Dr. Nora Volkow — Director of the National Institute on Drug Abuse (NIDA), psychiatrist and neuroscientist, pioneer in brain imaging of addiction, and great-granddaughter of Leon Trotsky.
The gist
Tim Ferriss interviews Dr. Nora Volkow, longtime director of NIDA, about the science and treatment of addiction. She traces her path from a childhood in the Mexico City house where Trotsky was assassinated to becoming one of the first scientists to image the brains of drug users. The conversation covers the current overdose crisis driven by fentanyl, the failures of the War on Drugs and its role in structural racism, and the emerging science of psychedelic-assisted therapy for depression, PTSD, and substance use disorders. Volkow also details neuromodulation technologies (TMS, deep brain stimulation, and especially low-intensity ultrasound) that she believes could one day cure addiction. She closes by emphasizing comorbid mental illness and social determinants of health as critical, under-addressed factors.
Big reveals
- Volkow describes her firsthand experience of opioid withdrawal after a car accident: she stopped Demerol-class pain medication cold turkey, suffered withdrawal that was 'worse than pain,' and gained personal insight into the drug's allure and danger.
- She identifies 2016 as the 'transformative, very malignant change' when fentanyl was introduced, explaining its potency, cheap synthesis, and ease of smuggling made it uniquely dangerous and economically attractive to dealers.
- Volkow states the War on Drugs 'created a mechanism that could perpetuate structural racism,' citing crack vs. powder cocaine sentencing disparities (at least 10x harsher penalties) that fell disproportionately on Black Americans.
- She says the strongest psychedelic evidence is for psilocybin in depression, especially for terminal cancer patients, with significant effect sizes despite small sample sizes, while warning the data is still 'very preliminary.'
- Volkow makes a striking claim: 'one day we may be able to cure addiction,' pointing to cases where strokes in the insula cause people to spontaneously stop using drugs entirely.
- She reveals pilot data on low-intensity ultrasound targeting the nucleus accumbens: a single 10-minute session produced near-immediate reductions in anxiety and craving lasting two to four weeks.
- She emphasizes addiction is frequently comorbid with anxiety, depression, and suicidality, and that people often use drugs to escape a painful mental state rather than simply to get high.
Things worth remembering
- Volkow's father was the grandson of Leon Trotsky, and her family lived in the very house in Mexico City where Trotsky was assassinated, which her father preserved as a museum.
- In 1984 at the University of Texas in Houston she became 'probably the first person to use these new technologies for the investigation of drugs of abuse,' but her work documenting strokes from cocaine was initially rejected.
- Her seminal cocaine paper was rejected by The New England Journal of Medicine and her NIDA grant was turned down; it took three years before The British Journal of Psychiatry published it.
- Fentanyl is widely used legitimately in medicine for breakthrough cancer pain and by anesthesiologists, but is so potent that only 50 times less volume is needed compared to heroin.
- Dealers now mix fentanyl with xylazine, a veterinary anesthetic that does NOT respond to Narcan, the standard fentanyl overdose antidote.
- Two milligrams of fentanyl can kill, and counterfeit pills can contain five milligrams (two-plus lethal doses).
- Psilocybin studies for nicotine dependence showed quit rates significantly greater than FDA-approved medications like Chantix or nicotine replacement therapy, though based on a single small study.
- Ferriss underwent two weeks of ketamine infusion and, though not seeking pain relief, had no chronic mid-thoracic back pain (a 10-year condition) for about six months afterward.
- High-intensity ultrasound was recently approved for Parkinson's disease, allowing precise ablation of brain tissue (e.g., subthalamic nuclei) without opening the skull.
- A West Virginia group treating opioid addiction with deep brain stimulation saw dramatic anxiety reduction and decreased opioid use in three of four patients.