all
issues as well.
Speaker 2 (37:26):
Just before we go off GLP ones.
Speaker 1 (37:28):
And my question is there are all these other consequences
that they're having that are extraordinary, like people are giving
up smoking and gambling and other sorts of things.
Speaker 2 (37:38):
What's your take on this?
Speaker 3 (37:39):
Well, it makes sense right again, you're the neuroscientist. I'm not,
but they seem to this. They seem to be things
that are also affected by these pathways. So substance abuse, drinking,
drinking alcohol to access. Uh, these are all behaviors that
where we're hitting our pleasure centers, we're hitting our dopamine
receptors whatever it is they work on our brain and
(38:02):
GOLP ones somehow turn it off, and it's I think
where they're just starting to do clinical trials in these areas.
It's extremely promising. It's extremely hopeful for human health much
more broadly. And remember, we're getting much stronger, better, more
effective GLP ones in the pipeline. We're going to start
(38:23):
having oral GLP one's pills. Right now it's injections. So
once we get to pills and that are going to
be more efficacious at fixing or addressing some of those behaviors,
some of those issues. I think the doors are wide
open to how these drugs are going to help us
in the years ahead.
Speaker 1 (38:44):
Now, by the way, you made a very interesting calculation
in your podcast, which is that it would cost, as
you mentioned earlier, one point five trillion to get let's
just say we're talking about ABCD to get everyone with
ob city in America on these trucks. But what you
calculated is why this might actually make sense to spend
that money.
Speaker 3 (39:00):
Yeah, well that's with the caveat that's full list price.
So you know they're talks about doing deals with the
drug companies to lower those prices. But roughly that had
one point five trillion dollars.
Speaker 2 (39:10):
If it were that ye, why would it be worth it.
Speaker 3 (39:12):
Yeah, So the reason it's worth it, I think is
because we spend hundreds of billions of dollars. We spend
five trillion dollars on healthcare in this country every year, right,
more than any other nation on Earth. And out of
that five trillion, we spend hundreds of billions of dollars
on obesity. We spend hundreds of hundreds of billions of
(39:33):
dollars on diabetes, hundreds of billions of dollars on heart disease.
Speaker 2 (39:37):
So if we're.
Speaker 3 (39:39):
Addressing obesity, which is upstream from all of these other conditions, well,
we would be chipping away at the amount we're expending
on those issues, right, So there it wouldn't be kind
of erasing them altogether, but we would spend far less
on diabetes if we had far fewer people go from
(40:00):
obesity into diabetes. That's one point, But the other issue
is really I think goes to kind of quality of
life and quality of health span, Like how do we
help people have the best possible life that they can,
the best possible health they can before they get sick.
And that's one of the things that's so promising about
(40:22):
these GLP ones is they're really good at prevention, and
so if we can if we can help people pay
that one point five trillion dollars to give people better
lives instead of waiting for them to get sick and
go in the hospital and you know, surgery and all
these other things that we spend that five trillion dollars on.
That's that's probably a good argument to spend that money.
Speaker 1 (40:50):
That was my interview with Thomas Getz. Thomas's podcast Drug
Story dives into many topics that we didn't touch on here,
like lipiitour and heart does ease, or zoloft and depression,
or xanax and anxiety, or ambient and insomnia and so on.
So I just want to summarize by hitting three issues first.
(41:12):
From the point of view of biology, every drug is
a hypothesis.
Speaker 2 (41:18):
It is a guess.
Speaker 1 (41:19):
It's a carefully engineered intervention into a system that we
only partially understand. We identify a receptor or a pathway
or a circuit, and we nudget. Sometimes the result is great,
you get meaningful relief. Other times the effects are delayed,
or they're indirect, or they're only visible years later, when
(41:42):
millions of bodies have already been changed. The fact is
that even with all the massive progress in biology, we
still don't have predictable outcomes, and we're not going to
for as far as we can squint into the future,
We're always working to scratch out insight to a vast
dynamical system that is shaped by evolution and development and experience.
(42:07):
So when we intervene chemically, we always want to act
on a single system, but we essentially never can. Instead,
all we can do is perturb a system that's going
to adapt and compensate, and that often surprises us. For
the most part, medicine just can't tackle the complexity of
(42:27):
everything happening under the hood, at least not yet. Medicine
can't simulate the entirety of your biology, at least not yet,
and certainly can't simulate your biology decades into the future
to see what the long term effects of drugs are
or aren't. When you're dealing with exceedingly complex systems like
(42:49):
the human body, it's just impossible to have certainty. And
that's exactly why so many of the drugs on the
market come with complicated stories that stretch beyond the biology.
Speaker 2 (43:01):
Into societal issues.
Speaker 1 (43:03):
The second thing I want to point out is the
question that is always there about the distinction between normal
human experiences and medical conditions. If you have grief after
you lose a parent, or sadness after some hardship, or
anxiety in stressful moments, those shouldn't be thought of as diseases.
(43:25):
Those are just appropriate human responses to life. They become
medical diagnoses when they persist without a clear cause, when
they become chronic, when they start to impair your daily functioning,
like we see with clinical depression or anxiety disorders or
chronic pain. In those cases we can say, okay, the
(43:46):
issue is not just a specific event or injury, but
an ongoing physiological state, and treating it medically can both
be appropriate and life changing. And modern medicine has made
unbelievably great progress in addressing these conditions with drugs as
part of broader treatment approaches. But the boundary between normal
(44:09):
human suffering and diagnosable disease, that boundary is subjective sometimes
and it's always blurry, and that raises really difficult questions
about when treatment is warranted and how society decides which
conditions justify large scale medical intervention. And these are questions
(44:29):
for which there are no simple or definitive answers. Finally,
I want to highlight Thomas's view that many of the
conditions we now medicate, things like obesity and anxiety and
pain and insomnia, these are signals, their messages from nervous
systems doing their best to regulate themselves in a world
(44:51):
that often pushes them out of equilibrium. Drugs can help,
sometimes they help enormously, but they also reveal the limits
of a purely pharmacological solution. They remind us that biology
and culture are never cleanly separable, and that treating downstream
(45:11):
symptoms without addressing upstream causes is only going to take
us so far. So we're probably never going to find
the perfect molecules that finally fix everything. But perhaps we'll
get better at integration drugs alongside changes that we're able
to make in our environment and our behavior, in our
(45:34):
policy and our technology, we'll get better at pairing molecules
with psychology and neuroscience and social design. So to my mind,
one of the most important things about understanding prescription drugs
is resisting simple stories, and Thomas does a good job
with that. Prescription drugs have changed the world for the better,
(45:58):
and also their stories can be complicated. So what we
can do is keep researching. We can build bigger and
bigger simulations with the help of massive computational models.
Speaker 2 (46:09):
We can leverage AI to understand those models.
Speaker 1 (46:12):
We can measure carefully, we can watch for unintended consequences.
Speaker 2 (46:17):
And that's what science does.
Speaker 1 (46:19):
It just keeps getting better, such that in one hundred
years from now, when some future broadcaster makes Drug Story two,
the interplay between our drugs, our bodies, and the world
we've built will hopefully be much more straightforward. Go to
(46:40):
eagleman dot com slash podcast for more information and to
find further readings. Join the weekly discussions on my substack,
and check out and subscribe to Inner Cosmos on YouTube
for videos of each episode and to leave comments Until
next time. I'm David Eagleman, and this is Inner Cosmos.
Today we're going to talk about the fascinating world of
prescription drugs and their intersection with culture and society. And
for that we're going to be joined by science journalist
Thomas Getz. Medications are some of the most consequential advancements
of modern life, but their stories are often quite nuanced
(00:26):
and complicated. What if some of our most common diseases
are design flaws of modern life? In other words, we
always need to be asking when we're treating biological illnesses
and when we're medicating our way around the world that
we've built. Also, does it matter if we are fixing
(00:47):
a root cause versus just circumventing it. If a pill
can quiet hunger or pain or anxiety, is that cheating?
Do cures ever create the next crisis? So today we're
going to talk about the larger stories of social ills
and public health. Welcome to enter cosmos with me David Eagleman.
(01:14):
I'm a neuroscientist and author at Stanford and in these
episodes we sail deeply into our three pound universe to
better understand the world around us. Generally, when we think
(01:42):
about medicine, we picture a simple story, which is a
disease appears science identifies the cause and a drug fixes
the problem. But biology is sufficiently complicated that it rarely
cooperates with stories that are that your body is trying
to regulate hunger and mood and pain and sleep and anxiety.
(02:07):
It balances internal signals against the outside world. But the
fact is that world has changed faster than our biology
ever could, and we now live in environments saturated with
calories and stimulation and stress and chemical shortcuts, and much
of the world that we've built is designed explicitly to
(02:31):
capture our attention and to override satiety and to make
us feel better fast. So it's no surprise that many
of the most common conditions of modern life, obesity, anxiety, insomnia,
chronic pain, heart disease, are what scientists sometimes call mismatched diseases.
(02:52):
In other words, we are ancient biological systems operating in
a world that we weren't really designed for, and when
those systems strain, we reach for medications. Now, prescription drugs
are fascinating from a biology perspective because they are in
a sense controlled perturbations. You stick some molecules into the bloodstream,
(03:16):
and those cross barriers and binder receptors and nudge the
activity in some circuits, and then we watch what happens.
Sometimes the effects are kind of miraculous, other times they're subtle,
And sometimes only decades later do we realize that a
drug meant to solve one problem created some new problem.
(03:37):
So we end up with medications for anxiety that camp
down fear, but they create dependence. We get painkillers that
blunt suffering, but they cause addiction. We have sleep aids
that knock us out but damage our normal sleep architecture.
Even the most elegant drugs can rip through the system
(04:01):
in ways that we never anticipated. Now. Part of the
challenge is scale. A lot of side effects don't reveal
themselves until thousands or millions of doses have been taken,
and part of it is just an issue of humility.
Our biology is staggeringly complex even today, prescribing a drug
(04:21):
as something like sending out a sonar ping and hoping
the echo tells us something useful about what's happening beneath
the surface. So this raises deeper questions. Are drugs treating
diseases or sometimes treating symptoms of the world we've built.
If a pill can quiet hunger signals or reduce cravings
(04:45):
or lift mood or dull pain. Does that mean the
problem is solved or merely postponed? And what about responsibility?
When nearly half the population struggles with obesity, or when
anxinxiety and depression are among the leading causes of disability worldwide,
is it meaningful to frame these as individual moral failures?
(05:09):
Or are we forced to confront the interaction between biology
and behavior and environment and forced to rethink what choice
really means. So these questions sit right at the intersection
of medicine and society. So to dig in on these topics,
there's no one better to sit down with than science
(05:32):
journalist Thomas Getz, who has just come out with a
new podcast series called Drug Story. Every episode of Drug
Story takes a single prescription drug like ozembic or xanax,
or ambient or opioids, and uses that drug as a
lens to tell a much larger story, a story about
(05:52):
disease and biology, but also about markets and incentives and
unintended consequences. Thomas gets is an award win journalist. He's
the former executive editor at Wired and the author of
The Decision Tree and The Remedy. He spent years reporting
on medicine and science, and he has a special eye
for connecting molecular mechanisms to human behavior and individual patients
(06:17):
to systemic forces. So here's my conversation with Thomas Getz. So, Thomas,
you've just come out with a podcast series called drug Story.
Speaker 2 (06:31):
Tell us about that.
Speaker 3 (06:32):
I spent the last ten twelve years on an unexpected
journey deep into pharmacy. So my background is in journalism
and I have a background in public health. But I
kept on thinking about the way we use drugs in
our society to really treat problems which are manifestations of
much larger problems. So when you think about the major
(06:55):
kind of maladies of the modern life, like the heart disease, ibetes, obesity,
even things like depression or anxiety, a lot of these
things are manifest because of the world we've built. But
then the thing that we have, one of the things
that we have to treat them are drugs. And so
we have medications and we have prescriptions, and it works
(07:17):
pretty well for some people, but it doesn't actually solve
the root problems of what's going on. And so I thought,
I thought the idea of the podcast is to use
individual drugs to tell these larger stories about disease and
society and economics and business, but really to focus on
the drug as a as a kind of proxy or
(07:39):
mcguffin to tell this larger story.
Speaker 2 (07:41):
So let's take an example of some of the drugs.
Speaker 1 (07:43):
You looked at the EpiPen for allergies, you look to
ambient for insomnia, xanax for anxiety, at opiates for pain.
What kind of through lines do you see when you
when you examine these different stories.
Speaker 3 (07:58):
Right, Well, with that group you just did, all of
those drugs, oddly have had pretty massive unintended consequences.
Speaker 2 (08:07):
So like EpiPen.
Speaker 3 (08:09):
You know, EpiPen treats anaphylaxis, which is an allergic reaction,
a severe allergic reaction. But the reason that that kind
of we had this upsurge in food allergies over the
last twenty thirty years was actually because the official guidance
on food and possible allergic foods was exactly backwards. For
(08:30):
twenty years, the American Academy of Pediatrics was recommending that
parents avoid exposing their kids to peanuts and milk and
eggs early in life. Well, then that was under the
precautionary principle, the idea that they should you know, people
should do no harm and if something seems risky, then
avoid it until the kids are a little older.
Speaker 2 (08:50):
Cow's milk, I assume, yeah, yeah, yeah, cow's milk.
Speaker 3 (08:52):
Yes. Well, turns out that was exactly wrong. So it
turns out that early exposure is really useful and actually
helps actate their body in the immune system to these
possible allergens. And in fact, in countries where kids are
exposed to things like peanuts from a very early age,
there are basically no peanut allergies. So that was just
this massive unintended consequences of well well minded, well intended
(09:17):
guidance that that was just backwards. And so along comes
the EpiPen and and it was perfectly timed to take
advantage of this upsurge in food allergies. And along the
way they raised the prices click click click, and made
a lot of money and then had congressional hearings and
it was it was there was a lot of outrage
about the cost of drugs, which was really the EpiPen
(09:37):
was case a. But when you look at these other
drugs like xanax and ambient for instance, these were drugs
that at the time when they first came out, they
thought they were perfect pills. They thought they were magic,
almost magic pills, and because they worked, because they worked
really well, like ambient works pretty well to put people
(09:58):
to sleep, and and xanax worked really well to eliminate
somebody's anxiety really quickly.
Speaker 2 (10:04):
But it turns out that.
Speaker 3 (10:05):
These these same medications, because they work so well, they
create different human behaviors, and so people take them too much.
They tend to abuse them, they tend to get tolerant
to them, and it's really hard to stop using them oftentimes.
Speaker 2 (10:20):
So those are great examples of kind.
Speaker 3 (10:21):
Of the the unintended results of using these medications in
great amounts millions of people without enough kind of attention
paid to what are the possible consequences.
Speaker 1 (10:37):
Yeah, our society is like a giant and amical system,
and so when you push down over here, you get
something else happening over here, and so on. Would we
have been better off without these drugs, though presumably not,
because if somebody has insomnia, or somebody has high anxiety
or an allergic reaction, we still want to be able
to help them.
Speaker 2 (10:56):
What's your take on that.
Speaker 3 (10:57):
Yeah, Yeah, totally. So, yes, these are useful medications. The
trick is how to use them. So again, thinking about
xanax or ambient, they're really at this point intended to
be used for very short periods of time when something
is acutely wrong. Right, so somebody is having a lot
(11:18):
of trouble sleeping, then maybe an ambient is appropriate to
use for a very short duration and then to remove
it and come up with much more durable, sustainable solutions
like not using your screen in bed and things like that,
more behavioral solutions. The trouble is that patients get prescribe
(11:38):
these drugs and they work, and so the patient reasonably
it says, why can't I keep on taking these drugs?
Where they're not necessarily cognizant of the dependencies or the
talents that their body are acclimating to the drugs. So
we have to think about these drugs not as the solution,
but as part of a much order kind of program
(12:02):
or treatment program. And one of the problems that we
have in medicine is that a lot of doctors are
just not trained or don't have the time to manage
individual therapies closely enough. And it's just a matter of
time and man hours and billing, and it's the complexity
of our healthcare system. But what happens in reality is
(12:25):
people get prescribed to drug, they leave the doctor's office,
it works, and they just keep refilling it. And so
for those drugs, those drugs that have potential abuse or
dependency issues, those are really the ones that we need
to work out or watch out for. And obviously opiates
are a prime example of this. You know, they really
should have only been prescribed for acute pain temporary short durations,
(12:47):
but they were widely prescribed for even moderate chronic pain,
and people took them for months, years, and we had
an epidemic of addiction.
Speaker 1 (12:56):
And speaking of pain medications like opiates, where are we
now with that now, How that opiates are considered persona
non grata, what's the future of pain control?
Speaker 3 (13:05):
One of the things about opiates that was that was
again kind of an undertended consequence, was that they were
really widely prescribed. When pain experts started to recognize that
and argue that pain should be acknowledged, should be a
was worthy of treatment, because pain was really not considered
(13:27):
and doctors were not treating patients for their pain, so
they there was a program around the late nineties early
two thousands called pain as the fifth vital sign, where
they instructed doctors. They were recommended doctors ask people just
like they took their blood pressure or their their breathing rate.
They said, okay, a fifth vital sign would be ask
(13:47):
your patients whether they're experiencing pain. So it was a
zero to ten scale. Zero is no pain, ten is
excruciating unbearable pain, and doctors started asking their patients about
their pain level. That was one dull in terms of
flushing out a problem that people a lot of people have.
Twenty twenty five percent of Americans deal with chronic pain,
so it's a massive issue. The problem, the unattended consequence
(14:11):
was that once that was on the table, it became
something that the physician was then obliged to treat. And
different people had very different ways of rating their pain.
So for me, what would be a two, could for
you be a ten. The doctor was really in no
way of understanding what the relative concern was. But the
treatment at hand at the time was opioids, and specifically
(14:35):
oxy content, which had just been approved as a supposedly
safe version of an opioid. So it seemed like a
great opportunity to use a so called safe drug to
treat a newly cognizant condition. Well, it didn't work out
that way. It turns out oxy content was highly addictive.
People would abuse it rampantly. So opioids solved the problem,
(14:59):
but they, as we've been saying, they created other problems.
So now or pain therapy are they're trying to find
new ways of dealing with again that very real problem
for twenty twenty five percent of Americans. So there are
new drugs, There are non opioid drugs. There's a new
one called gernaviks, which was just approved last year twenty
(15:19):
twenty five, by Vertex Pharmaceuticals. It's a non opioid peripheral
nerve agent, so it doesn't work on the brain, doesn't
work on the opioid receptors. They're very insistent and glad
that it works on the peripheral nerve systems. The trick though,
is that has only been approved for acute pain, not
chronic pain. So people can use it for two weeks
(15:43):
four weeks, but insurance will only cover it, will only
pay for the drug for that amount of treatment. Now,
I spoke for my podcast, I spoke to some patients
who actually have found it very useful for their chronic pain,
but their pain out of pocket, and that's one of
the problems. And it's about a thousand dollars a month
to pay out a pocket, which which is a lot
of money. So the drug company is trying to get
(16:06):
evidence that it works for chronic pain on a population level.
They're trying to bring that to the FDA. That's a
whole process that is ongoing. But we're still trying to
find solutions to pain. One of the things that actually works.
And again you know more about this than I, but
cognitive behavioral therapy for a lot of these issues turns
(16:26):
out to be a very effective long term solution. But
the issues there are access to therapists, access treatment, so
there are consequences or concerns onto a self.
Speaker 1 (16:39):
I mean, the good news is with apps and AI
and so on, things like cognitive behavioral therapy can be
addressed at scale now in new ways totally. Yet people
still like in a sense taking pills. What's the attraction
to saying, hey, here's a solution, I swallow this, I'm
going to be fixed.
Speaker 3 (16:57):
Well, it seems like an easy fix, and one of
the things I learned was it's only really in the
last fifty seventy five years that we've had this kind
of medicine cabinet of drugs like behind in most pharmacies
there are about two or three thousand drugs behind the counter.
A lot of those drugs have been only developed in
recent decades.
Speaker 2 (17:16):
The big boom in the pharma.
Speaker 3 (17:18):
Industry was in the fifties, sixties, seventies, eighties, where we
had these whole classes of drugs emerge. So they provided
real answers or apparently provided real answers to all these
problems heart disease, diabetes, you know, the ps, psychiatric concerns.
Speaker 2 (17:37):
So that's awesome, but on the other.
Speaker 3 (17:40):
Hand, we've only had a few years to understand what
works best. And one of the things that has always
surprised me is that the odds of any drug working
for any individual are roughly a coin flip. It's roughly
about fifty percent chance. So you go to something like
an antidepressant and there's kind of a thirty percent chance
(18:03):
than any given antidepressant is going to work for any
given patient.
Speaker 2 (18:07):
So what that means is trial and error.
Speaker 3 (18:10):
So patients are kind of start a drug, they take
it for a few weeks, they see if it works.
If it doesn't, they go to a different drug. If
that doesn't work, they go to a different drug. Well,
on average, it can take a person seeking treatment for depression.
It can take them six months or more to find
something that works. We talk about that as a process,
but it's not exactly a process for the patient's experience, right,
(18:31):
it's a it's a kind of a trudging through darkness.
It's a real struggle to get to something that works.
And that's true not just for psychiatric conditions or chronic pain.
It's also true for something like heart disease because you
have other variables like side effects like diarrhea is probably
the most common side effect to drugs. When you're taking chemicals,
(18:54):
putting them into the body, your body reacts in some
ways that are intended, some ways that are not intended.
Sometimes you can tolerate those unintended consequences, sometimes you can't.
So that all adds up into the recipe of does
it work. It's not just a clinical sense, it's like
does it work for you as a patient, And for
most conditions, that is a process, and it's a messy one.
(19:17):
And it's a muddy one, and it has a lot
of frustration and anxiety and frustration to it.
Speaker 1 (19:39):
It seems to me the central issue is that biology
is insanely complicated, right. I mean, we often talk about
the brain is the most complex thing we've discovered in
the known universe. And so what we're trying to do
is say, look, here's a here's a molecule of a
particular shape, and if you take a bunch of those in,
they'll bind some receptor. And what we're going to hope
(19:59):
is that that that fixes this whole system, whether that's depression, anxiety, insomnia,
whatever it is. And it seems almost impossible that that
will ever work. But sometimes not just things in the
right direction, or let's say, for fifty percent of patients,
as you mentioned. So, what is your take on how
you see the drug industry nowadays? Having been doing this
(20:21):
drug story for a while now, how.
Speaker 2 (20:23):
Are you seeing this?
Speaker 1 (20:23):
Do you see drugs as miracles of biology that they
work sometimes or problems for society?
Speaker 3 (20:31):
You're exactly right, these are complicated systems. You've got biology
and the brain, like the brain is even in these
biological illnesses, the brain is still at play. Like just
with allergies, there's this constant fear and concern about that
people have before they take an EpiPen shot. People who
have an EpiPen in their purse, they describe to me
(20:53):
this whole thing about like is a reaction EpiPen worthy
because they just aren't sure if they should waste that
shot or take that shot which costs three hundred dollars
or so. So there are all these psychological concerns that
get wrapped up into the biological So that's the first thing.
Now back to your question, like what about the drug industry.
I think drugs are an amazing accomplishment of our society
(21:17):
and of medicine and of clinical medicine and of public health.
Right like, they save and treat thousands of people, millions
of people every day in this country around the world.
They save lives, full stop. Drugs are a benefit to society.
The trouble comes when we expect drugs as you as
we just were talking about, like you take the pill
(21:39):
and it's going to fix the problem. That that isn't
the way it works. On the one hand, biology isn't
that simple, and two it isn't fixing the larger problems
of these these deeper social conditions that oftentimes are creating
the disease or the illness. So there's this great evolutionary
(22:01):
biologist in at Harvard called Daniel Lieberman, you might know them.
So he talks about these as mismatched diseases that we've
put our body like we've designed a world that is
very comfortable and accommodating, but it's not necessarily the world
that our bodies evolve to inhabit. And so we a
lot of these diseases, like heart disease or obesity, are
(22:24):
the results of the context in which we live. And
so the diseases we're getting, like like heart disease or obesity,
are not the inevitable result of human life. They are
the exact consequence of the world we've built, the food
systems we've created.
Speaker 1 (22:41):
So this is a good segue into GLP one. Yeah, yeah,
so let's talk about that, right.
Speaker 3 (22:45):
So glp ones are so I should say when I
started the episode on GLP one, so ozempic.
Speaker 1 (22:52):
I was, by the way, for anyone who doesn't know,
GLP one's glucagon like peptide one.
Speaker 2 (22:56):
And these are the drugs that people are taking for
weight loss.
Speaker 3 (22:59):
Yes, and they they basically you'll describe it better than
I will, but I'll describe it in simple terms. They
basically interfere with the signal between your gut and your brain,
and so they turn off your cravings.
Speaker 2 (23:11):
That's exactly right.
Speaker 1 (23:12):
These are normal hormones that you have in your gut
that tell the brain, Okay, now you're full, go on,
do the next thing. And the GLP one drugs are
what are called agonists to these receptors. They mimic the
action of these hormones so that they tell the brain, hey,
no problem, you're full.
Speaker 3 (23:28):
A lot like you're a neuroscientists, you explain it better
than I would. So the GLB ones what they do
is they they because they interfere with that signal, they
turn off what is called food noise in the brain.
So they stop people from craving these foods that you know,
eat more and more and more.
Speaker 2 (23:45):
And they have other benefits as well.
Speaker 1 (23:47):
But so what people feel like is just not hungry.
I'm just not thinking about.
Speaker 3 (23:51):
Food, right, And so sometimes they so people who oftentimes
had spent decades trying to just not eat one or
find it easy to not eat one more or not
at all, and so it's been extremely helpful for individuals
for whom who have been struggling for years, for decades
(24:12):
with being overweight, being obese, and the consequent health consequences
of that like diabetes, joint pain, you know.
Speaker 1 (24:22):
Obstructive sleep, app now, all the things that come with obesity,
that's right.
Speaker 3 (24:25):
Just being able to move, just being able to live
a active life.
Speaker 2 (24:30):
And how many millions of people are on these GLP
one drugs now?
Speaker 3 (24:33):
Well, so there are there are about forty percent of
Americans ro obese, so that's that's more than one hundred
million people. And so far about ten percent of Americans
have taken a GLP one so that's that's thirty million people.
Speaker 1 (24:50):
And when you say have taken, once you start, you
really have to continue, right, so you are taking people for.
Speaker 3 (24:56):
Most people, but there is there is a it is
possible or for some I should say this, some people
do have success in tight trading, in backing off where
they reach their target weight and they're able to then
kind of maintain behavioral fixes that that don't make them
depend on the drugs. But yeah, for most people, they're
going to be taking the GLP one for the rest
(25:17):
of their life now, that there's nothing bad about that.
Speaker 2 (25:20):
There's no shame in that.
Speaker 3 (25:21):
If you are prescribed as statin, you will take your
statin for the rest of your life. If you have
a high bloodressure medication, you're you'll be taking that for
the rest of your life.
Speaker 2 (25:28):
Blood thinners rest of your life. Yeah, exactly.
Speaker 3 (25:30):
So it's not that that is that is one of
the things that we wait one of the ways we
use medicine. But the thing about golp ones is it's
very much an individual treatment, right it is. It is
one person changing the way they eat and it solves
the problem for them. When you're talking about a population
wide problem like obesity, again forty percent of Americans being obese,
(25:53):
soon to be fifty percent, you're looking at really huge
social issues that when you are prescribing things like glp ones,
which at present are very expensive drugs, it just becomes
a really difficult proposition to think about, Okay, well, how
are we as a society going to afford that, and
(26:13):
are there other changes that we could be making that
would be given the amount of money that we would
be spending, which is something like one point five trillion dollars.
If you put everyone everyone in America who's obese on
a GLP one at full price, it would be one
and a half trillion dollars.
Speaker 2 (26:30):
So that's a lot of money.
Speaker 3 (26:32):
We could do a lot of things with one and
a half trillion dollars, including change some of the food
systems that we have. So you just have to think
about the kind of trade offs and costs.
Speaker 1 (26:42):
So specifically, what you're thinking about is you feel like
food manufacturers have done things to optimize food for consumption,
to make them salty and sugary and fatty and small
and tasty and so on, So you can keep going
with it.
Speaker 2 (26:59):
This is what you're addressing. Yeah, well there's I mean,
they have been doing that.
Speaker 1 (27:03):
Right and so and so the point you're addressing here
is that not only could we be addressing this with
drugs with JLP ones, but also doing something about the
food industry. I do have a question, though, what would
you How would you actually legislate that, because what they're
doing is making food so that people will buy that
food and enjoy that food, and you can't exactly legislate
(27:24):
to say, hey, don't make it as tasty as you have.
Speaker 3 (27:28):
Right, So I'm not saying that you have to legislate it.
I'm not saying that it requires government intervention. It could,
but it doesn't require that. I think one of the
things that's interesting that we're seeing is that when people
take these GLP ones and the food noise turns off,
they independently change what they decide to eat. They eat
(27:51):
more vegetables, right, They don't eat the stuff that is
full of sugar, fat and salt that is on the
shelvesult processed foods, and so what you end up seeing
is that the food companies themselves are trying to anticipate
new products and develop new products that are in fact
(28:12):
more healthy, more appealing to the millions of people who
are taking glp ones. So that is a market based solution, right,
People's people are changing their behavior and the industry is
trying to change in turn. That would be wonderful if
food companies develop healthier, less quote unquote less addictive foods
(28:35):
that that people would want to buy and and that
don't don't end up, you know, manifesting in in excess
body fat and obesity.
Speaker 2 (28:45):
So so some of that is.
Speaker 3 (28:47):
Market based, but there is possibly a role for you know,
the FDA, the f and FDA stands for food. Food
labeling is something that they governed. They can control kind
of claims of being healthy, they can control claims of
good for you, things like that. So there are ways
that that regulatory arms can be brought to bear.
Speaker 1 (29:09):
Yeah, and it makes sense because when people are on
GLP ones and they start eating more healthy foods, more
salubrious foods, it's because they know that they should be
doing it, and they no longer have the pull of
this tempting sugar, salt fat thing over there, so they're
able to just think through the problem and make the
right choice. And so making sure the labeling is correct
(29:31):
so that something doesn't erroneously say falsely say hey this
is healthy for you allows people to make good decisions
use the rationality there.
Speaker 3 (29:40):
But I have a question for you, and I'm actually curious,
what do you make of the idea that foods are
addictive or might be addictive, that some foods could be addictive.
Speaker 2 (29:52):
Do you think that's true that other I do think
it's true.
Speaker 1 (29:56):
What's interesting is people sometimes use the word designed there
as in the companies designed the food. But there's also
a sense in which it's just evolved. It's a natural
evolution that you know, people gravitate towards things with more
salt and fat and sugar and so on, and they
like these things. So we've always had, you know, junkie
(30:17):
food like this, and we just have more and more
of it. So this leads to this interesting question that
you post in your podcast, which is does it seem
like it's cheating to take GLP ones? So, first of all,
what have you seen in your interviews in your research
do people feel like, hey, this is cheating to take
(30:37):
this drug and lose weight that way as opposed to
doing the hard work of going to the gym and
resisting and using willpower.
Speaker 3 (30:45):
So that is the debate that is that has been
the debate in part around GLP ones. That has also
been the debate around obesity itself for decades, that this
was something that individuals should just you know, take control
of their own free will, live better, exercise more, lose
the weight. It's not that easy, and it hasn't worked
(31:05):
that way because that argument has been made for decades
and the obesity rate has been climbing every year, so
there's larger systems at play. Part of the problem I
think with that debate is that one the foods actually
are manipulating our brains in ways that are maybe outside
of our personal control, that they are addictive in some sense,
(31:27):
some of these foods. The other concern is that this
debate around cheating is one where we are blaming people.
There's still this kind of this notion of blame and
responsibility for obesity in particular, which we don't necessarily have.
There's a lot of stigma to obesity that we don't
(31:50):
have with other diseases, even something like high cholesterol. It's
just often behavioral based. It doesn't appear you don't look
when you have high cholesterol. It doesn't really look like
you do. So there's not as it's not as easy
to attribute stigma. But it's also a particularly American problem
or American argument about individual responsibility. Other countries, other cultures
(32:14):
do not have as strong a history of individualism and
individual responsibility, where there's two edges to the sword that
you are both have the freedom to pursue your own interests,
but also you have to be in control and suffer
the consequences of your decisions and choices. That is a
(32:37):
very American way of looking at individual choices, and again
Europe other societies do not have as strong a strain
of individualism. They have much more of a commonality or
communal notion of health and responsibility, and so they don't
kind of have this culture of blame, which is problem
(33:01):
again uniquely American one.
Speaker 1 (33:17):
So this is interesting because it all comes down to
this question of whether obesity is a choice. Right, you're
saying with the double edged sword, you know, you have
all those freedom to do things, but also you're responsible
for your choices. But this is really the heart of
the issue is biologically there's a huge amount of variation
on any axis that you measure, and some of these
(33:39):
axes have to do with, for example, how much food
noise one has, how saated one can be when one eats,
and so on. There are genetic differences, there are you know,
childhood differences and so on. All these things add up
to people being quite different from one another. So the
question here is about choice, because this doesn't take weigh
(34:00):
somebody's choice, but it does bound it. And this is
I think the important part to recognize with all this
is that we all make choices and we're all bound.
We're fenced in by our biology, and sometimes we're fenced
in differently so the answer is both, we're you know,
we're making decisions, but we don't come to the table equally.
Speaker 2 (34:22):
But I totally agree with that.
Speaker 3 (34:24):
I would also say we're fenced in by our society
and culture and by industry. So in the nineteen eighties,
Nabisco and Craft, that two of the largest food companies
in the world, were bought by big tobacco companies, and
big tobacco brought all the science and engineering and marketing
that they had learned in cigarettes to food, and so
(34:47):
they started to create snack foods that were even better,
even more irresistible. Now you might say, like that's just
good business, that was just smart, you know, of their markets,
but there was a recent study that actually showed that
the food products that were sold by those companies when
(35:10):
they were owned by big tobacco were actually eighty percent
higher in salt, sugar, and fat than products that were
owned by non tobacco companies. So they were actually engineered
to be very high in those ingredients because people like them.
(35:31):
As you say, because that's what people are choosing. But
at what point does that notion of choice and choosing
certain products just because they taste better, just because we
crave them. At what point does that stop being an
individual decision and start being something that you know. There
are larger structures and forces at work. There's marketing in
(35:52):
terms of the grocery stores, and we're what's being put
at light level, that's paid for, that's placement. There's the
commercials that were being told these foods are irresistible and
that's a good thing. So those are all the contexts
that I think also surround these ideas of individual choice
that have a great deal of influence and have had
(36:13):
a great deal of invisible influence on our diets and
on our behavior in the past decades.
Speaker 1 (36:20):
Absolutely right, And I think the way we can put
this together is to think about the fence lines around
your own behavior, given your biology, in the context of
the world that you're in. Some people will just have
the capacity to watch it Rito's commercial and resist and
not pick them up. And other people will watch it
and they have so much food noise from that, and
they have so much craving, and they're influenced by the
(36:42):
marketing and so on, and they go for it. The
question is, given your genetics and your experience, what is
your capacity to resist and make good choices in the
context that you're in.
Speaker 3 (36:55):
Yeah, and it does have I mean there are socioeconomic
variables here too. Wealthier people have more opportunity and more agency.
One of your former colleagues, Albert Bendora, talks about self efficacy,
the ability to form our own make our own choices,
the confidence that we have to guide our own paths.
(37:16):
That is something that that wealthy people have much more
of than people who are not wealthy.
Speaker 2 (37:21):
They they you know, more.
Speaker 3 (37:22):
Stresses in life. So those are all those are all
issues as well.
Speaker 2 (37:26):
Just before we go off GLP ones.
Speaker 1 (37:28):
And my question is there are all these other consequences
that they're having that are extraordinary, like people are giving
up smoking and gambling and other sorts of things.
Speaker 2 (37:38):
What's your take on this?
Speaker 3 (37:39):
Well, it makes sense right again, you're the neuroscientist. I'm not,
but they seem to this. They seem to be things
that are also affected by these pathways. So substance abuse, drinking,
drinking alcohol to access. Uh, these are all behaviors that
where we're hitting our pleasure centers, we're hitting our dopamine
receptors whatever it is they work on our brain and
(38:02):
GOLP ones somehow turn it off, and it's I think
where they're just starting to do clinical trials in these areas.
It's extremely promising. It's extremely hopeful for human health much
more broadly. And remember, we're getting much stronger, better, more
effective GLP ones in the pipeline. We're going to start
(38:23):
having oral GLP one's pills. Right now it's injections. So
once we get to pills and that are going to
be more efficacious at fixing or addressing some of those behaviors,
some of those issues. I think the doors are wide
open to how these drugs are going to help us
in the years ahead.
Speaker 1 (38:44):
Now, by the way, you made a very interesting calculation
in your podcast, which is that it would cost, as
you mentioned earlier, one point five trillion to get let's
just say we're talking about ABCD to get everyone with
ob city in America on these trucks. But what you
calculated is why this might actually make sense to spend
that money.
Speaker 3 (39:00):
Yeah, well that's with the caveat that's full list price.
So you know they're talks about doing deals with the
drug companies to lower those prices. But roughly that had
one point five trillion dollars.
Speaker 2 (39:10):
If it were that ye, why would it be worth it.
Speaker 3 (39:12):
Yeah, So the reason it's worth it, I think is
because we spend hundreds of billions of dollars. We spend
five trillion dollars on healthcare in this country every year, right,
more than any other nation on Earth. And out of
that five trillion, we spend hundreds of billions of dollars
on obesity. We spend hundreds of hundreds of billions of
(39:33):
dollars on diabetes, hundreds of billions of dollars on heart disease.
Speaker 2 (39:37):
So if we're.
Speaker 3 (39:39):
Addressing obesity, which is upstream from all of these other conditions, well,
we would be chipping away at the amount we're expending
on those issues, right, So there it wouldn't be kind
of erasing them altogether, but we would spend far less
on diabetes if we had far fewer people go from
(40:00):
obesity into diabetes. That's one point, But the other issue
is really I think goes to kind of quality of
life and quality of health span, Like how do we
help people have the best possible life that they can,
the best possible health they can before they get sick.
And that's one of the things that's so promising about
(40:22):
these GLP ones is they're really good at prevention, and
so if we can if we can help people pay
that one point five trillion dollars to give people better
lives instead of waiting for them to get sick and
go in the hospital and you know, surgery and all
these other things that we spend that five trillion dollars on.
That's that's probably a good argument to spend that money.
Speaker 1 (40:50):
That was my interview with Thomas Getz. Thomas's podcast Drug
Story dives into many topics that we didn't touch on here,
like lipiitour and heart does ease, or zoloft and depression,
or xanax and anxiety, or ambient and insomnia and so on.
So I just want to summarize by hitting three issues first.
(41:12):
From the point of view of biology, every drug is
a hypothesis.
Speaker 2 (41:18):
It is a guess.
Speaker 1 (41:19):
It's a carefully engineered intervention into a system that we
only partially understand. We identify a receptor or a pathway
or a circuit, and we nudget. Sometimes the result is great,
you get meaningful relief. Other times the effects are delayed,
or they're indirect, or they're only visible years later, when
(41:42):
millions of bodies have already been changed. The fact is
that even with all the massive progress in biology, we
still don't have predictable outcomes, and we're not going to
for as far as we can squint into the future,
We're always working to scratch out insight to a vast
dynamical system that is shaped by evolution and development and experience.
(42:07):
So when we intervene chemically, we always want to act
on a single system, but we essentially never can. Instead,
all we can do is perturb a system that's going
to adapt and compensate, and that often surprises us. For
the most part, medicine just can't tackle the complexity of
(42:27):
everything happening under the hood, at least not yet. Medicine
can't simulate the entirety of your biology, at least not yet,
and certainly can't simulate your biology decades into the future
to see what the long term effects of drugs are
or aren't. When you're dealing with exceedingly complex systems like
(42:49):
the human body, it's just impossible to have certainty. And
that's exactly why so many of the drugs on the
market come with complicated stories that stretch beyond the biology.
Speaker 2 (43:01):
Into societal issues.
Speaker 1 (43:03):
The second thing I want to point out is the
question that is always there about the distinction between normal
human experiences and medical conditions. If you have grief after
you lose a parent, or sadness after some hardship, or
anxiety in stressful moments, those shouldn't be thought of as diseases.
(43:25):
Those are just appropriate human responses to life. They become
medical diagnoses when they persist without a clear cause, when
they become chronic, when they start to impair your daily functioning,
like we see with clinical depression or anxiety disorders or
chronic pain. In those cases we can say, okay, the
(43:46):
issue is not just a specific event or injury, but
an ongoing physiological state, and treating it medically can both
be appropriate and life changing. And modern medicine has made
unbelievably great progress in addressing these conditions with drugs as
part of broader treatment approaches. But the boundary between normal
(44:09):
human suffering and diagnosable disease, that boundary is subjective sometimes
and it's always blurry, and that raises really difficult questions
about when treatment is warranted and how society decides which
conditions justify large scale medical intervention. And these are questions
(44:29):
for which there are no simple or definitive answers. Finally,
I want to highlight Thomas's view that many of the
conditions we now medicate, things like obesity and anxiety and
pain and insomnia, these are signals, their messages from nervous
systems doing their best to regulate themselves in a world
(44:51):
that often pushes them out of equilibrium. Drugs can help,
sometimes they help enormously, but they also reveal the limits
of a purely pharmacological solution. They remind us that biology
and culture are never cleanly separable, and that treating downstream
(45:11):
symptoms without addressing upstream causes is only going to take
us so far. So we're probably never going to find
the perfect molecules that finally fix everything. But perhaps we'll
get better at integration drugs alongside changes that we're able
to make in our environment and our behavior, in our
(45:34):
policy and our technology, we'll get better at pairing molecules
with psychology and neuroscience and social design. So to my mind,
one of the most important things about understanding prescription drugs
is resisting simple stories, and Thomas does a good job
with that. Prescription drugs have changed the world for the better,
(45:58):
and also their stories can be complicated. So what we
can do is keep researching. We can build bigger and
bigger simulations with the help of massive computational models.
Speaker 2 (46:09):
We can leverage AI to understand those models.
Speaker 1 (46:12):
We can measure carefully, we can watch for unintended consequences.
Speaker 2 (46:17):
And that's what science does.
Speaker 1 (46:19):
It just keeps getting better, such that in one hundred
years from now, when some future broadcaster makes Drug Story two,
the interplay between our drugs, our bodies, and the world
we've built will hopefully be much more straightforward. Go to
(46:40):
eagleman dot com slash podcast for more information and to
find further readings. Join the weekly discussions on my substack,
and check out and subscribe to Inner Cosmos on YouTube
for videos of each episode and to leave comments Until
next time. I'm David Eagleman, and this is Inner Cosmos.
Host
David Eagleman
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