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how hard is it for you to put down your phone how badly do you crave that morning cup of coffee do you gamble shop or drink just a little bit too much the potential for addiction is everywhere in our society and in this episode of the knowledge
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project psychiatrist and author Dr Anna Lemke helps uncover the mysterious gap between pain and pleasure that is so often filled with addiction Shane and Anna discuss dopamine dopamine is the most important neurotransmitter for the
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experience of pleasure reward and motivation addictive behaviors tolerance alone isn't sufficient to make the diagnosis of addiction warning signs and treatment for addiction for people who have become addicted 30 days is the bare
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minimum to begin to reset reward Pathways two weeks is almost never enough how your brain handles pain and pleasure in life Pleasure and Pain are co-located in the brain so the same parts of the brain that process pleasure also process pain and they work like
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opposite sides of a balance [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
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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
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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
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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 interesting things you said there one motivation so
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dopa 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
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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
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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 the way the rat would starve to death so the absence
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of dopamine in that reward circuit essentially took away that that rodents desire to strive to do the work to get the reward so so that's just it right so the the motivation part of this is we have a goal we want to do something and
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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
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lifetime memory of that experience and the desire to recreate it in order to again experience the 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
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in the reward circuit that then 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 be start to become addicted what's Salient is not so much the release of dopamine when they're getting
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high or 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
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that the decrease from a baseline I'm assuming sure so to in order to understand that it's it's essential to appreciate that Pleasure and Pain are co-located in the brain so the same parts of the brain that process pleasure also process pain
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and they work like opposite sides of a balance if you imagine like a central full crew and a beam on that fulcrum 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
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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
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deviation from neutrality so for example let's say I read a romance novel I get a release of dopamine my pleasure pathway or my reward circuit and my balance tilts to the side of pleasure no sooner has that happened then my brain starts
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to adapt to that increased dopamine by down regulating my own dopamine receptors and my dopamine dopamine production not just to Baseline levels but actually below Baseline levels and this is really the key piece of neuroadaptation I like to imagine this
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as these little neuroadaptation 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
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equal and 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
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fantasy world now if we wait long enough those neurotic patient 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
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choice can be almost overwhelming so the urge to want to restore neutrality once that balance is tipped to the side of pain is almost overwhelming now if we wait long enough the Gremlins hop off and homeostasis is restored but if we
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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
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we need more of our drug and more potent forms of our drug just to level the balance and especially we need more potent forms 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
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those those Gremlins are now camped out there tents and barbecues and 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
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insomnia dysphoria and craving and this explains why people with addiction will relapse to their drug of choice even you know weeks and months after they've stopped using it's because it takes a long time for those Gremlins to hop off
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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
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our drug of choice or other intoxicants and other more modest rewards are no longer appealing because of course they can't compete with the army of Gremlins that is now you know sitting on on the pain side when we think about recovery from
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addiction the primary goal is to restore homeostasis or restore a 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
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restored sometimes people are not able to do that in which cases there are medications that we can use to try to help you know restore homeostasis so that that's the first and essentially second rules of the balance the first
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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
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or similar 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 threshold such that we need
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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
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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 relentless relentlessly seeking out the next best thing in order to survive but it's a
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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
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that we would think of typically as healthy behaviors like like gaming like sex like eating um you know more more modern forms human connection has become drugified through social media so it's become a much more difficult environment to thrive in as
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humans because we're really not adapted for the world that we've created addiction like we seem to use this term very cavalierly which leads us to sort of discount addiction like we even show joke around about how we're addicted to
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something like addicted to going to the gym or how do you define addiction so when I use the word Addiction I'm really um talking about a severe form of Psychopathology that is defined as the continued compulsive use of a substance
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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
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are on a 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
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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
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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 uh so quantity and frequency matter of
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they're not technically in the diagnosis the diagnosis is 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
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colloquially and casually um you know they're trying to describe or capture the sort of minor addictions that we all experience on a regular basis um and and you know I don't think they necessarily think of themselves as really struggling with a psychological
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disorder but it's a sort of a way to describe the growing problem of compulsive over consumption 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
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substances and addicted to behaviors it's almost as if there's a spectrum is there something that makes um 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
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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
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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 you know there are people for whom uh regular intoxicants are actively
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aversive and they would not seek those intoxicants out again um also importantly you know speaking to sort of the the world we live in now there are so many more drugs than there used to be and even you know healthy activities have become drugified and the
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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
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seek out dopamine are we trying to get pleasure or are we trying to avoid pain really 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
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that's definitely a reason that many people use some people are actively using drugs and Drug up drugified behaviors in order to solve a problem and that problem can range from you know anxiety depression insomnia poor concentration to loneliness boredom
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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
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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
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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
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repetitive nature of the drug use is essentially to get out of pain or restore level balance so in other words 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
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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 years and all of a sudden it takes three glasses of wine to get to the same yeah yeah so tolerance
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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 and it must
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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
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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
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identify as part of a major depressive disorder or generalized 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
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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
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uh 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
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almost universally resist this idea initially for good reason because they tell me that well that my drug is the only thing in the moment that alleviates my depression levius my anxiety and what I say to them was yes temporarily it is
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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 that I do often in these cases is to have them abstain for a month from their drug of choice
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acknowledging that that's really hard to do but the promise is that at the end of that month those neuroadaptation Gremlins will have hopped off the pain side of the balance dopamine homeostasis or Baseline dopamine firing will have been restored and there are symptoms of
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depression and anxiety will largely have revolved spontaneously without my having to do any other intervention and about 80 percent of patients this will happen so it's really a very large group that will get relief from depression anxiety
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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 you know from situation to situation but I
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can tell you after Decades of clinical work and this this supported this idea supported by many of my colleagues and also by some of the early Neuroscience into this area is that for people people who have become addicted 30 days is the
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bare minimum to begin to reset reward Pathways two weeks is Almost Never Enough what happens when we first stop our drug of choices that our pleasure pain balance slams down to the side of pain we experience the universal
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symptoms of withdrawal some are unique to that drug but but the others the psychological ones are Universal and those will persist for about two weeks and then once people get to week three or week four of abstinence the Sun starts to come out people start to
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notice improvements in their Baseline mood anxiety and functioning sleep concentration everything so in general I advise 30 days of abstinence this is also supported by some preliminary work by Nora volkoff of the National Institute of drug abuse
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which is she has shown in imaging studies that if you image the nucleus accumbens which is the 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
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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 uh people are still in this dopamine
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deficit state so they're dopamine Transmission in the nucleus accumbens is still below normal um and that that's consistent you know with uh with our my clinical experience as well also there's a very important study done by shuck it and brown many
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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
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put them in a an enclosed setting let's say a hospital environment but you don't give them any treatment all you do is you know take away their alcohol you make sure that they safely detox then they don't go into life-threatening
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withdrawal what you find is at the end of four weeks eighty percent 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 uh
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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 if the universal psychological characteristics of withdrawal that you
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talked about so the universal symptoms of withdrawal from any substance or drugified behavior are anxiety irritability insomnia dysphoria and craving it seems like addiction is sort of hard to talk about in some ways because we we think like there's many
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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 the entry point into uh you know you seek out alcohol or another drug of choice this and that
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becomes the vector into this I don't think that's true so there are many doorways you know into addiction um 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
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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 the key point however is that once people
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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 develop another problem
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and that problem is the disease of addiction and addiction is its own primary Progressive disease 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
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depression 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
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trauma or give somebody you know the perfect life and everything they wanted once they've developed the disease of addiction they have addiction and if you don't intervene for that problem it's it's typically not going to resolve uh you
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know spontaneously and it's not going to resolve because you resolved the other problem so so really the important thing here is that addiction is its own primary Progressive disease and I think that's really important especially in
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this age of sort of trauma-informed care where we seem as a collective to be focusing a lot on you know what is the reason that this person is addicted and many times you know there is trauma in people's lives that does partially explain why they developed the disease
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of addiction the problem is that just understanding that that origin or that etiology or the spark that contributed to addiction is not going to resolve the addiction itself you know addiction is treated by it's a biopsychosocial
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disease and it typically needs a biopsychosocial treatment in order for people to get into recovery what are the 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
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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
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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 uh you know pay attention to when we're you know lying
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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 an addiction he developed the lying habit which which
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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 at Burger King and a friend called and said where are you he'd say I'm at McDonald's
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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
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the other things are the you know 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 uh where we're initiating use even though when we hadn't planned to initiate use
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um and a lot of our mental real estate is occupied with thinking about using the drug very narrowly focused on the drug as our source of relief and pleasure craving is overwhelming feelings of wanting to use that can be manifested as
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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 you know looking around at the consequences which because
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we can't see them very well ourselves there's really a quite a literal disconnect between um you know 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 um those around us are
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telling us about the impact of our consumption even if we don't see it ourselves so at a high level what is sort of treatment look like from your point of view are there sort of steps that people commonly go through uh you
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know 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
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social or contextual Origins and urban 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
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patients for 30 days of abstinence from their drug of choice now importantly we would not ask this of somebody who was at risk for life-threatening withdrawal so for example people can have life that threatening withdrawal from alcohol from
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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 a drug in order to restore
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homeostasis the classic examples of that are using methadone maintenance or buprenorphine to restore a level balance in people with severe opioid use disorder they're not getting high on those opioids they're basically just
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getting a Level Playing Field to be able to you know enter other aspects of recovery um so that that biological pieces is really important but even after restoring homeostasis um you know it's not like the solution like the problem
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is over right addiction is a 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
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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
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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
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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 the that little increase in dopamine from the light we actually go below Baseline
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levels in dopamine firing we go into 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
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insulating ourselves from triggers and reminders of our drug of 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
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um and there are different medications now that have come out that can help people with that um to sort of limit the reinforcing effects of craving one of them for example is a medication called Naltrexone which is an opioid receptor
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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 Naltrexone and they
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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 cravings
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so the biological interventions are part of it psychological interventions we know that both individual and group Psychotherapy are particularly effective for addiction I mean essentially you know many people talk about addiction as an attachment
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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
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connections so the individual in group therapy I think is really about re-teaching people how to be in connection with other people in a meaningful gratifying and intimate way and then the social peace or contextual piece is really acknowledging
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um you know all the the contextual reasons that uh and stressors and how stress leads to addiction how having a sober social network of friends helps people not use their drug um and so it's it's that kind of complete picture so two follow-ups there
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one is 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 for explicitly talking about the double life which is familiar to many people
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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
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them is and you can't tell any lies this month um 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 lives per day
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and usually it's little lies about sort of why we were late for a meeting but 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
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who have the most robust recovery are the ones who have learned that they have to tell the truth about about pretty much everything so that's one thing that I prescribe and I think that really resonates and seems to help the second
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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
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sounds like 30 days sounds like this incredibly long period of time yeah well first of all 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
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environment will be unable to do that and and you know it becomes pretty obvious pretty early who those people are they just say I 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
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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
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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
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would never have been able to get into recovery without a restricted environment that allowed them to get their frontal lobe back in line so they could actually make choices about their lives that's what people don't understand they think that people are
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choosing to use but once people are addicted their 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
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able to so these residential treatment facilities are really essential having said that there are many many people who can stop on their own um you know with encouragement and support and an understanding of the Neuroscience that explains why and the
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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 they're here for a reason and if I explain to them that geez you know your anxiety could get a lot better if you
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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 um I see this is an experiment and you know it's just a sort of sift out you know what's causing what
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um 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
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off of work let your support structures know that you know 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
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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 um you know for fully for their behavior in that state even though it seems very
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volitional the other thing that I often recommend too in addition to radical honesty is I 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
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reset reward Pathways they're using or paying for our dopamine up front 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
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water bath any kind of Mind Body Work Martial Arts yoga felden cries um 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
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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
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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 well I do think we're facing a unique kind of stress and unprecedented
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kind of stress and I actually think that living in a world of overabundance is its own source of stress so how do we Define stress in biological systems stresses any deviation from homeostasis or our neutral Baseline position so
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every time we tilt that pleasure pane balance in 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
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stress in in Modern Life is the constant stimulation the constant hits of pleasure from reaching from our for our phone in the morning to our you know morning cup of Joe to the donuts to the Netflix binges at night to the hookah
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you name it we're actually experiencing stress as a result of over abundance but it's also true that this is you know a time of great social dislocation multi-generational trauma poverty and unemployment are serious forms of stress
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I think the most vulnerable 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 the stress and
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Trauma of unemployment poverty many times racial discrimination you know 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
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more access to luxury goods luxury consumer goods than they ever have had in the history you know of humans so it's kind of this this you know Nexus this perfect storm of risk factors for addiction you know animal experiments show that if you
38:44
um get a 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 route will stop doing that because it learns that there's no more cocaine
38:57
coming and then 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
39:08
this pleasure pain balance that the Gremlins 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 and
39:22
one of the reasons that it does that fascinating uh is that uh 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
39:39
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 the inherent components of it that make it more likely to succeed
39:58
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
40:17
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
40:33
about their experiences and found that through that process they were able to remain sober so they founded Alcoholics Anonymous it's uh it's got its own philosophy the 12 steps as well as the 12 traditions and it's not a religious organization
40:50
but a Cornerstone of the philosophy is this idea of surrender to a 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
41:07
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 or surrendering it to a higher power which can you know again be
41:24
a a supernatural power or can be just the fellowship itself or can as they joke in a can even be the doorknob as long as it's not you is something that that is key to to that process the data over there so there are millions and millions of people who have
41:39
gotten into recovery or what they call sobriety through Alcoholics Anonymous it's it's one of the really the most remarkable social movements of the last hundred years um part of its success is that it remains unaffiliated with any Financial
41:54
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
42:08
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
42:25
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
42:37
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 um a lot of what can both Drive addiction but also motivate people to
42:56
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
43:12
motivate people to stop using an Alcoholics Anonymous does that really well first of all there's a huge D shaming process that happens when people join Alcoholics Anonymous and other 12-step meetings because they're surrounded by other people with the same
43:25
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 de-shaming and very very
43:38
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
43:51
know if they get 30 days without using and 60 days without using and 90 days without using and um there's a lot of support uh in the group for abstinence and a lot of celebration of abstinence and a lot of internalized anticipated shame if they were to
44:09
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
44:25
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
44:38
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
44:52
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
45:03
our addiction our brains are not working right they really aren't you know we've got the Gremlins driving our 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 frontal lobes back
45:15
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 a ritualistic aspect to Alcoholics Anonymous that uh also acts as a counterbalance to feeling isolated and
45:33
alone and yeah I mean there's a many ritualistic aspects to almost all um robust um human communities where there are Club Goods what we call Club Goods those intangible goods that we get from belonging to a human organization
45:52
um and you know one of the rituals is just going to meetings right I mean not even necessarily going uh 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
46:07
very unproscripted ways of talking in Alcoholics meaning alcoholics of introducing you know I you know my name is such and such and I'm I'm an alcoholic there are particular ways that people are socialized to tell their story in Alcoholics Anonymous this is
46:23
what this is where I was this is what happened and this is where I am now and there's some nice studies in the anthropology literature looking at the uh you know addiction recovery narrative and Alcoholics Anonymous there's the
46:36
whole rituals with the chips there's the ritual of working the steps and getting a sponsor an 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 AAA really know what it
46:51
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 AAA considers to be key to recovery um so a lot it's like a it's a it's a whole you know World unto itself it
47:07
sounds um like focus is also important and I'm sort of 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
47:23
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 AA sayings is take it one day at a time and there is something really biochemically important and
47:40
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't exclusively rely on our
47:56
willpower we have to really um you know put what I call self-binding 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
48:09
after sleep after a night of sleep we're renewed again you know we we can start over so there's something very very powerful about just saying if I can just make it through today without using you know I can start again and be reborn
48:24
again tomorrow and that really does happen biochemically and do we see in the data that people tend to um I'm going to get the term wrong like relapse or reuse but it's always towards the end of the day when they're trying
48:39
to abstain is that sort of I mean many people it's a good question I don't know if anybody has specifically looked at that um many people do use at the end of the day there's a kind of a Work Hard Play Hard mentality that permeates our
48:54
culture where people do all their work and then they reward themselves right in fact you can or you could argue that so much of our life our book ended by our rewards how we're gonna finish this to get to the next thing which is our
49:05
reward and then over time the kind of progressive disappointment in those rewards as they stop working I mean 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 you know
49:22
which gets to another halt acronym hungry angry lonely tired which are the sort of things to watch out for um as we're trying not to relapse which is why a lot of meetings also occur you know in the evening time where people
49:36
can replace the time they're using with with going to meetings but meetings also occur in the morning you know I mean they're probably meeting at every time of day so it kind of depends on the person you know every people that have
49:48
their different using rituals some people use first thing in the morning it sort of depends I I know a lot of people myself included who sometimes say you know I need a glass of wine to unwind at the or at the end of the day after a particularly difficult day
50:02
um I think that you know one of my friends actually when I was telling him this he said you know uh he realized that he had a problem because he didn't want to drink alone but he ended up he was calling people he didn't actually like he was arranging
50:18
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's realized like I was hanging out with all these people I didn't like but I was doing it because that was the a vector
50:29
like I could 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
50:43
lots of college kids with serious substance use problems who will say well I I don't you know I drink the same amount as everybody else so if you if you met my friend Joe you know you'd see that I don't have a problem at all and
50:54
that's where this sort of explaining of well yeah you know you and you and Joe actually represent the one percentile of your college class and by hanging out together and using the other you've normalized it to each other but the vast
51:06
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 themselves well I only use on special occasions all of a sudden their week is full of special occasions right a little
51:19
bit like your friend you know there's always you can always find a part you can tell yourself I only use at parties I never drink alone but you can find a party pretty much every night of the week so these kinds of rational
51:28
realizations are very very common the way that we normalize and rationalize problematic use well what got you interested in this field well initially I wasn't interested in treating patients with addiction we know when I went through medical school and even
51:42
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 willpower problem um and um I really didn't want to treat patients with addiction
51:59
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 an antidepressant Paxil and I became convinced that she was some kind of you
52:16
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
52:30
three quarters of a year we talked about all her childhood all the 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 rollover car accident I said
52:42
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
52:57
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
53:15
um you know so it was 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 of addiction I'm harming patients because it's not the responsibility of our patients to volunteer this information
53:30
it's our responsibility to ask and explore these issues with them and I had not once asked her about drugs and alcohol and I had misread her falling asleep uh you know in session as some kind of weird response to Paxil when in fact nodding
53:46
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
54:04
learned an enormous amount through those meetings and I started asking my patients about drugs and 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
54:15
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
54:29
to what's the hardest thing to teach them or hardest thing for them to learn my fellows come from many different backgrounds some are psychiatrists but many of them are family medicine and Internal Medicine doctors for those doctors the hardest thing for them is
54:46
to adjust to having more time with patients they're used to having you know 15 to 30 minutes where they have to go through a list of 10 significant health problems and for them to have you know 30 to 60 Minutes to really open up
55:01
Pandora's Box about um psychological and emotional problems including addiction is 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 sort of don't want to go back to
55:16
practicing primary care because they just feel like the depth of the connection and the meaningfulness of the interactions so much more powerful um I think that then you know just generally for all fellows I think the hardest thing is
55:32
um to know you know when we're helping patients and when we're enabling them because there are ways in which we as healthcare providers can enable our patients addiction and so trying to it's important to be really alert to that you know for
55:49
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 insist they come and so they show up and they're checking the box and fulfilling some obligation but
56:00
they're not really really you know doing the work to get into recovery and so you know learning to talk with patients in an empathic way about like what are we actually doing here you know and what is it that you know you want and how can I
56:14
help you get there um and having sort of the harder discussions around that it uh it reminds me when you said that about them being there but not really wanting to be there that one of the the sort of things or red flags that I have with people is
56:29
that uh if they're asking for help and I'm working harder for them than they're working for themselves right yeah and that's that you know that's something that we talk about a lot about you know it's like you want to care and you want
56:42
to you know show up in a in you know a professional and empathic way you want to be fully present but yet it's at some point if you realize the patient is really not they may be physically there but they're not really showing up
56:55
psychologically this is where this whole idea of motivational interviewing got started motivational interviewing is just sort of a way to package um certain psychotherapeutic techniques that have existed for many many decades but in a way that can be sort of
57:12
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
57:26
of like you know asking people if we can give them feedback rolling with resistance I'm trying to explore their motivations so that's what we try to do to move people to find out what what might motivate them to make a change I'm
57:40
wondering if you can talk to us a little bit about your trouble with sleeping and insomnia my own trouble yeah oh yeah well it really began um when I stopped nursing our last child so you know nursing a baby for me anyway I can
58:01
tell you it released a lot of chemicals which really helped me go to sleep and I never needed to rely on chemicals before but somehow nursing changed my brain and so in our when our last child uh wean and he kind of weaned himself he was done at about a year
58:19
and uh so so I suddenly found myself experiencing quite a bit of insomnia um 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 and um but I discovered a
58:36
certain genre of of Novel romance novels that somehow allowed me to um deal with this time in between trying to go to sleep and actually falling asleep and what happened was I actually got got addicted to romance novels I it became the way that I put myself to sleep
58:57
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 um and didn't even really realize I was
59:12
getting addicted to that behavior until I was a good year or two into it and then you know and then realized um through talking to somebody else in a kind of a not very serious way initially I thought to me like wow you know I
59:28
think this has really become a problem because then then I wasn't just using romance novels to go to sleep at night I was also um not wanting to do other things during the day I was not really you know paying attention to my husband and my children
59:40
the same way I I didn't want to go to parties I'd rather stay at home and read romance novels at one point I actually brought a romance I want the book it to work and was reading you know in the 10 minutes between patients
59:51
and I think that was probably my my my bottom as they say you know in 12 steps um but the real test I guess the real Clarity on the fact that I had become you know addicted to this Behavior was when I tried to stop so I decided to
1:00:08
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 um I just was like lying my bed unable to fall asleep um and that that continued for about two
1:00:23
weeks and then weeks three and four it got a lot better just you know just like my patients described so it was interesting to go through it myself um 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
1:00:35
Romans so I did and I binged that whole weekend and I didn't sleep at all and uh then I was like okay nope I can't do this this is a problem so I essentially abstained pretty much since then that was a good many years ago I still have
1:00:49
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
1:01:02
so it's it's interesting how it's a kind of a it's like a little narrative that a tape that plays 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
1:01:15
someone my age but I've learned to just sort of accept it and um you know know that uh it what doesn't occur every night thankfully and that I'll have a good night uh sleep in between that'll make up for it it seems like a lot of
1:01:28
people are struggling with sleep these days too it almost seems heightened or Amplified for the last couple years yeah I mean I just they're again into a sort of our overstimulated world there are lack in general of physical activity
1:01:42
um 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
1:01:57
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
1:02:09
have um 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 um and sometimes we remember those Awakenings and sometimes we don't it's
1:02:22
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 were evolutionarily designed to be awake for a time in the middle of the night for a lot of evolutionary different reasons
1:02:35
um you know people a lot of my patients will use Ambien say but I sleep so much better with Ambien the truth is that Ambien only gives you about 15 more minutes of sleep which is surprising right because people feel like I slept
1:02:46
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 um so so yeah so there's a sleep is I
1:03:01
think a part of the problem is we we somehow think we should be sleeping you know like little babies I appreciate you opening up about your struggles with that sure yeah the last question we normally ask people is what is success for you
1:03:16
um you know success for me is like a good day um I keep I keep after the good day uh some days I get pretty close and a good day for me often amounts to um feeling a sense of accomplishment around a pretty small thing like let's say there's some kind of you
1:03:38
know project or I I have for work and I want to like get it down on paper and and I do and like that's a good day or I I wanted the family to have dinner together at five and I cook a pretty good dinner and everybody's there and we
1:03:54
enjoy each other's company you know that's a good day so it's 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