Dr. Anna Lembke: Between Pleasure and Pain

People can use, as I said, because they want to have fun. People can use because they're trying to self-medicate a psychological problem. People can use because they're trying to escape a traumatic situation, or they've had a negative experience, and they're trying to get away from that. All of those are reasons that people use substances. Once people begin to use addictive substances in large quantities on a regular basis, it changes their brain. Now they have a secondary problem, right? They might have started using for one problem, but they eventually developed another problem, and that problem is the disease of addiction. Welcome to the Knowledge Project. I'm your host, Shane Parish. This podcast is about mastering the best of what other people have already figured out, so you can apply their insights to your life. If you're listening to this, you're missing it. If you'd like access to the podcast before public release, private episodes that only appear in your feed, hand-edited transcripts, including my personal highlights, and more, you can join that FS.blog/membership. Check out the show notes for a link. This episode is about pleasure and pain, and the relationship between pleasure and pain, and how understanding that relationship is one of the keys to living in a world of abundance. Drugs, food, news, Twitter, gambling, shopping, work, texting, just think about the potency of highly rewarding stimuli today. The smartphone is, in the words of our guest today, the modern-day hypodermic needle that delivers digital dopamine 24/7. My guest today is Dr. Anna Lemke, Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic at Stanford University School of Medicine. Dr. Lemke is a psychiatrist working in the trenches, treating addictions of all kinds, drugs, alcohol, food, sex, video games, gambling, etc. Dr. Lemke is the author of dopamine nation finding balance in the age of indulgence, which prompted me to reach out. I wanted to talk to Anna about dopamine and addiction. We tend to think that addicts are people other than us, but the more I looked around researching the show, the more apparent it became that many of us are addicted to, myself included. Together we explored dopamine, what it is and how it works. Addiction and why behaviors can be as addictive as drugs, early warning signs to look for it in yourself and others, treatment, and her struggles with insomnia. Let's take a simple idea and take it seriously. It's time to listen and learn. [MUSIC] Let's just jump right in. What does dopamine, how does it work? So dopamine is a chemical that we make in our brain. It's a neurotransmitter and neurotransmitters are the molecules that bridge the gap between neurons and that gap is called the synapse. So neurotransmitters allow for fine tuning of the electrical circuits that are conducted by the neurons themselves. Dopamine is the most important neurotransmitter for the experience of pleasure, reward, and motivation. It's not the only neurotransmitter involved in that process, but it is the common pathway for all reinforcing substances and behaviors. Anything that's reinforcing releases dopamine in a specific circuit of the brain called the reward circuit, the more dopamine it releases, and the faster it releases dopamine, the more reinforcing and potentially addictive that substance or behavior is. There's a couple of interesting things you said there. One, motivation. So what's the correlation or tie between dopamine and motivation? Well, it was originally thought that dopamine was primarily related to the experience of pleasure, euphoria, getting high. But a series of important experiments suggest that dopamine may be even more important for motivation, that is our willingness to do the work to get high, than for the experience of pleasure itself. And one very important, seminal study, bioengineered rats to have no dopamine receptors in their reward circuit. And what the researchers discovered is if they put food in that rat's mouth, it would eat the food and seem to get pleasure from the food. But if they put the food even a body length away, the rat would starve to death. So the absence of dopamine in that reward circuit essentially took away that that rodents desire to strive to do the work to get the reward. So that's just it, right? So the motivation part of this is we have a goal. We want to do something and we get a dopamine response from that. So we're motivated to do it. Well, it's first of all that we have to have been exposed to that stimulus and have experienced it as reinforcing in some way. And then that lays down really a very permanent lifetime memory of that experience and the desire to recreate it in order to again experience the release of dopamine. Once we are reminded of our drug of choice, we actually get a little bit high or we get a little release of dopamine in the reward circuit that that also creates the desire or craving to want to do the work. The other thing is that that's very important here is that once people start to become addicted, what's salient is not so much the release of dopamine when they're getting higher, experiencing pleasure, but it's actually the decrease in dopamine in between or the dopamine deficit state that leaves them in a constant state of craving that then motivates them to want to do the work. Can you go deeper on that, the decrease from a baseline I'm assuming? Sure. So in order to understand that, it's essential to appreciate that pleasure and pain are co-located in the brain. So the same parts of the brain in that process, pleasure also process pain. And they work like opposite sides of a balance. If you imagine like a central full-criminic beam on that full-crimin something like a teeter totter in a kid's playground, and that represents how we process pleasure and pain. And there are three rules governing that balance. And the first and most important rule is that the balance wants to remain level. It doesn't want to be tilted very long to the side of pleasure or pain. And our brains will work very hard to restore a level balance with any deviation from neutrality. So for example, let's say I read a romance novel, I get a release of dopamine in my pleasure pathway or my reward circuit and my balance tilt to the side of pleasure. No sooner has that happened than my brain starts to adapt to that increased dopamine by down regulating my own dopamine receptors and my dopamine production, not just to baseline levels, but actually below baseline levels. And this is really the key piece of neuro adaptation. I like to imagine this as these little neuro adaptation gremlins who hop on the pain side of the balance to bring it level again, but the gremlins really like it on the balance. So they don't get off as soon as the balance is level. They stay on until it's tilted in equal an opposite amount to the side of pain. That's the come down, the hangover, the after effect or just that moment of wanting to read one more chapter in my romance novel, that inability to put it down that unwillingness to leave that fantasy world. Now, if we wait long enough, those neuro adaptation gremlins hop off and a level balance is restored, but as long as those gremlins are sitting on the pain side of their balance, our urge to find and use more of our drug of choice can be almost overwhelming. Now, if we wait long enough, the gremlins hop off and homeostasis is restored. But if we don't wait, if we continue to consume our drug of choice, we accumulate more and more gremlins on the pain side of the balance until we have enough gremlins to fill this whole room. And once that happens, we're now in addicted brain. Now we need more of our drug and more potent form of our drug just to level the balance. And especially we need more potent form if we're actually going to get high. And when we're not using our drug, our balance is tilted to the side of pain. Those gremlins are now camped out there tense and barbecues in tow. And that means that we're experiencing the universal symptoms of withdrawal chronically. And the universal symptoms of withdrawal from any addictive substance or anxiety, irritability, insomnia, dysphoria, and craving. And this explains why people with addiction will relapse to their drug of choice even weeks and months after they've stopped using. It's because it takes a long time for those gremlins to hop off and for homeostasis to be fully restored. And in the meantime, that person is walking around with a balance tilted to the side of pain. The other thing that happens in addiction is that we narrow our focus to just this one pleasure, just our drug of choice or other impoxicants and other more modest rewards are no longer appealing because of course they can't compete with the army of gremlins that is now sitting on the pain side. And we think about recovery from addiction, the primary goal is to restore homeostasis or restore level balance. And the way that we do that in most instances is to abstain from our drug of choice for long enough for all of those gremlins to hop in for homeostasis to be restored. Sometimes people are not able to do that in which cases there are medications that we can use to try to help restore homeostasis. So that's the first and essentially second rules of the balance, the first rule being that for every pleasure we pay a price and that price is pain. We tip to the pain side before going back to the level position. What goes up really must come down. And then the second rule of the balance is that with repeated exposure to the same or more stimulus, that initial response to pleasure gets weaker and shorter and that after response to pain gets stronger and longer. And eventually we reset our pain thresholds and our pleasure thresholds such that we need much more pleasure to feel any pleasure at all. And even with the slightest pain or the absence of pleasure, we are in pain. And this used to benefit us. Absolutely. So this very fine tuned neural circuitry, which by the way evolved over millions of years of evolution and remains unchanged across species is an absolutely genius circuit for a world of scarcity and ever present danger where we have to be relentlessly seeking out the next best thing in order to survive. But it's a very maladapted circuit for the world that we live in now, which is this world of overwhelming abundance, a world in which almost every human activity has become drugified in some way, not just drugs, but also behaviors, even behaviors that we would think of typically as healthy behaviors like gaming, like sex, like eating more modern forms. Human connection has become drugified through social media. So it's become a much more difficult environment to thrive in as humans because we are really not adapted for the world that we've created. Addiction. We seem to use this term very cavalierly, which leads us to sort of discount addiction. Like we even joke around about how we're addicted to something like addicted to go into the gym or how do you define addiction? So when I use the word addiction, I'm really talking about a severe form of psychopathology that is defined as the continued compulsive use of a substance or behavior, despite harm to self and or others. When we make this clinical diagnosis, we use the diagnostic and statistical manual of mental disorders, which has these 11 criteria. The more criteria you meet, the more addicted you are on the spectrum of mild moderate to severe. And those criteria can simply be summarized as the four C's, control, compulsions, cravings and consequences. Importantly, quantity and frequency are not in those criteria. It's not because quantity and frequency don't matter. If you use more of a drug and you use it more often, you're more likely to get addicted. But the reason that it's not in the DSM, which is our sort of Bible of diagnosis, is because they wanted a unifying diagnosis for all different forms of addiction, and so they didn't want to put quantity and frequency in there. Also, we don't really have good data for how much is too much, except for alcohol, where we have pretty good data for that. So quantity and frequency matter, they're not technically in the diagnosis, the diagnosis, based on these complex behaviors that ultimately lead to significant consequences and the person's inability to stop in the face of those consequences. I think when people use the term addiction colloquially and casually, they're trying to describe or capture the sort of minor addictions that we all experience on a regular basis. And I don't think they necessarily think of themselves as really struggling with psychological disorder, but it's a sort of a way to describe the growing problem of compulsive overconsumption that many of us feel in the world today, even if we're not meeting threshold criteria for addiction. And so we can be addicted to substances and addicted to behaviors, and it's almost as if there's a spectrum. Is there something that makes one particular thing more addictive than another? Yeah, so this is a great question. In general, the more dopamine a substance or behavior releases in the reward circuit and the faster it releases dopamine, the more likely it is to be addictive. However, the huge caveat to that is that there's enormous inter individual variability. So what might release a lot of dopamine in your reward circuit might not release a lot of dopamine in my reward circuit and vice versa. In general, intoxicants tend to be intoxicating for the majority of people, but there are people for whom regular intoxicants are actively aversive and they would not seek those intoxicants out again. Also importantly, speaking to the world we live in now, there are so many more drugs than there used to be. And even healthy activities have become drugified. And the result is that we're all more exposed to a potential drug of choice and hence also all more vulnerable to the problem of addiction. I want to come to sort of some of the factors that lead to addiction. But before we do that, when we seek out dopamine, are we trying to get pleasure or are we trying to avoid pain? Obviously initially it's about either getting pleasure or solving a problem. So some people use, you know, not because they're looking to have fun, although that's definitely a reason that many people use. Some people are actively using drugs and drugified behaviors in order to solve a problem. And that problem can range from, you know, anxiety, depression, insomnia, poor concentration to loneliness, boredom, existential crisis. So there are lots and lots of sort of reasons that people use to get out of a dysphoric state, which also explains why people with co-occurring psychiatric disorders are generally at higher risk of developing addiction than people without those disorders because individuals with psychiatric disorders are more likely to turn to a substance to try to solve that psychiatric psychological or emotional problem. Once people have started to take their drug regularly, whether or not they started for fun or to solve a problem, they will eventually end up in this dopamine deficit state where they've changed their reward threshold. And then the drug use, especially the compulsive repetitive nature of the drug use, is essentially to get out of pain or restore level balance. So in other words, we start chasing our tail. Is that sort of like, does that come across with alcohol when people say their tolerance is going up? Right? So originally you have like one drink of wine and maybe you get a little buzz out of it and you're happy. But, you know, fast forward a couple of years and now the sudden it takes three glasses of wine to get to the same sort of mental state. Yes. So tolerance is definitely a marker of a brain that is entering, you know, that dopamine deficit state chronically and therefore, you know, at risk of addiction. But tolerance alone isn't sufficient to make the diagnosis of addiction. It must be associated with these compulsive out of control behaviors in the face of ongoing consequences. And the other thing is that tolerance is just one aspect of this dopamine deficit state. I think what people really underestimate is the kind of chronic dysphoria that results from chronic exposure to drugs of all kinds. And let me give you an example of a very common clinical scenario that I encounter. I have a patient who comes in and they're here to see me for depression or for anxiety, which they identify as part of a major depressive disorder or generalizing anxiety disorder, panic disorder, what have you. And I discover in the course of my clinical screening that this person is smoking cannabis every day or compulsively masturbating to pornography every day or playing video games for hours on end every day. And what I suggest to them based on what I know about the neuroscience of pleasure and pain is that their depression and anxiety is potentially actually being caused by their compulsive consumption of their drug of choice and that they've driven their brains into this dopamine deficit state as their brains try to compensate for dopamine overload. Now my patients almost universally resist this idea initially for good reason because they tell me that well, my drug is the only thing in the moment that alleviates my depression, alleviates my anxiety. And what I say to them was yes, temporarily it is restoring homeostasis for you. But in the long term what it's doing is it's driving more gremlins onto the pain side of your balance. So the first intervention that I do often in these cases to have them abstain for a month from their drug of choice, acknowledging that that's really hard to do. But the promise is that at the end of that month those neuro adaptation gremlins will have hopped off the pain side of the balance, dopamine homeostasis or baseline dopamine firing will have been restored and their symptoms of depression and anxiety will largely have revolved spontaneously without my having to do any other intervention. About 80% of patients this will happen. So it's really a very large group that will get relief from depression anxiety just by stopping their drug of choice for long enough to reset reward pathways. And how long do we have to stop? What is long enough is this? like seven days, 30 days, half a year. - It probably differs from situation to situation, but I can tell you after decades of clinical work, and this is a part of this idea supported by many of my colleagues and also by some of the early neuroscience into this area, is that for people who have become addicted, 30 days is the bare minimum to begin to reset reward pathways. Two weeks is almost never enough. What happens when we first stop our drug of choice is that our pleasure pain balance slams down to the side of pain. We experience the universal symptoms of withdrawal, some are unique to that drug, but the others, the psychological ones are universal. And those will persist for about two weeks, and then once people get to week three and week four of absence, the sun starts to come out, people start to notice improvements in their baseline mood, anxiety, and functioning sleep, concentration, everything. So in general, I advise 30 days of absence. This is also supported by some preliminary work by Nora Volkov of the National Institute of Drug Abuse, which has she has shown in imaging studies that if you image the nucleus accumbens, which is one of the key areas of the reward circuit, if you image the nucleus accumbens two weeks after individuals who have been addicted to a variety of drugs have stopped using, and you compare their dopamine transmission to the brains of people who have not used drugs, which you find is that two weeks after stopping using, people are still in this dopamine deficit state. So their dopamine transmission in the nucleus accumbens is still below normal. And that's consistent with my clinical experience as well. Also, there's a very important study done by Shucket and Brown many years ago now showing that if you take a cohort of middle-aged men who are addicted to alcohol and drinking on a daily basis, large amounts of alcohol, and also meet DSM criteria for major depressive episode. They have all the stigmata of clinical depression. And you put them in a enclosed setting, let's say a hospital environment, but you don't give them any treatment. All you do is take away their alcohol, you make sure that they safely detox, and they don't go into life threatening withdrawal. What you find is that the end of four weeks, 80% of those individuals no longer meet criteria for major depressive episode. So just stopping alcohol alone resolves the stigmata of depression, and that's entirely consistent with what we see clinically on the outpatient side and what I've seen in my clinical work over the years. - You said substances have unique withdrawal characteristics, but what are the universal psychological characteristics of withdrawal that you talked about? - So the universal symptoms of withdrawal from any substance or drug-ified behavior are anxiety, irritability, insomnia, dysphoria, and craving. - It seems like addiction is sort of hard to talk about in some ways because we think, like there's many messages we get about addiction, and we think that it's like a downstream problem. Like, for example, you lose your job, and that becomes the entry point into, you seek out alcohol or another drug of choice, and that becomes the vector into this. I don't think that's true. Talk to me about that. - Yeah, so there are many doorways into addiction. The key point, however, is that once people begin to use addictive substances in large quantities on a regular basis, it changes their brain. And now they have a secondary problem, right? So they might have started using for one problem, but they eventually developed another problem, and that problem is the disease of addiction. And addiction is its own primary progressive disease. And what I mean by that is contrary to some of the early hypotheses around self-medication, this idea that, well, if only we could treat the underlying depression and anxiety, the addiction would spontaneously resolve. It turns out that's not true, and there's lots of evidence over the last century showing that it's not true, that even if you could take away the depression or the trauma or give somebody the perfect life and everything they wanted, once they've developed a disease of addiction, they have addiction, and if you don't intervene for that problem, it's typically not going to resolve spontaneously, and it's not going to resolve because you resolved the other problem. So really the important thing here is that addiction is its own primary progressive disease. And I think that's really important, especially in this age of sort of trauma-informed care, where we seem as a collective to be focusing a lot on what is the reason that this person is addicted. And many times, there is trauma in people's lives that does partially explain why they develop the disease of addiction. The problem is that just understanding that origin or that ideology or the spark that contributed to addiction is not going to resolve the addiction itself. Addiction is treated by, it's a biopsychosocial disease, and it typically needs a biopsychosocial treatment in order for people to get into recovery. - What are the early warning signs that we can look for in ourselves for addiction? - One important early warning sign is something called the double life or the lying habit. This is where we start to lie about what we're consuming, how much and how often. And we're lying to other people, but we're also in a way lying to ourselves. It's very easy to minimize in our own minds, how much and how often we're consuming our drug of choice. And it's very hard to see the true impact of our drug use on our lives while we're chasing dopamine. So an early indicator is that we need to pay attention to when we're lying, even if we're just sort of telling the truth about using, but we're minimizing the amounts or the frequency. One of my very beloved patients once told me that when he was in addiction, he developed the lying habit, which meant that he was lying not just about his drug use, but really about all kinds of things even unrelated to his drug use. So for example, if he was having lunch a Burger King and a friend called and said, where are you? He'd say, I'm at McDonald's. If he was at McDonald's, he'd say, I'm at Burger King. And it didn't make any sense, and there was no reason to lie, but his brain had just sort of flipped into the lying habit. So I think that's a really important thing to pay attention to. The other things are just the four C's out of control use using more than we plan to on any given occasion, compulsive use where there's this level of automaticity where we're initiating use, even though when we hadn't plan to initiate use, and a lot of our mental real estate is occupied with thinking about using the drug. Very narrowly focused on the drug is our source of relief and pleasure. Craving is overwhelming feelings of wanting to use that can be manifested as intrusive thoughts of our drug, but also as physiologic feelings like sweating, stomach cramps, just an overwhelming panicky feeling that if I don't use right now, the world's going to come to an end. And then finally, looking around at the consequences, which because we can't see them very well ourselves, there's really quite a literal disconnect between our behaviors and what it's doing to us and the people we love. We have to be really open and willing to listen to what those around us are telling us about the impact of our consumption even if we don't see it ourselves. So at a high level, what does treatment look like from your point of view? Are there steps that people commonly go through? It's an abstinence seeming to be one of them. So the treatment is a biopsychosocial treatment because it's a biopsychosocial disease. And that means there are biological origins and interventions, there are psychological origins and interventions and there are social or contextual origins and interventions. So when I think about biological interventions, the first and most important step is to restore homeostasis or baseline dopamine firing. And typically the way we do that is we ask patients for 30 days of abstinence from their drug choice. Now importantly, we would not ask this if somebody who was at risk for life threatening withdrawal. So for example, people can have life threatening withdrawal from alcohol, from benzodiazepines like Xanax, from opioids like oxycontin. So in those situations where there was risk of that, we would want to medically manage detox to get people off of the drug or in some cases, we would actually want to use the drug in order to restore homeostasis, the classic examples of that are using methadone maintenance or buprenorphine to restore level balance in people with severe opioid use disorder. They're not getting high on those opioids. They're basically just getting a level playing field to be able to enter other aspects of recovery. So that biological piece is really important. But even after restoring homeostasis, it's not like the problem is over, right? Addiction is a problem. chronic relapsing and remitting disease. So craving can come up again. One thing I didn't mention was the third, the third rule of the balance, which is that the balance remembers. And that those gremlins once created don't entirely disappear. They're hanging around in the wings and they're eager to hop up on that balance again so that we can get craving. Even just being reminded of our drug of choice, what we see in animal studies is that if you put a probe in a rat's brain and you train that rat to know that if it sees a light, it can go to a lever, press the lever and get cocaine. What you see of course is that once it gets the cocaine, there's a huge spike in dopamine in the reward pathway. But there's also a little mini spike in dopamine when they see the light. So just anticipating the drug gets us a little bit high, but the really interesting thing is that right after that little increase in dopamine from the light, we actually go below baseline levels in dopamine firing, we're going to a dopamine deficit state and that's craving and craving is then the thing that, you know, drives us to do the work to get the reward and it's very, very hard to resist that. Which is why part of recovery is also insulating ourselves from triggers and reminders of our drug choice that we're not going up to, you know, the edge of the abyss. And then trying to keep ourselves from jumping in right we're just not even going near it. And there are different medications now that have come out that can help people with that to sort of limit the reinforcing effects of craving one of them, for example, is a medication called an altruxone, which is an opioid receptor blocker. It's used of course to treat opioid addiction, but interestingly also very effective for treating alcohol addiction. Why because alcohol is mediated largely by the endogenous opioid system. So when people take an altruxone and they take a drink, they don't typically find it as reinforcing or if they're reminded of alcohol and they're passing a local watering hole, they don't get the same bump in dopamine and hence they don't get the same deficit that drives the craving. So the biological interventions are part of it. Psychological interventions, we know that both individual and group psychotherapy are particularly effective for addiction. And essentially, you know, many people talk about addiction as an attachment disorder and the substance is a replacement for the human connection lacking in that person's lives life. And sometimes you know, it's some people have connections, but they're not intimate connections or they're not healthy connections. So the individual and group therapy, I think is really about re-teaching people how to be in connection with other people in a meaningful, gratifying, intimate way. And then the social piece or contextual piece is really acknowledging, you know, all the contextual reasons that and stressors and how stress leads to addiction, how having a sober social network of friends helps people not use their drug. And so it's that kind of complete picture. So two follow-ups, there one is there a component of treatment that involves addressing the double life or the honesty with yourself? Well, what I've developed over the years is asking explicitly talking about the double life, which is familiar to many people with addiction. But one thing that I do is I actually prescribe honesty or what I call radical honesty. So in addition to asking patients to abstain from their drug of choice for 30 days in order to reset reward pathways, what I also say to them is, and you can't tell any lies this month. And these aren't, I don't just mean you can't lie about your use. I mean, you can't lie about anything, which turns out to be really hard to do because the average adult tells one to two lies per day. And usually it's little lies about sort of why we relate for a meeting. Even those little lies can trip us up and get us telling the bigger lies related to our addiction. What I've learned from patients in recovery over the years is that the ones who have the most robust recovery are the ones who have learned that they have to tell the truth about pretty much everything. So that's one thing that I prescribe, and I think that really resonates and seems to help. The second question was sort of around the, you know, abstinence for 30 days. It's one thing to say that, but people are, there's an addiction here. How is it? Are there are sort of like ways that people can do this that they're unaware of? Because I mean, it sounds like 30 days sounds like this incredibly long period of time. But I want to acknowledge that for some people that ask is too much and that people with severe addiction, you know, in remaining in their usual environment will be unable to do that. And you know, it becomes pretty obvious pretty early, who those people are. There's no way I can do that or I've tried that a million times and it doesn't work for me. And that's where we then recommend a higher level of care. So for example, an intensive outpatient program where people go all day and go home at night or an even higher level of care where they go and they stay in a residential facility where they don't have access to their drug. And you know, the rehab is sort of like the butt of many jokes these days, but I can tell you as an addiction treatment provider, I'm very grateful for residential treatment settings and for rehabs because I have many patients who would never have been able to get into recovery without a restricted environment that allowed them to get their frontal back and lines so they could actually make choices about their lives. That's what people don't understand. They think that people are choosing to use, but once people are addicted, their reward centers have essentially been hijacked and they've lost a great deal of their autonomy and their ability to choose. They can even they can want to stop and yet not be able to. So these residential treatment facilities are really essential. Having said that, there are many, many people who can stop on their own, you know, with encouragement and support and an understanding of the neuroscience that explains why and the carrot of the promise of what might get better if they do that. So patients who show up in my office, they want help right there here for a reason. And if I explain to them that, geez, you know, your anxiety could get a lot better if you just stop masturbating every day. They're often willing to try it, even if they go in skeptically. And I always kind of present it as an experiment. I see this is an experiment. And you know, it's just to sort of sift out, you know, what's causing what. And 30 days is an amount of time people can usually accept. I also don't minimize how hard it's going to be. I let people know it will be hard, especially those first two weeks will be really hard. You might need to take some time off of work. Let your support structures know that you're going to be not well for a couple of weeks. You know, so we kind of prepare for it as you might prepare for chemotherapy. And I do like to liken it to cancer because I think it's important to emphasize the disease nature of addiction and how once it has taken hold of our brains, it really, it really is a disease. And people can be blamed, you know, fully for their behavior in that state, even though it seems very politional. The other thing that I often recommend to in an addition to radical honesty is I recommend that people do things that are hard during this time. And this is the whole science of hormesis that is to say using pain to reset reward pathways are using or paying for our dopamine upfront with pain as opposed to, you know, getting a high initially and then experiencing pain afterwards. So this is things like I recommend exercise. I recommend ice cold water baths any kind of mind bodywork martial arts yoga, felon cries. I recommend prayer and meditation. These are all healthy ways to get our dopamine indirectly. And they can also speed up the process of returning that pleasure pain balance to the level or neutral position. One of the other things you said was the the relationship between stress and addiction. Can you go deeper on that because it feels like we're in this world that is increasingly out of control where the baseline level of stress that people have is just at a level that we've maybe never experienced before or maybe that's just how some people are feeling. I'd love to hear your take on this. I do think we're facing a unique kind of stress and unprecedented kind of stress. And I actually think that living in a world of over abundance is its own source of stress. So how do we define stress and biological systems stresses any deviation from homeostasis or our neutral baseline position. So every time we tilt that pleasure pain balance to the side of pleasure or pain, we're also setting off our own endogenous adrenaline or stress hormone. That is the definition of stress a deviation from homeostasis. So I think that in many ways the source of our stress in modern life is the constant stimulation, the constant hits of pleasure from reaching from our for our phone in the morning to our morning cup of Joe to the doughnuts to the Netflix pinches at night to the hookah you name it. We're actually experiencing stress as a result of over abundance, but it's also true that this is a time of great social dislocation multi generational trauma poverty and unemployment are serious forms of stress. I think the most vulnerable people vulnerable people in the planet are actually poor people living in rich nations as opposed to poor people living in poor nations. Because poor people living in rich nations have all of the stress and trauma of unemployment poverty many times racial discrimination, lack of judicial fairness. but then at the same time they have access to these highly potent cheap. forms of dopamine because even though we have enormous income inequality, poor people today have more access to luxury goods, luxury consumer goods than they ever have had in the history of humans. So it's kind of this nexus, this perfect storm of risk factors for addiction. You know, animal experiments show that if you get a rat, for example, addicted to cocaine by pressing a lever, but then you take the cocaine away. Eventually that lever pressing will extinguish the rat. We'll stop doing that because it learns that there's no more cocaine coming and that it will go about its business and do other things. If you then expose that rat to a very painful foot shock, the first thing the rat will do is run to the lever and start pressing it. So that speaks to rule number three of this pleasure pain balance that the grandma's remember and that what can trigger relapse is not just a reminder of the drug, as I've mentioned before, or exposure to the drug itself, but actually a severe and painful trauma will trigger that relapse. And one of the reasons that it does that, fascinating, is that severe pain actually causes a huge dopamine release. So severe forms of pain are akin to drugs themselves and therefore can trigger this kind of compulsive drug seeking response. Alcoholics anonymous seems to be sort of one of the best methods of treatment available for a lot of people. What is it and why is it so successful? What are the inherent components of it that make it more likely to succeed? So alcoholics anonymous was started in the 1930s by two men who themselves were addicted to alcohol, Dr. Bob and Bill W. And they came together in desperation and realized that by talking to each other and sharing their lived experiences, they managed amazingly not to drink even when all these other medical interventions hadn't been helpful. So they essentially started going around and finding other alcoholics and talking to them about their experiences and having them talk about their experiences and found that through that process they were able to remain sober. So they found it alcoholics anonymous. It's got its own philosophy, the 12 steps as well as the 12 traditions. And it's not a religious organization but a cornerstone of the philosophy is this idea of surrender to a higher power. Now that higher power can be really anything you want it to be as long as it's not you. Part of the philosophy of alcoholics anonymous is that part of what drives addiction is what they call self will run riot or narcissism and letting go of being the person who's willing our lives and instead surrendering us or rendering it to a higher power which can you know again be a supernatural power or can be just the fellowship itself or can as they joke an egg and even be the doorknob as long as it's not you. I is something that is key to that process. The data over there so there are millions and millions of people who've gotten into recovery or what they call sobriety through alcoholics anonymous. It's one of the really the most remarkable social movements of the last 100 years. Part of its success is that it remains unaffiliated with any financial, political or other external organization. It's a completely grassroots fellowship. It's not professionally run. It's not about money. It's not about politics. And so I think that kind of independence and single-minded pursuit of getting alcoholics sober through attending meetings and practicing the 12 steps is part of its incredible success. How does it work? There's been an enormous amount of research on this. It's actually hard to research because it's a volunteer grassroots mutual help organization but it probably works through multiple different mechanisms. One of them being just having a sober social network, right? Affiliating with other people who are not using or who are trying not to use. It probably works in part through the 12 steps and the spiritual transformation that people experience. And then I speculate that the other way that it works is by leveraging pro-social shame. And what I mean by that is that a lot of what can both drive addiction but also motivate people to get into recovery is the shame they feel for their behaviors related to their use. If that shame, you know, becomes destructive shame, it will perpetuate the addictive cycle. But if we can turn it into pro-social shame, then it can help motivate people to stop using. And alcohol ics anonymous does that really well. First of all, there's a huge deshaming process that happens when people join alcoholics anonymous and other 12 step meetings because they're surrounded by other people with the same problem and they realize, oh, wow, I'm not the only one. And I'm not some horrible human because I have this problem. This is a problem that other people have. This is just, you know, part of being human. So that's hugely deshaming and very, very helpful for people trying to get into recovery. But on the other hand, alcoholics anonymous, you know, has a lot of behaviors that it asks people to do, like, for example, count their days and go to a meeting every day and get a chip, you know, if they get 30 days without using and 60 days without using and 90 days without using. And there's a lot of support in the group for abstinence and a lot of celebration of abstinence. And a lot of internalized anticipated shame if they were to relapse and have to go back and declare themselves as newcomers. And it's anticipating the shame of that. That motivates a lot of people, at least initially, to not use. And to me, that's a very good use of shame. Importantly, if people do relapse in alcoholics anonymous, they're not kicked out of the group. They're not shunned. They're not made to feel less than. In fact, they become very valuable members because they have to come back and declare themselves as newcomers. And then the rest of the group, you know, helps them then to get back into recovery. So so they add to what, you know, behavioral economists call the club goods of the organization. I like how you said that shame was useful at least in the beginning. And it sounds like that the most critical period is the beginning where you're going through the abstinence and you have to get to this point where your brain starts to reset a little bit. Absolutely. Yeah, that's really important that you know, when we're in our addiction, our brains are not working right. They really aren't, you know, we've got the Gremlins driving our bus. And we're not really, it's not a bus anybody would want to be on. So we really have to get our front alobs back online and connected to our limbic brain and to be able to make clear decisions. There's two sort of sub questions I have here. One is like, is there a ritual ritualistic aspect to alcoholics anonymous that also acts as a counterbalance to feeling isolated and alone and sort of yeah, I mean, there's a many ritualistic aspects to almost all robust human communities where there are club goods, what we call club goods, those intangible goods that we get from belonging to a human organization. And you know, one of the rituals is just going to meetings, right? I'm not even necessarily going because we feel like it, but going because it's like brushing our teeth because we know we need to in order to stay well. There are very unscripted ways of talking in alcoholics, or I'm meeting alcoholics, I've been reducing, you know, I, you know, my name is such and such and I'm an alcoholic. There are particular ways that people are socialized to tell their story in alcoholics anonymous. This is what this is where I was. This is what happened and this is where I am now. There's some nice studies in the anthropology literature looking at the, you know, addiction recovery narrative and alcoholics anonymous. There's the whole rituals with the chips. There's the ritual of working the steps and getting a sponsor, another person in the group with whom, you know, you work those steps. There's a lot of A-A lingo, right? That only people in A-A really know what it means. For example, the dry drunk is the person who stops drinking, but doesn't really do the psychological work and the interpersonal change that A-A considers to be key to recovery. So lots, it's like a, it's a whole, you know, world unto itself. It sounds like focus is also important and I'm still reading between the lines here. If I focus on the gap between now and 30 days from now, that seems almost insurmountable and so it's like why bother trying? But if I focus on what can I do today? Talk to me a little bit about how where people focus changes their ability to accomplish things. Yeah, well, one of the very famous A-A sayings is take it one day at a time and there is something really biochemically important and magical about the 24 hour cycle. Our willpower is not, you know, an inexhaustible resource. We wake up in the morning, whatever our morning is with more willpower than we'll have at the end of the day because we've tired it out. So we can exclusively rely on our willpower. We have to really, you know, put what I call self-finding strategies or barriers between ourselves and our drug of choice that allows us to press the pause button between desire and consumption. But amazingly, you know, after sleep, after a night of sleep, we're renewed again. You know, we can start over. So there's something very, very powerful about just saying if I can just make it through today without using, I can start again and be reborn again tomorrow. And that really does happen biochemically. - And do we see in the data that people tend to, I'm gonna get the term wrong, like relapse or reuse, but it's always towards the end of the day when they're trying to abstain? - I mean, many people, it's a good question. I don't know if anybody has specifically looked at that. Many people do use at the end of the day. There's a kind of a work hard play hard mentality that permeates our culture where people do all their work and then they reward themselves, right? In fact, you can argue that so much of our lives, our book ended by our rewards, how we're gonna finish this to get to the next thing, which is our reward. And then over time, the kind of progressive disappointment in those rewards as they stop working and as they cause problems. So many people do use at the end of the day, which is also the time that we're tired and hungry. And lonely and angry, which gets to another halt acronym, hungry, angry, lonely, tired, which are the sort of things to watch out for as we're trying not to relapse, which is why a lot of meetings also occur in the evening time where people can replace the time they're using with going to meetings, but meetings also occur in the morning. I mean, they're probably meeting it every time of day. So it kind of depends on the person, people have their different using rituals and people use first thing in the morning. It sort of depends on their particular disease, their substance, the severity of the disease. - I know a lot of people, myself included who sometimes say, I need a glass of wine to unwind at the end of the day after a particularly difficult day. I think that one of my friends, actually, when I was telling him this, he said, you know, he realized that he had a problem 'cause he didn't want to drink alone, but he ended up, he was calling people, he didn't actually like. (laughing) He was arranging meetings with them, like, let's go out, let's do this thing, but he's like, you know, after a few months of this, he realized, like, I was hanging out with all these people I didn't like, but I was doing it because that was the vector. Like I can have alcohol if I did that. - Yeah, so that's very, very common where people will normalize their substance use by affiliating and hanging out with other people who use similarly and also in heavy amounts. So for example, I see lots of college kids with serious substance use problems who will say, well, I drink the same amount as everybody else. If you met my friend Joe, you'd see that I don't have a problem at all. And that's where this sort of explaining of, well, yeah, you and Joe actually represent the 1% tile of your college class and by hanging out together and using the other, you've normalized it to each other, but the vast majority of your cohort and your peers are not using in that way and your use is problematic. The other thing that people will do is they'll say to them, so I only use on special occasions. All of a sudden, there are a week as full of special occasions, right? A little bit like your friend. You know, there's always, you can always find a party, you can tell you stuff, I only use it parties and every drink alone, but you can find a party pretty much every night of the week. So these kinds of rationalizations are very, very common in a way that we normalize and rationalize problematic use. - What got you interested in this field? - Well, initially I wasn't interested in treating patients with addiction. We know why I went through medical school and even psychiatry residency. I didn't learn very much about addiction. It wasn't really considered a brain disease. It was considered a social problem, a moral problem, a will power problem. I really didn't want to treat patients with addiction, but what happened was I was seeing a young woman, a phenomenally for depression, who was frequently nodding off or falling asleep in our sessions and I was prescribing her in an antidepressant paxil. And I became convinced that she was some kind of, you know, metabolizing the paxil in a weird way that caused her to have this incredible, soporific, you know, sedated episodes. And she and I talked about that. I was thinking about writing up a case report. I saw her for, you know, about three quarters of a year. We talked about all her childhood, all this psychodynamic stuff. She didn't seem to be getting any better, however. And then one day her brother called me and he said, well, she's been in a row over a car accident. I said, oh, that's terrible. What happened? He said, well, she's been using again. And I just didn't even really know what he was saying. And I said, using what? And he said, using heroin isn't that what you've been treating her for? And it was just like this moment of intense shame that I experienced realizing, oh my goodness, I had no idea that she was using any drugs at all, much less that she was addicted to heroin. He said, yeah, she's upstairs right now using her rig. I didn't even know what a rig was. You know, so it was really this moment of just like, oh my gosh, I'm a bad psychiatrist. Like, I'm not a neutral factor here. Out of ignorance of addiction, I'm harming patients. Because it's not the responsibility of our patients to volunteer this information. It's our responsibility to ask and explore these issues with them. And I had not once asked her about drugs in alcohol. And I had misread her falling asleep in session as some kind of weird response to Paxle. When in fact, nodding off is a classic sign of opioid addiction and I missed it. So after that, I decided to learn as much as I could about addiction. I talked to my many wonderful colleagues in the field. I started to go to California Society of Addiction Medicine meetings. I learned an enormous amount through those meetings. And I started asking my patients about drugs in alcohol. And they were probably my best teachers. And they were eager to talk about it. I mean, that's the thing. Once you make it clear that you as their psychiatrist want to know, they are very willing to talk about it. Well, they feel like it's a safe space. And there's not a lot of safe spaces to talk about that. That's right. Exactly. With your fellows, I'm super curious as to what's the hardest thing to teach them or hardest thing for them to learn? My fellows come from many different background, summer psychiatrists. But many of them are family medicine and internal medicine doctors. For those doctors, the hardest thing for them is to adjust to having more time with patients. They're used to having 15 to 30 minutes where they have to go through a list of 10 significant health problems. And for them to have 30 to 60 minutes to really open up Pandora's box about psychological and emotional problems, including addiction, is very, very strange. It can make them very anxious. But once they start to do it and learn to do it, they love it. And then many of them don't want to go back to practicing primary care because they just feel like the depth of the connection and the meaningfulness of the interactions is so much more powerful. I think then just generally for all fellows, I think the hardest thing is to know when we're helping patients and when we're enabling them because there are ways in which we as health care providers can enable our patients addiction. And so trying to-- it's important to be really alert to that. For example, let's say a young person who comes to see us, not because they really wanted to get into recovery, but because their parents since they come. And so they show up and they're checking the box and fulfilling some obligation, but they're not really doing the work to get into recovery. And so learning to talk with patients in a empathic way about what are we actually doing here? And what is it that you want and how can I help you get there? And having sort of the harder discussions around that. It reminds me when you said that about them being there, but not really wanting to be there, that one of the sort of things or red flags that I have with people is that if they're asking for help, and I'm working harder for them, then they're working for themselves. Right. Yeah. And that's something that we talk a lot about. It's like you want to care and you want to show up in a professional and empathic way. You want to be fully present. But yet, at some point, if you realize the patient is really not-- they may be physically there, but they're not really showing up psychologically. This is where this whole idea of motivational interviewing got started. Motivational reviewing is just a way to package certain psychotherapeutic techniques that have existed for many, many decades, but in a way that can be encapsulate. How do we move people from not being motivated to address a certain problem to being motivated to do it, especially in a culture where we do not have the ability to force people to engage in treatment. And so that's a lot of asking people if we can give them feedback, rolling with resistance, trying to explore their motivations. So that's what we try to do to move people to find out what might motivate them to make a change. I'm wondering if you can talk to us a little bit about your trouble with sleeping in insomnia. My own trouble? Yeah. Oh, yeah. Well, it really began when I stopped nursing our last child. So nursing a baby-- for me, anyway, I can tell you, it really still-- a lot of chemicals, which really helped me go to sleep. And I'd never needed to rely on chemicals before, but somehow nursing changed my brain. And so when our last child, a wean, and he kind of weaned himself, he was done. at about a year. And so I suddenly found myself experiencing quite a bit of insomnia, which I had never experienced before. And then what happened was I started, I've always been a reader. I've read my whole life, but I discovered a certain genre of novel, romance novels, that somehow allowed me to deal with this time in between trying to go to sleep and actually falling asleep. And what happened was I actually got addicted to romance novels. It became the way that I put myself to sleep accompanied with other behaviors, which I'll let you fill in the blanks on that. And I essentially became physically dependent on that as a way of going to sleep and could not go to sleep without that. And didn't even really realize I was getting addicted to that behavior until I was a good year or two into it. And then realized through talking to somebody else in a kind of a not very serious way initially, I thought to myself, well, you know, I think this has really become a problem. Because then I wasn't just using romance novels to go to sleep at night, I was also not wanting to do other things during the day. I was not really paying attention to my husband and my children the same way. I didn't want to go to parties. I rather stayed home and read romance novels. I went to actually brought a romance novel to book to work and was reading in the 10 minutes between patients. And I think that was probably my bottom as they say in 12 steps. But the real test, I guess the real clarity on the fact that I had become addicted to this behavior was when I tried to stop. So I decided to stop for 30 days to take the advice that I give my patients. And it was incredibly difficult. I experienced an enormous amount of anxiety and dysphoria. I just was like lying my bed unable to fall asleep. And that continued for about two weeks. And then weeks three four, it got a lot better just, you know, just like my patients described. So it was interesting to go through it myself. And I was sleeping better by about week four. And then I thought, okay, well, now I'm done. I can go back to reading romance novels. So I did and I binge that whole weekend. And I didn't sleep at all. And then I was like, okay, no, I can't do this. This is a problem. So I essentially abstained pretty much since then. That was a good many years ago. And I still, I still have problems going to sleep honestly. It's still, it's still not entirely easy. I just get a lot of peak anxiety going to sleep. And I have this feeling that I'm not going to be able to sleep even if I'm very tired. But then I do fall asleep. So it's, it's interesting how it's a kind of a, it's like a little narrative that taped that place in my head that's not even really true because I do fall asleep. Now I have a lot of mid cycle awakening as it's not that unusual for someone my age. But I've learned to just sort of accept it and you know, know that it doesn't occur every night thankfully and that I'll have a good night sleep in between that'll make up for it. It seems like a lot of people are struggling to sleep these days too. It almost seems heightened or amplified by the last couple of years. Yeah, I mean, I just, they're again, it's sort of our overstimulated world. There are lack in general of physical activity. You know, I do prescribe exercise as the most potent sleeping pill. You can take, but you know, it's not foolproof. Like you can get a lot of exercise and still have trouble falling asleep at night. I also think that people's expectations around sleep in the modern world are too high. I think people think that, you know, a healthy sleep for an adult is that you fall asleep easily. You're completely unconscious the night long and then you wake up refreshed. And the truth is that it's very normal to have, first of all, all through the night we have intermittent awakenings. Like that is normal sleep. We go from deep sleep to these intermittent awakenings. And sometimes we remember those awakenings and sometimes we don't. It's also very normal to wake up in the middle of the night. Some people think that normal adult sleep is actually in two chunks and that we're evolutionarily designed to be awake for a time in the middle of the night for a lot of evolutionary different reasons. You know, people, a lot of my patients will use ambience, say, but I sleep so much better with ambience. The truth is that ambience only gives you about 15 more minutes of sleep, which is surprising, right? Because people feel like I slept so much more deeply. What it really does is it makes you amnestic for the periods of awakening. So it doesn't actually have you sleeping all that much longer in the night, but you can't remember all the times you woke up. So yeah, so there's a sleep is I think a part of the problem is we somehow think we should be sleeping, you know, like little babies. I appreciate you opening up about your struggles with that. The last question we normally ask people is what is success for you? Success for me is like a good day. I keep after the good day. Sometimes I get pretty close. And a good day for me often amounts to feeling a sense of accomplishment around a pretty small thing. Like let's say there's some kind of, you know, project or I have for work and I want to like get it down on paper and I do. And like that's a good day. Or I wanted the family to have dinner together at five. And I cook a pretty good dinner and everybody's there. And we enjoy each other's company. You know, that's a good day. So it's really I really work on the accumulation of a lot of small things over the course of a single day because what I've discovered is a lot of good days add up to a pretty good life. I like that a lot. Thank you so much Anna for taking the time today. Yeah, you're very welcome. Thanks for your really mellow style. Thanks for listening and learning with us. For a complete list of episodes, show notes, transcripts and more, go to fs.blog/podcast. We're just Google the knowledge project. Until next time.