E68: Dopamine, Addiction, Recovery, Social Media (with Dr. Anna Lembke)

Dr. Anna Lembke is a psychiatrist and author. She is the Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic at Stanford University and is the author of the New York Times bestseller Dopamine Nation: Finding Balance in the Age of Indulgence.

Today we discuss

- Dopamine and the different psychological functions it serves
- Different addictive behaviours ranging from drugs to alcohol to social media and how they affect can our mental health
- The relationship between pleasure and pain and how they are intimately tied together
- How you can re-sensitise yourself to dopamine
- The process of recovering from an addiction
- The importance of an overarching life philosophy when trying to manage an addictive behaviour

Interviewed by Dr. Alex Curmi - Give feedback here - thinkingmindpodcast@gmail.com Follow us here: Twitter @thinkingmindpod Instagram @thinkingmindpodcast

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Transcript

Well, I would start by just saying. A common misconception is that dopamine is just about pleasure. In fact, even aversive or sort of unpleasant but very potent stimuli can also release dopamine. What it really is, is about survival. It's the way that our brain signals that that something is happening in the environment or in our bodies that is really important and that we need to pay attention to because it's fundamental for our survival. 3s You have found the Thinking Mind podcast. 4s Welcome back to the Thinking Minds podcast. Our guest today is psychiatrist and author Dr. Anna Lemke. Dr. Lemke is the chief of the addiction clinic at Stanford University. She's also the author of the New York Times bestseller Dopamine Nation Finding Balance in the Age of Indulgence. She's been on various podcasts before, ranging from The Joe Rogan Experience to Modern Wisdom. And it was a pleasure to spend some time speaking with her. Today we discuss dopamine and the different psychological functions it serves different addictive behaviors ranging from drugs to alcohol to social media apps like Instagram, and how they can affect our mental health. The difference between pleasure and pain and how they are intimately tied together. How you can re sensitize yourself to dopamine, the process of recovering from an addiction, and the importance of an overarching life philosophy when trying to manage an addictive behavior or another life problem. This is the Thinking Mind Podcast, a podcast all about psychiatry, psychology, therapy, and related topics. If you like it, there are a few ways you can support it. You can share it to the friend. Follow or subscribe on Apple, Spotify, or wherever you listen. Give us a rating or if you want to support us further, you can check out the Buy Me a Coffee link in the description. Thanks for listening. 10s Dr. Lembke, thank you so much for joining me today. Well, thank you for inviting me. I'm happy to be here. Dopamine. So much good information, so much misinformation. So I thought we had to get the person that wrote, literally wrote the book about dopamine. You're an addiction psychiatrist, of course. What motivated you to write this book? Writing a book is, of course, a huge undertaking. What was what was the the thing or collection of things that motivated you that made you think, I need to just put pen to paper, write a book about this topic? Yeah, thanks for asking that. Well, you know, within sort of the house of medicine or academic medicine, there aren't that many venues for expressing clinical earned knowledge. You know, there's lots of vehicles for writing about placebo controlled trials and observational studies, epidemiologic data, but there's not really a lot of good opportunities to talk about, you know, clinical experience and the knowledge that we gain from that. So I really was itching to share with folks some of the conclusions and observations that I had made over 20 plus years of seeing many, many patients struggling with all kinds of problems, but in particular the problem of compulsive overconsumption and also expressing certain, let's say, more abstract or philosophical ideas that I had garnered that I just knew were never going to fly, you know, in a peer reviewed medical journal because they're speculative or abstract or qualitative. But it really was a particular patient that I met who is featured in the book, you know, under the pseudonym of Jake, a Stanford professor with a very serious addictive disorder who I met. And I thought, oh my gosh, this is like the perfect crucible in which to sort of hang these ideas. And fortunately, he was so generous and willing to share his story to help others. So that was sort of then the kind of the, the thing that kicked it off. What do you wish that people would understand about dopamine that perhaps they don't? We do think of dopamine as people. I think it has entered awareness that dopamine is associated with pleasure. But what misconception about dopamine would you like cleared up or what do you just wish everyone knew? We think society would be better off if people understood this about dopamine. Well, I would start by just saying. A common misconception is that dopamine is just about pleasure. In fact, even aversive or sort of unpleasant but very potent stimuli can also release dopamine. What it really is, is about survival. It's the way that our brain signals that that something is happening in the environment or in our bodies that is really important and that we need to pay attention to because it's fundamental for our survival. And what initially draws us into wanting to pay attention or repeating a certain behavior, or ingesting a certain substance repeatedly is a kind of disgorgement or release of dopamine all at once. In this particular part of the brain, called the reward pathway. But that with repeated exposure over time, the brain basically compensates by down regulating dopamine transmission. And then the behavior is driven not by pleasure, reward, novelty or even, you know, kind of this initial potent aversive experience that that our brain deems essential to pay attention to. It's really driven by this dopamine deficit state, which has us repeating the behavior to stop feeling bad rather than approaching a signal, because it's important for our survival, important information. And I think that that's really so you have these different stages, right? You have the initial salience attractiveness, rewarding potential interest that that draws us in. But but with repeated exposure the brain changes. And then what's driving it is no longer the life sustaining reason for initial engagement. We get into kind of where we're circling the addiction vortex, and now we're just using to sort of mitigate withdrawal from the last dose. I guess one of the problems of modern life is. 1s So little of the things which stimulate dopamine release in our brain now have anything to do with survival, because survival is kind of automatic. It's kind of a given in modern Western society for most people. So there's a there's a staunch artificiality. We've created this artificial worlds. We're always getting dopamine pumped into our brains all the time from things that if you look at it in the big picture, if you zoom out a little, don't actually matter that much. Do you think that's fair to say? Precisely. I agree with you. Hence the title Dopamine Nation. Essentially, what's happened is that almost every aspect of modern life has become drug ified. That is to say, made more potently reinforcing, which is another way of saying releases a lot of dopamine all at once with initial exposure in our brains reward pathway, but also more abundant, more novel and more Bountiful. Right. It kind of never runs out. We have massive amounts of everything, especially when you think of digital media as a potential addictive drug like TikTok never runs out. So this kind of drug ification of everyday life has made us all vulnerable to the problem of addiction. And I think we're living that now, whether it's our attachment to our smartphones or the drug ified food supply that we ingest, where sugar and salt and flavor are added to so much of what we eat, it's hard to escape it, and it's that we get in that same loop, you know, sugar drives, that sort of appetitive dis control where we never feel satiated because of the way that it modifies these appetitive brain circuits, 1s you know, to to traditional drugs, like there's a lot more of traditional drugs than there used to be. Opioids is a great narrative to illustrate that. We went from opium. You know, for thousands of years that you had to grow a poppy field and you had to harvest the poppies and you had to extract opium from the poppies. Now we have fentanyl, which doesn't even require a plant precursor. It's 50 to 100 times more potent than opium and morphine. And it's available cheaply on almost every street corner. At least it is in many major cities in the world. And it's deadly. It's so incredibly potent and deadly. So this is sort of the story of the last 200 years that we're really now facing a brand new, unprecedented human challenge, which is the mismatch between our ancient wiring, which has us wanting to binge on everything because we might not find it very soon again. And we need it for survival to a world in which we can now binge on everything. And these are things that are highly, highly addictive and are not helping us be healthy. Yes. And it's interesting because we normally think of addiction as a narrowing of focus onto the one addictive drug or behavior. Someone has a full life with lots of things, and then slowly over time, they become addicted to gambling, say, or cocaine or alcohol or whatever it is. I think. Patients in your clinic who maybe they're not addicted to just one thing, but because of what we've just described that the world has taken on this artificial, addictive quality. They're kind of strung out on a whole bunch of things, like they do the internet gaming and the energy drinks and too much coffee, and also maybe a bit of a cocaine habit and maybe promiscuity. Do you find patients who are kind of a little bit addicted to a whole bunch of things? Absolutely. In fact, this is normative today, and it's a huge generational shift. So, you know, 50 years ago, even 25 years ago, you know, primarily we were treating patients with alcohol use disorder or some kind of single substance cocaine, opioids, cannabis, nicotine products. Now, what we what we treat most often is what we end up calling polypharmacy, where people are using a lot, a lot of or a little bit of many different highly reinforcing substances and behaviors. And it has changed the way we have to do screening, because a lot of patients will actually use multiple substances and behaviors in an addictive way, but rationalize to themselves that they're not addicted because they're taking a break between cocaine, or they're taking a break between, you know, a pornography and masturbation or whatever it is. But so when we do our screening questions, we sort of say, well, you know, did you use anything on Monday to change the way you feel? And then we get much a much different kind of reporting. And what we find is that that person is every day using some kind of intoxicant or other, you know, to, to sort of modify their internal experience. So that's very common now. So we're all or a lot of us at least are chasing these dopamine highs. One way I've heard it phrase and maybe this is a little simplistic, but you can tell me one. There's a high associated with dopamine and everyone can relate to, like the feeling of getting a promotion at work or a sudden increase in your bank balance or a sudden increase in status. And that's what we associated with with dopamine. But there's also a kind of pleasure that typically we associate more with serotonin, more about warmth, connection, a feeling of satisfaction rather than a feeling of chasing. And I want the. Are a lot of people trying to fill a serotonin hole with dopamine. Do people lack the stimuli that they should have in their life for serotonin? And that could be a close connection family, meaning something that gives them more of a satiation and they lack that. And so to feel good for them means to chase dopamine. Is that something that you've observed? Yeah. So I mean, I think the spirit of that idea is, is true, which is to say that, 2s you know, there are healthy ways to experience reward, usually by paying for our dopamine up front, by committing to a person or a project, and every day sort of showing up and doing the work and delaying gratification that comes with that sort of intentional investment of effort over time and then there are intoxicants which make us feel good right away. And those are typically things that release a lot of dopamine all at once. I probably wouldn't, you know, I mean, the oversimplification, it's all sort of an oversimplification. The brain is still a mysterious black box when we're talking about dopamine. People aren't actually getting addicted to dopamine, right? Like if you took a spoonful of dopamine, it wouldn't wouldn't do anything because it wouldn't cross the blood brain barrier. It's a chemical we make in our brain in response to rewarding and reinforcing stimuli. And it's kind of just a good metaphor to explain the process of neuro adaptation more broadly, because different substances and behaviors work through different chemical cascades. For example, human connection we know, works through primarily the serotonin system. Alcohol works primarily through the Gaba and in endogenous opioid systems. Nicotine works with the nicotinic acetylcholine system. Cannabis works through our own endogenous cannabinoid system. But the final common pathway for all reinforcing substances and behaviors is the release of dopamine in this dedicated reward pathway, which is why it has become a kind of common currency for measuring addiction in animal models. 2s But I would be wary of saying that. Oh, like if something just releases a lot of serotonin, it's good because LSD releases ecstasy and ecstasy releases a lot of serotonin, you know? And human connection certainly is mediated in part by, you know, oxytocin, the love hormone, which binds to dopamine, releasing 2s neurotransmitters in the reward pathway. But people can also get addicted to the cycle of love, right. We have real bonafide love addiction especially, you know, combined with sex, love and sex addiction. So anything really that releases a lot of dopamine in the reward pathway has the potential for addiction, including otherwise healthy adaptive behavior because of the drug ification of adaptive behaviors. And one of the things I talk about in the book is how I got addicted to romance novels. And the reason that I felt it was important to share that is because we don't think of reading as, you know, an addictive behavior. And, you know, 50 or 100 years ago, it probably wasn't because it didn't have the same potency, quantity, novelty and access that we have today. But now, you know, you have an industry that pumps out, you know, highly reinforcing novels of specific genres. In my case, you know, romance novels that are formulaic, you know, you know exactly what you're getting. You can now get them through a Kindle. You don't have to go to the library or wait for them to come in. You know, you can chain read if you don't like it, you can just stop and go to the next one. You can get free copies on Amazon. So the whole everything and whether it's talking about reading or chess or exercise or even work, right, it's all become kind of drug ified, like made sort of kind of gamified or gamble ified, gambling fied in a way. I mean, I think leaving the neurobiology aside because as you said, it's really complex. 1s It's definitely good for a person to start thinking about what are my sources of reward in life. Everyone's going to have a mix of different sources of reward. And then how sustainable are these sources of reward in that if I if I follow this source of reward down five years, ten years down the line, am I in a better place or not? If I follow this cocaine habit? And if I extrapolate ten years, is that going to be is that going to put things in a better position for me or not? Or conversely, if I am, let's say, more addicted to the rewards of work and getting promoted, where will that put me in ten years? And then how does that balance? With balance out with every other aspects of my life. So there's thinking about it. 1s In terms of sustainability, but then also the relationship to discomfort. So so one way I might frame that to a client is there is going to be discomfort. Discomfort is a part of life either as you've mentioned before, you pay the discomfort upfront and you get a bit of reward later. Or you choose a drug ified activity, or a drug or fight, or a drug. 1s And then you go into discomfort. That discomfort is delayed into the future and you can delay it for a while, you know, if you have access to good drugs. So or maybe just Instagram. You can delay discomfort for a while, but then at some point, the discomfort Grim Reaper is going to come and take its toll. Yes. Yeah, I think that's a beautiful way to put it. And I agree with that conceptualization. You know, broadly speaking, the definition of addiction is the continued compulsive use of a substance or behavior despite harm to self and or others. The problem is that when we're chasing dopamine, it's not so easy to see the harm. So one of the things that I think is quite helpful is something that a colleague of mine, Stephen Crane, calls the regret principle and even applied over a single week. When I look back at this week, are there things I did that I regret that I wish I hadn't done, at least not with that frequency, and that that much or things that I, you know, opportunity costs thing. Other things that I had planned to do or hope to do and didn't do, and for me right now are really active piece of this is like, I have gotten into this fairly compulsive habit of wanting to watch YouTube videos in the evenings when I'm tired after work, and yet in the morning I tell myself, I'm not going to watch YouTube tonight, I'm going to read a book, or I'm going to maybe go out for a little evening walk, or I'm going to actually listen to my husband tell me about his day. And there and there I go. You know, I just kind of at the end of the day comes, my willpower is exhausted. I feel like I deserve a reward, or maybe I don't even think about it. I just kind of reflexively and compulsively, you know, go on to YouTube. I almost like, you know, roll the die. And I sort of like, like to see what the algorithm, you know, is offering up, like, it's some kind of friend of mine. It's no friend of mine, 1s but, you know, it feels like it in the moment. So I think these are the types of behaviors that we, you know, we have to really be alert to, because otherwise it's not just the end of the week where we look back and regret, as you say, it's a decades or the end of our lives. Wow. I spent, you know, millions of hours watching YouTube videos. That's such a waste. And I think going going on from what you're saying. 1s It's easy for someone to be listening to a conversation like this and just hear it as a moralistic, puritanical, like, you should abstain, you should abstain. You failing to abstain is a sign you're not doing your best. It's really important to point out just how vulnerable our brains are to something like Instagram, something like junk food, just the level that I think most people aren't aware of, the level of intentional design that has gone into these products to make sure they're absolutely as captivating as possible. I wonder if you took an example like Instagram, say, and if you broke that down for us, why? Why would something like Instagram be addictive, for instance? Right. Well, let's go back to just those four categories of drug ification. So if you look at potency, Instagram is this incredibly potent combination of visual stimuli stationary or moving and moving stimuli. Video is very, very potent for the human brain. We are just transfixed, especially by other people moving, but just by moving objects combined with bright colors, bright lights, 1s you know, quantification. So the number of likes or the rankings. Dopamine is very sensitive to numbers because in part, dopamine or reward more broadly is also about social status and ranking ourselves against others and trying to get ahead and see where we are in the hierarchy. And that's really reinforcing and deeply evolutionarily ingrained in us as part of being social creatures. So it's incredibly potent, and it was engineered to be potent. And these AI algorithms essentially gather data on where we've spent time and then use that information to proffer to us ever more potent forms of what we've liked before, which essentially accelerate this addiction narrative. So potency is huge. If you look at Instagram from the perspective of quantity, you know you have the infinite scrolls, like you literally can never finish. And as I said, you know that you never get that feeling of doneness. But also the more we expose our brains to highly reinforcing substances and behaviors, the more our brain adapts and sort of down regulates dopamine transmission to try to compensate for the barrage. So you've got potency, you've got quantity, you've got novelty. And novelty has to do with how how we can overcome tolerance to a drug. One of the ways to do that is to take two drugs and combine them together, which is why, for example, people who get addicted to opioids often then combine them with benzodiazepines like Xanax, and then you get kind of a new drug that. 1s That is more potent. And the internet does this in a nanosecond, right? It'll take, you know, one kind of feature like, let's just say an attractive face, which is stimulating and rewarding and then fold it into a story. Right. You have Instagram Stories, and we have a whole part of our brain that's evolved over millions of years, elaborated for stories we love, stories we learn from stories. Right. And so a good story is incredibly reinforcing and rewarding. And so you get this kind of, you know, a sort of combining of stimuli that makes it ever more potent and novel. And again, the algorithms direct us to ever more potent content, usually, frankly, negative content, which is very polarizing and also gets people to these consumption of extreme versions, which is related both to novelty and potency. And then finally, you have access. One of the biggest risk factors for addiction to any substance or behavior is simple access. If you live in a neighborhood where drugs are sold on the street corner, we know from many epidemiologic studies of these neighborhoods compared to other neighborhoods, that if you live in that kind of neighborhood, you're more likely to try substances and more likely to get addicted. We now live in a virtual neighborhood where we have 24 access to the internet and to digital media in all its shapes and forms, you know, everywhere we go. So that's incredibly powerful combination of factors that make something like Instagram, you know, highly addictive. 1s I want to emphasize that that just like most people who drink alcohol will not get bonafide addicted to alcohol. You know, most people will be able to sort of self-correct their consumption of digital media, you know, in small ways and not develop some kind of life threatening addiction. But I can tell you in our clinic, we see that 10 to 15% who end up with a life threatening problem where they're so completely consumed by this medium that they literally cannot sleep, cannot care for themselves, cannot eat properly, 1s alienate loved ones, lose their jobs, become morbidly depressed and anxious, become suicidal, and even end their lives. So this is you mean from. Instagram and social media? Oh, yeah. Absolutely. 2s Wow. So this kind of leads us on to. Predisposition to a kind of addictive behavior. 1s I would imagine that a different kind of person might be predisposed to a social media addiction than to, for example, a cocaine addiction, because there. They seem to do different. They seem to trigger different psychological mechanisms somehow. Do you? Do you notice a different personality profile? Let's say, in people who get addicted to different things? Yeah. This is there's in some sense some research on this, but overall there's very little research on this concept of drug of choice, which is a well known concept that some people will find some rewards reinforcing and others other rewards, and that we're all kind of different. And from an evolutionary perspective, it makes sense. You wouldn't want everybody in your tribe going for the same berry bush. You would want some people interested in finding sexual partners, other people interested in eating meat, so that as a tribe, everybody gets what they need. 2s It is certainly true that when it comes to social media, we see more women who are sort of compulsively engaged with social media, and conversely, we see more men and boys who are compulsively engaged with video games and pornography. So there is overlap, obviously, from the genders, but as a general rule, that that is what we see, which just again, speaks to these inter individual differences. I will say that I think that the problem of addiction, again, has become much more ubiquitous because we have so many more drugs, including drugs that never existed before, like our digital media drugs. And in my case, for example, you know, I thought that I was immune to the problem of addiction just because traditional drugs had never been reinforcing for me, at least the ones that I had tried. Opioids are probably really reinforcing for me, as I've gotten some opioids perioperative for some surgeries that I've had and really liked them. Just like that could be a problem. But, but, but then I discovered romance novels and this whole realm of like, love and codependency. That's definitely, you know, my Achilles heel. The point being that there are so many more drugs that we're going to have a much larger catchment of people who are struggling with this problem. Having said that, we do have data with regards to substances like alcohol that if you have a biological parent or grandparent with an alcohol use disorder, you're at four times increased risk compared to the general population of developing an alcohol use disorder. So we do know that there is familial or genetic vulnerability. But again, I can't beyond sort of the personality trait of impulsivity more broadly as a risk factor for addiction or co-occurring mental illness as a risk factor for addiction. I can't say that I've seen a certain personality type that tracks clearly. I think it has much more to do with environmental access 1s than probably like individual vulnerabilities. 1s I was speaking to an evolutionary psychiatrist named Randy ness, and we were discussing gambling and gambling. 1s Does seem to be. It's a very particular kind of activity gambling, high risk, high reward. And we did wonder whether the gambling might attract the kind of individual who, perhaps, in our Manchester Times, might have been attracted to a more high risk, high reward way of life than the average person. Is that speculation at this point, or is there any evidence about any kind of particular predispositions for gambling? 1s Yeah. I don't know of any evidence tied to specific personality types. That data might be out there, but I'm not. I'm not aware of it, but I think it's I mean, it's a reasonable hypothesis. You know, in general, when I think about sort of people who are vulnerable to addiction more broadly, I do think that these are people who are natural seekers and strivers. These are people who often are interested in a lot of novelty, but also wanting to control the exposure to novelty. So, you know, I feel like the neo or the big five character traits, you know, the these data are probably out there, but I don't think they're tied to specific substances. Right. That's where I think it's a little bit. I don't think there's a whole lot of evidence on that addiction. More broadly, you can attract a certain personality traits impulsivity, novelty seeking, 2s and those those could be good things because you can imagine a context like being being in sports, for example, being very impulsive can be useful because you need to make decisions quickly, for instance. Right? Absolutely. Or being in a life threatening situation where you're not going to have time to like, run the spreadsheet on what you should do next. You got to have somebody who can think really quickly and be like, we got to go. Um, yeah. So and I think that's true. I mean, I personally sort of believe that about all mental illnesses that they're, they're preserved in the population through multiple generations because in certain situations, what we call psychopathology. In our current environment is actually a highly adaptive, useful trait in a completely different environment. And I would even say that about addiction. Right? Like so if you think about what people with addiction or people who are willing to work a lot harder and, you know, spend a lot more time acquiring a very specific reward. And in a world of scarcity, which is the world that humans have inhabited for most of our existence, that would be a very important and valuable trait. You would want those people. They would be like the leaders of the tribe, right? It turns out in this world of overwhelming overabundance, it's a liability. It's fascinating to think about what different kinds of societies reward. I did an episode not too long ago about delayed gratification, and we're obviously in a society which hugely rewards delayed gratification. If you are able to delay gratification in a modern Western society over a ten, 20, 30 year period, you can rise to the top of your industry. But yet the baseline level of people's ability to delay gratification is going down and down and down, meaning that that individual who can delay gratification is becoming rarer. But when they can, it becomes a winner take all scenario. Right. And even that can be its own kind of trap, right? Where you get to a point where, like you, all you can do is delayed gratification and you don't anymore know how to sort of live in the moment and, you know, pick each flower. And so, you know, but yeah, it's we certainly are becoming we certainly have a society in an ecosystem that promotes instant gratification, quick fixes. It's really true. Yeah. And you mentioned living in the moment. And this is something I wanted to touch on is the. Again, the time aspect dopamine being on a dopamine high is all about anticipation. I feel like being a dopamine. Being on a dopamine high is very much living in the future. You're thinking about what's going to come, what's going to come next. That's what happens when you're open your Instagram. You think, who's messaged me? Or what am I going to see? You're gambling. You think, how much am I going to win? You're thinking about doing cocaine tonight and you think, how fun is it going to be? And you mentioned living in the moment, which of course is on some level. An antidote. It's a it's a short circuit that and introduces something new, which is instead of trying to. Instead of being obsessed with what's what's going to happen next. How do you become happy right now if nothing changes? Right. Which is why one of the mantras in AA Alcoholics Anonymous 12 step group for people with alcohol addiction is to live one day at a time, right? So really kind of truncate the future horizon to just today and try to make today as good as you can make it. I really do think that modern life is essentially organized around a series of self rewards. We sort of bookend our entire experience around my coffee in the morning and my Netflix shows at night. One of the Duncan experiments that I often like to do myself when I have the energy and the fortitude or recommend to others, is to try to go through an entire day without engaging in any of the self rewards that are habitual for us. So if you're a coffee drinker, don't drink coffee. If you look forward to checking your email and seeing what's there, abstain from that for a day. No shows at night, no romance novels. And it really does change the subjective experience of time passing. Because if you don't have something to look forward to, you're forced to make the most of right here and right now. And what you and I are doing right, as opposed to always projecting yourself to some supposed better future. So I think it can be a really interesting experiment to engage in and really, I think, kind of promote more awareness and insight about the ways in which we use these self rewards, especially in the modern world, to kind of manage ourselves, to shape time, to change the way we feel, to try to control our experience, which really, I think does leave us very impoverished in terms of our ability to really flow through life. 2s Can you comment what you just said hinted on, I think subtly, the relationship between pleasure and pain. And we normally don't associate pleasure and pain. But a lot of what you talk about is how pleasure and pain are inextricably tied together. 2s Can you comment a little bit about the relationship between pleasure and pain? Sure. So to me, one of the really interesting findings in neuroscience in the past 75 years is the discovery that pleasure and pain are co-located in the brain to the same parts of the brain. That process intense pleasure also process intense pain, and they work like opposite sides of a balance, like a teeter totter or seesaw. When we experience pleasure, the balance tips one way pain, it tips the other. But there are certain rules governing this balance in the first and most important is that the balance wants to remain level, or what neuroscientists call homeostasis, so that with any deviation from neutrality, our brains work very hard to restore a level balance. So by way of example, when I read a, you know, a racy romance novel that releases dopamine in my brain's reward pathway, my balance tilts to the side of pleasure. But no sooner has that happened than my brain adapts by down regulating dopamine transmission, including postsynaptic dopamine receptors, but not just to baseline levels of dopamine firing, because we're always releasing dopamine at a kind of tonic baseline, but actually below baseline before going back to the level position. And I like to imagine that as these little gremlins hopping on the pain side of the balance to bring it level again, but they like it there. So they stay on until it's tilted and equal and opposite amount to the side of pain. And that's the comedown, the hangover, the after effect, or in my case, that moment of finishing a chapter, knowing I should go to sleep and then like, oh, I'm just going to read one more right now. The problem is that with repeated exposure to the same or similar reinforcing stimuli, those gremlins start to multiply, and pretty soon we've got enough gremlins on the pain side of the balance to fill this whole room, and they're camped out there. Once we've reached that point, we've entered addicted Brain where we've changed our hedonic and our joy set point. Now we need to keep using not to get that initial pleasure or rush or reward, but we need to keep using just to try to level the balance and feel normal. And when we're not using, we're walking around with the balance tilted to the side of pain with a bunch of gremlins jumping up and down, they're experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, dysphoria, and craving. You can summarize so many people's lives with just that last sentence. 1s Yeah. That's right. And we get a lot of patients coming in wanting help with anxiety, irritability, insomnia, depression. And a lot of times, you know, our first intervention is we say, hey, you know, you're engaging in this highly reinforcing dopaminergic behavior or substance. If you cut that out for four weeks, those gremlins will hop off, homeostasis will be restored, and you'll feel better without our having to do any other intervention. And we see that work so often that that's become really a first pass for us before going to things like antidepressants or anxiety medication. What do you think are the things that. 1s Whether someone's addicted to one substance hugely, or someone's kind of strung out on a different mix of stimuli. What do you think people misunderstand the most about addiction recovery? Well, it's important to recognize that it's a chronic relapsing and remitting disorder, right. So once we've laid down those addiction neural networks, they're probably there for our lifetime. But we can atrophy them by depriving them of oxygen. The longer we can abstain from engaging in them as we develop other healthier coping strategies. 3s Most of our patients don't actually want to stop. They want to moderate their use. And so we meet. We meet patients where they are. Even if it's a patient. I think that's a crazy idea. You know, I might say, well, I'm skeptical that that's going to be the right course for you, but let's give it a try. But even moderation should start with a period of abstinence of at least four weeks, as a way to get those gremlins off the pain side of the balance and reset reward pathways. So that's another misconception that like, oh, if I want to moderate, I can just reduce. In general, reducing slowly is harder than just stopping. Now, obviously, if somebody's at risk for a life threatening withdrawal from opioids or benzos or alcohol, you would not do this intervention. But as long as they're not at risk for that, we recommend that they actually go cold turkey for at least four weeks and then reevaluate. And then if they want to re-enter into using in moderation, because everybody wants to use differently and be more in control and not have the behavior, the substance control them, then we make a very specific plan for what that's going to look like. And that's another kind of myth or misconception that's been in the field that, oh, well, once somebody's been, for example, an alcoholic addicted to alcohol, they could never go back to drinking. And in fact, there are data showing. And in our clinic we see this rarely. But we do see it that somebody who's met criteria for an alcohol addiction, after a period of abstinence and with a lot of effort and work, some people actually can go back to using alcohol in moderation and maintain that over time. Now, again, I want to emphasize that's really a minority of people, and even the ones who can do it often say it's not worth the trouble. Like, you know, what did they say? One drink is too many and two is too few. In other words, moderating doesn't get them where they want to go. They've now adapted their brain to that substance such that if they don't binge on it, it's not going to do do what they want, so why bother? But these are some of the, you know, the the sort of, you know, general misconceptions or ideas that I have to sort of educate patients about. One thing that I noticed when I worked in a in an addiction clinic, I worked in one for about a year in quite a deprived area of the UK, and I noticed that there was obviously a lot of focus when someone was planning to come off a drugs. Let's say they're on there, they're on methadone because they're previously addicted to heroin, say, and they're planning on reducing their methadone and stopping it, or even just switching from heroin to methadone. There was a huge focus on the drug itself and and. 1s Relinquishing your addiction to that drug. But often these were clients who had. 1s Not. They were not getting their basic needs met. They didn't have a good family life. They didn't necessarily have a good romantic relationship or friends or meaningful work. So a lot of what I saw was a hyper focus on the drug, but no focus on starting to build a life that would make staying off this drug actually a sustainable experience. This was kind of highlighted in the movie Trainspotting, the famous movie which I'm sure you've watched about heroin addiction, which is the thing that got them back into using drugs, was boredom and a lack of a viable alternative way to live life. Is that something you've seen in your clinical experience where people have very deprived lives and. 1s It's much easier to stop using something that's harmful to you if you have an alternative life to live. 1s Yeah. So this is an important point that you're making. And what I'd like to sort of speak to here is the order of operations. So it is certainly true that having a life that is absent healthy rewards like meaningful relationships, meaningful work, access to nature, all of that stuff is going to put somebody at risk for getting addicted in the first place. But it's also true that you can have all those things and you can still get addicted and lose all those things, and we see that all the time. So that the starting place for getting those things back into a life really is to get into recovery from the addictive cycle itself, which is why we always start there and focus on that. But you're actually you're absolutely right. We can't just leave it there. It's not just about, okay, you're not using your drugs, so go on your merry way. Life is good. Absolutely. Then becomes about, okay, how do I live in the world without this drug as my way to have fun or my way to cope, or whatever my reason is for using? And how do I how do I create a life that's worth living? And the emphasis there is that many times once people become addicted, they only see two alternatives. Either I keep using drugs and I'm miserable, or I stop using drugs and I'm miserable. And what we're trying to put to them is there's a third way where you're not using drugs and you're not miserable, but it takes a lot of time and it takes a lot of work. And this is where I think recovery communities are so valuable and in fact, much more valuable than what I, a doctor, can provide. Right? Because I'm only present for the 30 to 60 minutes that you're seeing me, however often you're seeing me. But if you are as part of embedded in a recovery community, associating with people who value recovery, who value abstinence or moderation, whatever the goal is, who you're seeing on a regular basis, like in a 12 step for Alcoholics Anonymous, Narcotics Anonymous, or whatever. Your group is smart recovery, celebrate recovery. Whatever your orientation is, they become woven and embedded into your life. You can call a sponsor in a 12 step group, like any time of the night or day, and they will respond, I won't do that right. So creating these recovery communities that value abstinence or moderation, whatever the goal is and the way that we kind of reinforce and support each other in our everyday lives through these communities is so important. I mean, probably ultimately much more important than anything that a professional can do. And one of the good things about those organizations, particularly AA, is they don't just provide community and the structure and the sequence. They also provide an overarching philosophy for your life, which I think a lot of people are missing, is what should the meaning of my life be? What does living a good life mean? And it's remarkable how when people are trying to stop using drugs, especially if it's like a life threatening drug, things become existential very quickly. I had a friend back at university who was trying to stop smoking, and it's remarkable watching him try and talk himself into or out of stopping smoking. It's remarkable how quickly the dialogue switched to, well, what's the point of being alive anyway? Right, right. So why? Who cares? Right? Yeah, exactly. So I think there are huge role for addiction and actually having a coherent. Cogent way of thinking about your life, the value of your life, the values and virtues should you should be striving for and and addictions obviously being the things that can get in a way of that well-lived life. Oh, not just get get in the way. I think that we actively run away from those deeper questions in our culture in general, but we use addictive substances and behaviors as a way to distract ourselves from those questions. And instead what? Yeah, instead, what we can do is really turn toward those questions and engage with each other. Yeah. What what is the good life? What is it? How does how can I how can I thrive as a human being in the modern world? What do I care about? You know, what should I be doing? What are my priorities and my values? Those are the conversations that we need to be having instead of sort of just like numbing ourselves out of talking about those important things. Absolutely. Before I let you go, one question I like to ask clinicians is, as you've as you've worked with people over the years, what would you say is the thing that has surprised you the most about human nature? Um, I think that I am really always surprised and comforted 1s by how people can transform their lives for the good, even very late in life, and how I am actually a very poor predictor of who that will be. I used to think that I could tell patients walking through the door kind of who would get better and who wouldn't, and it turns out I'm not very good at that. And that patients that I really think, oh, there's no hope for this person can completely turn their lives around. And I find that incredibly inspiring and hopeful and mysterious and miraculous. And I don't know, that gives me a lot of hope. A very humbling note for us doctors, and an otherwise wonderful note for us to end on. Dr. Lembke, thank you so much for your time. You are very welcome. It was a pleasure. 9s Thanks so much for listening this week. Any feedback. As always, do get in touch. If you enjoyed the episode, why not give us a rating on Spotify or Apple Podcasts? Because it really helps other people to find us. 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