Health Matters 2022: Pain, Pleasure, and the Addictive Chase for Dopamine

Summary

In this enlightening talk, Dr. Anna Lembke explores the neuroscience behind addiction, highlighting the role of dopamine in the brain's reward system. She discusses how modern life, with its abundance of highly reinforcing stimuli, can lead to a dopamine deficit state, resulting in increased rates of addiction, anxiety, and depression. Dr. Lembke offers practical strategies for managing this 'dopamine overload,' including abstinence, mindfulness, and self-binding techniques, as well as the concept of hormesis to reset the brain's pleasure-pain balance. Her insights provide a framework for understanding and navigating the challenges of addiction in today's world.

Takeaways

• 🧠 Dopamine is a key neurotransmitter associated with pleasure, reward, and motivation, and plays a central role in addiction.
• 📈 The brain's reward circuitry, involving the ventral tegmental area, nucleus accumbens, and prefrontal cortex, is adapted for survival in a world of scarcity, not modern abundance.
• 📚 Dr. Anna Lembke's book 'Dopamine Nation' discusses how to find balance in a world of indulgence and the impact of dopamine on our lives.
• 🚫 Addiction is not just about drugs; it can also involve behaviors like excessive use of digital devices, pornography, and shopping.
• 🔄 Dopamine fasts can help reset the brain's reward pathways and reduce the desire for highly reinforcing substances or behaviors.
• 🧘 Mindfulness and meditation can be beneficial in managing cravings and restoring dopamine balance through effortful engagement.
• 📱 Reducing screen time, especially for children, can prevent the development of digital addictions and promote healthier coping mechanisms.
• 🤝 Supportive conversations with loved ones struggling with addiction should be approached with emotional regulation and without immediate expectations for change.
• 🔄 The concept of hormesis suggests that mild to moderate stressors can trigger the body's healing mechanisms and help restore dopamine balance.
• 🚭 Nicotine is highly addictive, and its delivery mechanisms, such as vaping and smoking, can be harmful and overshadow any potential therapeutic benefits.
• 📈 Rates of addiction, anxiety, depression, and suicide are increasing, particularly in wealthier countries, possibly due to constant stimulation of the reward pathway.

Q & A

What is the main focus of Dr. Lembke's talk?

Dr. Lembke's talk focuses on the biology and psychology of addiction, the role of dopamine in creating addiction, and strategies for managing our dopamine levels to avoid over-indulgence and find contentment.

How does Dr. Lembke describe the dopamine reward pathway?

Dr. Lembke describes the dopamine reward pathway as a dedicated circuit in the brain involving the ventral tegmental area, nucleus accumbens, and the prefrontal cortex, where dopamine is released in response to pleasure, motivation, and reward.

What is the significance of dopamine in addiction, according to Dr. Lembke?

Dopamine is significant in addiction because it is the neurotransmitter most intimately associated with the experience of pleasure, reward, and motivation. The more dopamine released and the faster it is released in the brain's reward pathway, the more addictive the substance or behavior.

How does Dr. Lembke explain the concept of 'drug of choice'?

The 'drug of choice' concept refers to the idea that different individuals may have varying amounts of dopamine released in response to different drugs, which can influence their susceptibility to specific addictions.

What is a dopamine fast, and how does it help in curbing over-indulgence?

A dopamine fast is a period of abstinence from activities or substances that trigger dopamine release, such as drugs, alcohol, food, or digital devices. It helps reset the brain's reward pathways, allowing individuals to experience pleasure in more modest rewards and reduce the desire to over-indulge.

How does Dr. Lembke relate her personal experience with romance novels to the concept of addiction?

Dr. Lembke uses her experience with romance novels to illustrate how even seemingly harmless activities can become addictive if they lead to increased tolerance, a need for more potent stimuli, and a neglect of other important aspects of life, such as family and social interactions.

What is the 'hedonic set point' and how does it change in addiction?

The 'hedonic set point' refers to an individual's baseline ability to experience pleasure. In addiction, this set point changes, leading to a decreased ability to experience pleasure from normal activities and an increased baseline state of pain, which drives the need to use the addictive substance to feel normal.

How does Dr. Lembke explain the impact of modern technology on addiction rates?

Dr. Lembke suggests that the easy access to highly reinforcing drugs and behaviors, including digital devices and online activities, has increased the vulnerability to addiction, especially in affluent societies where people have more disposable income and less access to healthy dopamine sources like nature.

What are 'self-binding strategies' and how do they help in managing addiction?

Self-binding strategies are barriers, both literal and cognitive, that individuals can implement to control their desires and prevent over-indulgence. Examples include not keeping drugs in the house, using devices only on special occasions, or limiting the time spent on certain activities.

What is the concept of 'hormesis' and how does it relate to dopamine regulation?

Hormesis refers to the use of mild to moderate noxious stimuli to trigger the body's healing mechanisms, which can lead to the up-regulation of dopamine and other feel-good hormones and neurotransmitters. This concept suggests that intentionally engaging in activities that cause mild discomfort can help reset the pleasure-pain balance towards pleasure.

Outlines

00:00

🎤 Introduction and Event Overview

Sandra Ben-Efraim, a member of the Stanford Medicine Community Council, welcomes the audience to the 'Health Matters' community event. She introduces Dr. Anna Lembke, a Professor of Psychiatry and Behavioral Sciences at Stanford University, who will speak about the biology and psychology of addiction, the role of dopamine, and how to maintain balance in a dopamine-saturated world.

05:01

🧠 The Neuroscience of Pleasure and Addiction

Dr. Lembke discusses the brain's dedicated circuit for pleasure, motivation, and reward, involving the ventral tegmental area, nucleus accumbens, and dopamine release. She explains how different drugs affect dopamine levels and the concept of 'drug of choice,' highlighting individual differences in dopamine response to various substances.

10:02

📉 Dopamine, Pleasure, and the Hedonic Set Point

Dr. Lembke describes how dopamine is always active in our brains at a baseline level, and how changes in dopamine firing lead to reinforcement or dysphoria. She shares her personal experience with addiction to romance novels, illustrating the development of tolerance and the narrowing of focus to the 'drug of choice.' She also explains the concept of the hedonic set point and how it can be altered by addictive behaviors.

15:03

🔄 The Balance of Pleasure and Pain

The speaker explains the brain's balance mechanism, likening it to a teeter-totter, and how it responds to pleasure and pain. She describes the neuro-adaptation process that occurs with repeated exposure to pleasurable stimuli, leading to a need for more potent or varied stimuli to achieve the same effect. Dr. Lembke also discusses the long-term effects of this process, including the persistent state of dopamine deficit in the brains of addicts.

20:03

🧠 Neurobiological Impact of Unmet Expectations

Dr. Lembke talks about the role of dopamine in managing expectations and the stressor effect of unmet expectations, which can drive individuals towards substance use. She emphasizes the importance of protecting young people from developing maladaptive coping strategies like addiction and discusses the neuro-architecture of the brain, which is shaped during early development.

25:07

🌶️ Pleasure, Pain, and Narratives

The speaker explores the complex interplay of pleasure and pain, using examples like spicy food and the placebo effect to illustrate how our perception of pain and pleasure is influenced by our brain's interpretation. She references studies on pain perception in soldiers and a construction worker's case to demonstrate how the brain can create real pain from perceived injury.

30:08

🌐 The Modern Ecosystem and Addiction

Dr. Lembke discusses how our evolutionary wiring is mismatched for the modern world of abundance, where highly reinforcing drugs and behaviors are easily accessible. She notes the increasing rates of addiction and mental health issues, suggesting a link between constant dopamine stimulation and societal misery. She advocates for learning from people in recovery to navigate the dopamine-saturated world.

35:08

🚫 Abstinence and Recovery Strategies

The speaker suggests an experiment of abstinence from addictive substances to reset the brain's reward pathways and restore homeostasis. She emphasizes the importance of understanding one's consumption patterns and the reasons behind substance use. Dr. Lembke also introduces the concept of self-binding strategies to prevent relapse and promote healthier coping mechanisms.

40:11

💪 Hormesis and Adaptive Dopamine

Dr. Lembke introduces the concept of hormesis, using mild to moderate noxious stimuli to trigger the body's healing mechanisms and up-regulate dopamine. She suggests that engaging in activities that are slightly uncomfortable can help reset the pleasure-pain balance and reduce the risk of cross-addiction. She also warns against extreme forms of pain as a potential for new addictions.

45:11

📱 Digital Devices and Dopamine

The speaker addresses the issue of smartphone addiction, recommending a 24-hour dopamine fast from digital devices for individuals and families. She discusses the initial discomfort and eventual benefits of such a fast, including reduced anxiety and improved focus on other activities. Dr. Lembke also suggests strategies for managing children's screen time and the importance of discussing digital etiquette and the risks of addiction.

🤔 Questions and Answers

Dr. Lembke answers audience questions on the susceptibility to dopamine highs, the effectiveness of meditation in retraining dopamine regulation, strategies for curbing smartphone addiction in children, the impact of screen addiction on children under five, and resources for explaining the pain-pleasure phenomenon to adolescents. She also addresses the topic of nicotine addiction and provides advice on how to approach a loved one suspected of having an addiction.

Keywords

💡Dopamine

Dopamine is a neurotransmitter associated with pleasure, reward, and motivation. In the video, Dr. Lembke explains that dopamine plays a key role in addiction, as substances and behaviors that increase dopamine levels can be highly reinforcing and lead to compulsive use. The concept of a 'dopamine fast' is introduced as a strategy to help reset the brain's reward pathways and reduce the desire for addictive substances or behaviors.

💡Addiction

Addiction is characterized by the continued compulsive use of a substance or behavior despite harm to oneself or others. Dr. Lembke discusses the biological and psychological aspects of addiction, emphasizing how the brain's reward circuitry and dopamine levels are involved. She also addresses the concept of 'drug of choice' and how different individuals may respond differently to various addictive substances.

💡Neurotransmitters

Neurotransmitters are chemical messengers that facilitate communication between neurons. In the context of the video, dopamine is highlighted as the primary neurotransmitter involved in the experience of pleasure and reward. Dr. Lembke explains how neurotransmitters like dopamine bridge the synaptic gap between neurons, using the analogy of a pitcher and catcher to illustrate this process.

💡Pleasure-Pain Balance

The pleasure-pain balance is a concept introduced by Dr. Lembke to describe the brain's natural tendency to maintain a level of dopamine activity, which is associated with feelings of pleasure or pain. When dopamine levels increase, the balance tilts towards pleasure, and when they decrease, it tilts towards pain. This balance is crucial in understanding the cycle of addiction and the brain's response to addictive substances or behaviors.

💡Hedonic Set Point

The hedonic set point refers to an individual's baseline level of happiness or pleasure. Dr. Lembke explains that in the pursuit of pleasure, individuals with addiction may lower their hedonic set point, making it harder to experience pleasure from non-addictive sources and increasing the need for the addictive substance or behavior to feel normal.

💡Dopamine Fast

A dopamine fast is a period of abstinence from addictive substances or behaviors designed to reset the brain's dopamine system. Dr. Lembke suggests this as a strategy to help individuals curb their innate desire to over-indulge and to restore the brain's ability to experience pleasure from more modest rewards.

💡Neuroadaptation

Neuroadaptation refers to changes in the nervous system in response to repeated exposure to a stimulus, such as an addictive substance. In the video, Dr. Lembke describes how neuroadaptation can lead to tolerance, where more of the addictive substance is needed to achieve the same effect, and how this process contributes to the development of addiction.

💡Self-Binding Strategies

Self-binding strategies are techniques used to control or limit addictive behaviors. Dr. Lembke discusses these strategies as a way to put barriers in place to resist the desire for addictive substances or behaviors. Examples include not keeping the substance at home, limiting use to special occasions, or setting specific rules around usage.

💡Hormesis

Hormesis is the concept of using mild to moderate stressors to trigger the body's own healing mechanisms. In the context of the video, Dr. Lembke suggests that intentionally pressing on the pain side of the pleasure-pain balance can help reset the balance towards pleasure, as the brain responds by up-regulating dopamine and other feel-good neurotransmitters.

💡Digital Addiction

Digital addiction refers to compulsive overuse of digital devices or online activities, such as video games, social media, or pornography. Dr. Lembke addresses the growing concern of digital addiction, especially in children and adolescents, and provides advice on how to manage and reduce screen time to prevent addiction.

💡Nicotine Addiction

Nicotine addiction is the compulsive use of nicotine, typically through smoking or vaping. Dr. Lembke discusses the addictive nature of nicotine and the rapid withdrawal phase associated with its use. She also touches on the potential therapeutic benefits of nicotine at lower doses, which are overshadowed by the harmful delivery mechanisms of cigarettes and vapes.

Highlights

Dr. Anna Lembke discusses the neuroscience behind addiction and dopamine.

Dopamine is the neurotransmitter most associated with pleasure, reward, and motivation.

Different drugs and behaviors increase dopamine levels differently, affecting addictive potential.

The concept of "drug of choice" highlights individual differences in dopamine release.

Dr. Lembke shares her personal experience with addiction to romance novels.

The brain's reward circuitry is mismatched for the modern world of constant stimulation.

Dopamine fasts can help reset the brain's reward pathways and curb over-indulgence.

The balance between pleasure and pain in the brain is crucial for understanding addiction.

Addiction can lead to a decreased ability to experience pleasure and an increased baseline state of pain.

The brain's reward circuitry can be reset through abstinence and self-binding strategies.

Mindfulness and insight are key to managing withdrawal symptoms and understanding addiction's effects.

Hormesis, the use of mild to moderate stressors, can help rebalance the pleasure-pain axis.

Meditation can be an adaptive source of dopamine and help in retraining dopamine regulation.

A 24-hour digital detox can help curb smartphone addiction and improve mental health.

Parents should minimize and supervise screen time for children to prevent digital addiction.

Nicotine is highly addictive, and its delivery mechanisms, like vaping, can be harmful.

When approaching a loved one about addiction, be emotionally regulated and use data to reflect their behavior.

Transcripts

(bright music)

- Good afternoon, everyone.

Thank you for joining us today at this wonderful event,

community event, "Health Matters."

My name is Sandra Ben-Efraim.

I am a local resident and a member

of the Stanford Medicine Community Council.

Thank you again for coming today. Before we...

(audience applauding) Thank you.

Thank you, and before we start today,

I do want to remind you that if you would like

to participate and ask questions,

we are going to be doing this via the QR code.

So if you're participating live,

you will find the QR code in your program,

or if you're online, it will be on your screen, okay?

I hope you've been able to enjoy

the informative sessions earlier today,

and that you will find the session,

"Pain, Pleasure, and the Addictive Chase for Dopamine"

to be highly educational and insightful.

I am now pleased to introduce you to Dr. Anna Lembke,

who is a Professor of Psychiatry and Behavioral Sciences

at Stanford University School of Medicine,

Chief of the Stanford Addiction

Medicine Dual Diagnosis Clinic,

and the author of the best-selling

"Dopamine Nation: Finding Balance in the Age of Indulgence."

Dr. Lembke is an expert in treating addictions of all kinds.

Today, she will share with us the biology and psychology

of why people become addicted

to certain substances and behaviors,

and the key role that our dopamine levels

play in creating addiction.

Dr. Lembke will also explain how to conduct a dopamine fast

in order to help curb our innate desire to over-indulge,

be it with drugs, alcohol, food, work,

the internet, and the list goes on.

Lastly, she will share how to find contentment

and connectedness by keeping our dopamine in check.

Please help me welcome Dr. Lembke.

(audience applauding)

- Well, thank you, everybody. I'm so honored to be here.

I wanna thank the organizing committee for putting on

such a great event against all kinds of odds,

and I'm thrilled to see so many people here in person today.

So what I'd like to do in the time that I have

is first talk about how our brains have evolved

over millions of years to process pleasure and pain,

and how those ancient neuro-circuits are mismatched

for our modern ecosystem, and what the result is.

And then finally,

how we can apply our understanding of the neuroscience

to our modern lives to increase our ability

to flourish in our dopamine overloaded world.

So let's start out first by just talking about

some of the most exciting discoveries in neuroscience

in the last 50 to 100 years.

And the first is that there is a dedicated circuit

in the brain specifically for pleasure,

motivation, and reward.

And you can see it represented here on the screen

by the ventral tegmental area and the nucleus accumbens,

where neurons release dopamine,

our pleasure neurotransmitter,

in communication with the prefrontal cortex.

The prefrontal cortex is that large gray matter area

right behind our foreheads,

which is so central to delayed gratification,

future planning, and all kinds of things

that help us put the breaks on dopamine.

For those of you who may not be

familiar with some of this terminology,

neurotransmitters are essentially those molecules

that allow our neurons to communicate one with the other.

So we have pre-synaptic neurons,

and we have post-synaptic neurons,

and between them is a gap called the synapse.

And neurotransmitters are the molecules

that bridge that space between neurons

to allow for fine-tuned communication.

One way to think of that is to imagine

that the pre-synaptic neuron is the pitcher,

the post-synaptic neuron is the catcher,

and dopamine is the ball

that the pitcher throws to the catcher.

Dopamine is the neurotransmitter

that is most intimately associated with the experience

of pleasure, reward, and motivation.

Now, it's not the only neurotransmitter

involved in those processes,

but it's probably the final common pathway

for all reinforcing drugs and behaviors.

And a wealth of animal studies over the past 50 to 75 years

has shown that different types of drugs increase dopamine

above baseline by different amounts.

And we do believe that the more dopamine that's released

in this brain's reward pathway

and the faster that it's released,

the more addictive is the substance or behavior.

And you can see here a summary slide of what happens

in rodents when they're exposed to certain types

of drugs or behaviors to their dopamine levels.

So a really important point here is that dopamine is always

being fired in our brains at a tonic baseline level.

So what the brain is looking for is changes

in dopamine firing around that tonic baseline level.

And when we have an increase in dopamine firing,

that is highly reinforcing, and that tells us to approach.

And when we have dopamine firing

that goes below those baseline levels,

that is dysphoric or unpleasant, that tells us to do

something to change our circumstance to get more dopamine.

Now, a concept that is not reflected in this slide,

but I think is really important to consider

is the concept of "drug of choice."

And what that means is that different people

will have different amounts of dopamine

released in response to different drugs.

So for example, what may release

a lot of dopamine in my brain

may not release as much in your brain, and vice versa.

And that becomes really relevant

for understanding the world that we live in now,

because not only do we have more and more

potent forms of traditional drugs,

but we also have new drugs that never existed before,

and that means that the susceptible population

on the planet earth for the problem of addiction

will grow, has grown, is growing.

The example that I talk about in my book

is my own addiction to romance novels.

(audience laughing)

I had long thought that I was immune

to the problem of addiction.

My father was a high-functioning alcoholic,

but I thought somehow though those genes skipped me.

But somewhere along in the middle of my life,

I discovered the "Twilight" saga.

(audience laughing)

For those of you who don't know,

that's a vampire romance novel written for teenagers,

and it absolutely transported me.

I read the whole series four times through,

then a friend recommended to me that I get a Kindle.

Getting that Kindle was crucial from transitioning me

from recreational romance reading

to addictive romance reading. (audience laughing)

All of a sudden, with the Kindle,

I had easy, instantaneous access to highly reinforcing books

that I could now get for cheaper and cheaper amounts.

I could get them even for free.

Amazon, like any good drug dealer,

knows the value of a free sample. (audience laughing)

And over time, I indeed found myself

spending more and more time reading,

wanting to escape into that fantasy life.

And here's a really important piece.

Over time, I developed tolerance to my drug.

What does that mean?

That means I needed more of my drug

and more potent versions of my drug to get the same effect.

So I progressed to tame vampire romance novels

written for teenagers to frank erotica

like "50 Shades of Grey."

And I would say that my bottom was when I found myself, at 2:00 in the morning

and wondering to myself, "what on earth am I doing here?"

(audience laughing)

So we laugh and we make light of it,

but indeed, it did impact my life.

And the definition of addiction

is the continued compulsive use of a substance or behavior,

despite harm to self and/or others.

And of course, I would never want to trivialize severe,

life-threatening addiction by comparing my experience

to that of people who are suffering

from terrible and life-threatening addictions.

But I will say that even

as an addiction medicine specialist,

I think that I was teetering over

into harmful, compulsive overuse.

I was not getting enough sleep.

I was starting to ignore my kids.

I certainly had begun to ignore my husband.

I was going to parties with a romance novel in my pocket

and actually escaping to rooms

to read instead of socializing,

and even bringing romance novels to work

and reading between patients, because I found then

that my real life experience began to lose salience.

And this is a really key piece

of the trajectory of addiction that our focus narrows,

that more modest rewards become less interesting to us,

that things that used to be really interesting and rewarding

get leached of their salience, and the only thing

that makes us feel good is our drug of choice.

And I wanna talk a little bit about

what's happening in the brain when that occurs.

I will also add that dopamine

is important for movement, right?

We know that Parkinson's Disease is a disease characterized

by a depletion of dopamine in the substantia nigra,

which affects movement, and it's no coincidence

that the same neurotransmitter that's important to movement

is also important to pleasure, reward, and motivation.

Because for most of human existence,

we have had to get up and go work to get our reward.

And again, that is no longer true.

So to understand how our brains process pleasure and pain

based on really exciting neuroscience

that we've discovered in the last 75 years,

imagine that in that part of the brain

that has that reward circuit, there's a balance,

kind of like a teeter totter in a kid's playground.

When that balance tips to one side, we experience pleasure,

and when it tips to the other, we experience pain.

But there are certain rules governing this balance,

and one of the most important rules

is that the balance wants to remain level.

It doesn't wanna be tilted very long

to the side of pleasure or pain,

and our brains will work very hard to restore

a level balance after any deviation from neutrality.

That means when I read a romance novel or eat chocolate

or watch "American Idol" YouTube videos,

I get the release of dopamine in my brain's reward circuit,

and my balance tilts to the side of pleasure.

But no sooner has that happened

than my brain begins the work

of down-regulating my own dopamine transmission,

down-regulating my own dopamine receptors

to bring me level again.

And I like to imagine that as these little

neuro-adaptation gremlins hopping on the pain side

of the balance to bring it level again.

But here's the thing about those gremlins.

They like it on the balance, so they don't get off

as soon as the balance is level.

They stay on until the balance is tilted

an equal and opposite amount to the side of pain.

That's the come-down, the after effect,

that moment when I reach the climax of the romance novel,

put it down, and immediately want

to start reading another one.

If I wait long enough,

those gremlins hop off, and balance is restored.

But if I continue to bombard my reward pathway

with highly reinforcing drugs and behaviors,

I accumulate more and more gremlins

on the side of the balance. What does this mean?

Now I need more of my drug

to restore homeostasis or to "get high."

I need more potent forms of my drug.

I need more variety in my drug.

And if I continue in this pursuit,

I eventually end up with gremlins camped out

on the pain side of my balance. This is the addicted brain.

What's happened here is I've changed my hedonic set point.

Hedonic is joy.

In my pursuit of pleasure, I have essentially

decreased my ability to experience pleasure

and increased my baseline state of pain.

Now I'm walking around with the balance chronically tilted

to the side of pain, which means what?

It means I need to use my drug not to get high,

but just to level the balance and feel normal.

And when I'm not using,

I'm experiencing the universal symptoms of withdrawal

from any addictive substance, which are anxiety,

irritability, insomnia, depression,

and intrusive thoughts of wanting to use.

This is a very famous study by Nora Volkow,

the Head of NIDA, and her team looking at

dopamine transmission levels in healthy controls,

which are the brains on the left-hand column.

And in these images,

red equals dopamine transmission in the reward pathway.

And as you can see here on the left-hand side,

in these healthy control subjects, there's plenty of red,

plenty of dopamine transmission in the reward pathway.

But if you look at the right-hand column,

that is the brain of individuals who have been using

cocaine, methamphetamine, alcohol, and heroin

for long periods of time in an addictive way.

And you can see that there's very little red

in their dopamine reward pathways.

They are in a dopamine deficit state.

They are walking around with a pleasure-pain balance

tilted to the side of pain, and this lasts for a long time.

These brains are images of these individuals two weeks

after they have stopped using their drug of choice.

Two weeks, they're still walking around

in a dopamine deficit state.

And understanding this was really a revelation for me

to understand why my patients with severe addiction

would relapse even days, weeks, and in some cases,

months after they had stopped using their drug of choice.

It was because they were trying

to restore homeostasis, or a level balance.

Another really important rule about the balance

is that those gremlins, once created, never go away.

In other words, the balance remembers.

So that means that if I'm walking around

and I see somebody, or I'm in a certain place,

or I see a thing that reminds me of my drug use,

that is a huge trigger for me to want to use my drug.

And how does it occur on a brain level?

This is an image from a very fascinating series

of experiments in rats who were trained to know

that if they saw a light, then if they went to a lever

and pressed it, they would get cocaine.

And what you'll see here on the vertical access

is dopamine levels in the rat's brain.

And what the neuroscientist discovered

was not only was there a huge increase in dopamine

after the rat got the cocaine,

but there was a little mini increase in dopamine

just when the rat saw the light.

So I'm gonna walk you through this graph.

You see the rat who sees the light. Look at below the line.

You see that slight increase in dopamine.

That means just being reminded of our drug of choice

gets us a little bit high.

But look at what happens right after the rat sees the light.

Dopamine levels don't go back down to baseline.

They go a little bit below baseline.

Now I'm in a state of craving.

I'm in a dopamine deficit state,

which creates an incredible physiologic motivation

to go and get my drug, to do the work

that it takes to get my drug.

And you'll see here that's exactly what the rat does.

Goes over, presses the button, gets cocaine,

and then has a huge release of dopamine.

So this is really important when we start to think about,

how can we live in a dopamine overloaded world?

Part of it is going to be avoiding our drug,

but another big part is going to be

avoiding triggers for our drug, because the trigger alone

can cause this cycle of intoxication and withdrawal,

which is exactly the vortex that gets people

into the terrible problem of addiction.

What happens if we expect a reward

and we don't get it, as in this case?

You can see the rat sees the light,

gets a little hit of dopamine,

goes into a dopamine deficit state,

does the work to get the cocaine,

presses the lever, no cocaine.

Look at those dopamine levels. Way below baseline.

And that's true from our life experience, right?

When we expect a certain reward,

let's say we go to a family gathering

and we think it's gonna be fun and it's not fun at all,

it's worse than if we had never expected it

to be fun in the first place, right?

And we go home really bummed out and say,

"I'm never going there again."

All of this is really important because dopamine is also

central to the way that we navigate the world

around these types of expectations.

And of course, if expectations are unmet

and we have the disease of addiction,

this can function as a stressor and then can drive us

to want to use a drug of choice again

to get out of that dopamine deficit state.

We talk a lot about how important it is to prevent

the problem of addiction in young people.

And there are neurobiological reasons for that.

And I'm gonna talk about that right here

with these series of brain scans.

What you see is that at about age five, we have more neurons

than we're ever gonna have in the rest of our lives.

Why? Because we're like sponges, right?

We're totally potent, we're plastic, we're ready to learn.

And neurons here are represented by red.

But over the course of our lives,

we prune back the neurons that we don't use.

And until about age 25, we continue that pruning process,

combined with the myelination process,

which is essentially greasing the wheels

of those neuro-circuits that remain

so that by the time we reach age 25,

we're left with the neuro-architecture

that we will use for the rest of our adult lives.

It doesn't mean that there's not the ability to change.

There's still plasticity.

We know that we still generate new neurons

throughout our lives, but much less quickly.

And this is exactly why it's so fundamental

to make sure that we try to protect our young people

from addiction as a maladaptive coping strategy

and we try to give them healthy coping strategies

at this pivotal point in their development

when they're creating the infrastructure,

the neuro-architecture that will last them a lifetime.

I want to just say, obviously,

this pleasure-pain balance is an oversimplification.

Dopamine is not the only neurotransmitter

involved in pleasure, motivation, and reward.

It's a complex constellation

of many different neurotransmitters,

and we can experience pain and pleasure

not just in diametrical opposition, but at the same time.

So for example, spicy food is an example

of experiencing both pleasure and pain at the same time.

Also, we have these narratives or meaning making

that are fundamental to the way

that we perceive pleasure and pain.

This is a very famous study by Henry Knowles Beecher

who studied the experience of pain

in World War II soldiers experiencing

severe injury on the battlefield.

And to his surprise,

he discovered that two-thirds of those soldiers experienced

zero pain in the immediate aftermath of their injuries.

Amazing. How did that happen?

It's because our perception of pain is not just

a bottom-up process of nociceptive injury,

telling our brain what we feel, but also a top-down process

of our brains interpreting what we feel.

And these soldiers made two interpretations

when they got injured on the battlefield.

Number one, "hey, I'm still alive."

And number two, "I'm probably going home."

And with that kind of meaning behind the pain,

the pain was experienced differently.

The corollary of that is this very famous case report

of a construction worker who jumped on a large nail

that went right through his foot.

He experienced excruciating pain,

was taken to the emergency room,

was loaded up on opioids, still didn't get relief.

Finally was given so many opioids

that he became unconscious, at which point,

the emergency medicine doctors slowly removed the nail,

removed the boot, and discovered that the nail

had gone right between his toes.

(audience laughing)

In other words, there was no tissue injury.

(audience laughing)

But his brain looked at his foot,

and he saw an injury, and he experienced real pain.

So it wasn't that he was making up the pain,

but the pain was real, and it originated in his brain.

Okay, now you have sort of a basic primer

on how we process pleasure and pain,

how the gremlins work, how they never disappear,

how we remember, how even cues can trigger the cycle.

Now, I wanna talk about the ways

in which this primitive wiring

is incredibly mismatched for our modern ecosystem.

So this kind of circuitry is perfectly evolved

for a world of scarcity and ever-present danger.

What better design than to have us experience pain

right after we experience pleasure to keep us striving

in a world where basic survival requires us

to walk tens of kilometers to get food,

clothing, shelter, finding a mate.

The problem is that we no longer live in that world.

We now live in a world of overwhelming abundance

where highly reinforcing drugs and behaviors

are at our fingertips, including, as I said,

drugs that didn't even exist before

and very, very potent forms of old-fashioned drugs.

And I would argue to you that the result

is not only that we have increasing rates of addiction,

which is borne out by epidemiology showing that rates

of alcohol use disorder in women

have gone up 80% in the last 30 years,

rates of alcohol use disorder in older people

have gone up 50% in the last 30 years,

and we have many, many more people now struggling

with addictions to things like online pornography,

online shopping, social media, video games, you name it.

But not only are we seeing increased rates of addiction,

we're seeing increased rates

of anxiety, depression, suicide.

And one of the things that I think is incredibly powerful

is if you look at countries around the world

and their rates of depression, anxiety, and suicide,

it is very clear that the richest countries

have the highest rates and the fastest growing rates

of depression, anxiety, and suicide.

What on earth is going on here?

How do we understand that paradox?

I would argue that part of the way to understand the reason

that we're all growing in our misery

is because we're constantly bombarding our reward pathway

with highly reinforcing drugs and behaviors.

We've drugified almost every aspect of our existence,

and the result is that we're walking around

in a dopamine deficit state,

experiencing the universal symptoms of withdrawal,

needing more pleasure to feel any pleasure at all,

and feeling injury at the slightest bit of discomfort.

So what can we do about it?

I hold up people in recovery from severe addictions

as modern day prophets for the rest of us

to how to navigate this dopamine saturated world.

And this is an acronym that I'll just very briefly go over,

but the pivot point of this acronym

is the A that stands for "abstinence."

What I have come to do in my psychiatric practice,

whether the individual is coming in with addiction

or whether they're coming in with anxiety and depression,

the first thing that I will do is screen them

for compulsive over-consumption of highly reinforcing

drugs and behaviors and suggest to them an experiment.

And the experiment goes like this.

"Try giving up this drug of choice for a month." Why?

Because in doing so, you will allow enough time

for the neuro-adaptation gremlins

on the pain side of your balance to hop off

and for homeostasis to be restored.

And only then will you be able to get joy

in more modest rewards, and only then will you be able

to see true cause and effect,

which is that compulsive over-consumption of these drugs

is actually causing your depression and anxiety.

Many of my patients on first pass

are highly skeptical of this hypothesis.

They say, "Dr. Lembke, my video games are the only thing

"that alleviate my depression."

"Dr. Lembke, smoking pot is the only thing

"that works for my anxiety."

And what I say is, "I hear you that in the moment,

"it feels like you are self-medicating

"your psychiatric problem, but I would posit to you

"that what you're really doing is just temporarily restoring

"a level balance while you're accumulating more gremlins

"on the pain side of the balance."

Of course, I would never recommend this intervention

for someone who is at risk for life-threatening withdrawal

from alcohol, benzos, or opioids.

I would not recommend this intervention in someone

who had repeatedly tried to stop

on their own and was unable to.

Those individuals need a higher level

of care and more support.

But for the vast majority of the patients

that we see in our clinic, this first pass intervention

can be not only instructive, but highly healing.

So how do we get them there?

The first pass is just to gather data.

This is where we ask patients to tell us,

"what are you using, how much, and how often?"

And the simple act of putting into words what we are doing

in terms of our consumption can have a revelatory impact

on our understanding of what we're doing.

Because as long as it stays in the dark recesses

of our minds, we can minimize it,

and we don't have to look at it.

But when we tell another human being,

it becomes real in a way that it otherwise cannot.

I ask then, "patients,

"what's your objective for using? why do you use?"

And again, this is because many times people will endorse

they use for one of two reasons.

To have fun or to solve a problem.

But as they get into the addictive cycle,

what happens is that their initial reason for use

gets very far away from their original reason for use.

But nonetheless, important for us to understand

what their rationalization is.

Then I ask patients about problems.

"What are the problems you note with use?"

And sometimes with young people,

the only problem they will endorse is that their parents

aren't happy with their use, but that's enough

if they have an alliance with their parents

and they wanna make that better.

Then I recommend this four weeks of abstinence.

Or if you can't do four weeks, do two weeks.

If you can't do two weeks, do a single day,

especially when it comes to digital drugs.

Put that phone away for 24 hours.

But in general, the data, however limited,

shows that it takes, on average, four weeks of abstinence

in order to reset brain reward pathways

and be able to experience pleasure in more modest rewards.

If patients don't do the four weeks

once they're already addicted,

all they're experiencing is withdrawal, right?

Remember, the balance, if you take away the pleasure weight,

those gremlins weighted down to the side of pain.

And in those first two weeks, patients are in withdrawal.

So I warn them, "you're going to feel worse

"before you feel better.

"You're going to experience the universal symptoms

"of withdrawal, anxiety, irritability, insomnia, dysphoria.

"If you can just get your way through that,

"you will eventually feel better in weeks three and four."

And for about 80% of my patients,

which is consistent with the scientific literature,

they do feel better at four weeks.

For those who don't feel better,

that's really important data, right?

That tells me, okay, your compulsive overuse

isn't the primary driver of your anxiety,

your depression, your psychosis, whatever it is.

I always talk about mindfulness. What is mindfulness?

It's a word we throw around a lot.

Mindfulness is essentially the ability to observe

our thoughts and feelings without judgment

and without reaching for our drug of choice

to get out of that space of discomfort.

So doing this experiment is a really wonderful opportunity

to learn and practice mindfulness.

So it's important for patients

to understand what that means and to realize

that even intense psychological discomfort is time limited.

Tincture of time alone will often heal this process.

It can pass over us like a wave.

And if we can separate ourselves from our thoughts

and emotions and watch ourselves go through the experience,

then we know that it's time limited.

Insight is the point that when we get away

from tasting dopamine, we can see true cause and effect.

And often I will have patients come in and say,

"Dr. Lembke, I really thought that this cannabis

"was treating my anxiety.

"It's only after I stopped it for a month

"that I realized that the cannabis

"was actually driving my anxiety,"

or the video games, or pornography.

Behavioral addictions are addictions

that don't involve a drug.

What do I do for pornography?

I say, "no watching pornography, but also no orgasms

"with yourself or anybody else for a month," right?

As a way to, again, reset reward pathways.

And resetting reward pathways is key to be able to have

the cognitive and emotional strength to do what's next,

which is decide next steps.

"Am I gonna go back to using this drug,

"or am I gonna continue to abstain?

"And either way, how am I gonna do that?"

And then we talk about self-binding strategies.

And what do I mean by that?

Self-binding strategies are barriers,

both literal and metacognitive, that we can put in place

to put the breaks on desire.

And they are absolutely fundamental in a world

in which we're being constantly tempted to indulge.

Self-binding means things like

not keeping your drug in your house,

or not keeping your drug in your room,

or making sure, if you're gonna use in moderation,

you only use on special occasions,

and then don't populate your calendar

with a special occasion every night.

(audience laughing)

I have a young man addicted to video games,

and he came up with a bunch

of great self-binding strategies.

One of them that was that he was gonna have

one laptop for video games and one laptop for schoolwork.

And that way, he had a state-dependent learning

that he didn't mix the two.

He decided there were certain video games

he couldn't play at all, like "League of Legends,"

because once he started, he couldn't stop.

He committed to playing only two hours a day,

only two days a week.

So he used time as a self-limiting strategy.

And he committed to playing only with friends,

never with strangers, and thereby made his recreational use

of video games something could extend into positive use.

Finally, in the last minute,

I wanna talk about one other strategy,

which is very counterintuitive and paradoxical,

but this really works. And it gets back to the balance.

It turns out that those gremlins are agnostic

to whatever the initial stimulus is.

So if we press on the pleasure side

by ingesting intoxicants in any form,

those gremlins will hop on the pain side

to try to bring us level again, tilting us to pain,

and then hopefully back to homeostasis.

But if we press intentionally

on the pain side in mild to moderate doses, guess what?

Those gremlins hop on the pleasure side.

And with iterative repetition,

we'll eventually reset our pleasure-pain balance

to the side of pleasure. This is the science of hormesis.

Hormesis is Greek for "to set in motion,"

and what we're essentially doing there is using

mild to moderate noxious stimuli to trigger

our body's own healing mechanisms by up-regulating dopamine

and other feel-good hormones and neurotransmitters

in response to these minor toxins or injuries.

So when patients are trying to abstain for those 30 days

and struggling in the moment, a lot of times we think,

"well, if you're uncomfortable,

"do something to make yourself comfortable."

If you're trying to quit eating sugar,

go binge on Netflix instead.

But what I say to my patients

is there's a big risk of cross-addiction.

If you give up one drug and replace it with another,

you may get addicted to that other drug.

But how about instead of, when you're feeling craving,

reaching for another drug, do something that's harder

or more uncomfortable or more painful

than the pain that you're feeling in the moment,

like exercising, like an ice-cold water bath,

like making any effortful engagement that forces you

to press a little bit on the pain side of the balance.

Now, can people get addicted to pain? Absolutely.

Have I seen people addicted to exercise? Yes.

Have I seen people kind of getting addicted

to ice-cold water baths? Absolutely.

Do I see people cutting on themselves,

which releases endorphins and get addicted to that process?

Yes, I do.

So we're not talking about hitting that pain side

really hard and really fast.

We're talking about mild to moderate

adaptive forms of dopamine.

In other words, we're talking about

paying for our dopamine up front so that we don't have

to suffer from the dopamine deficit state

that comes from paying for our dopamine after.

I hope this has given you some practical tools

for how to survive in a dopamine overloaded world.

Thank you. (audience applauding)

- Thank you. What an enlightening talk.

Again, if you would like to pose questions to Dr. Lembke,

please do via the QR code that's found

in your program or on the screen, if you're online.

I see that we already have a few questions.

And so first questions we have from the audience is,

"is everybody susceptible to the dopamine high,

"or are some more susceptible than others?"

- Some are more susceptible than others.

The risks of addiction can be broadly categorized

into nature, nurture, and neighborhood.

When we talk about nature, we talk about the inherited risk,

which is about 50 to 60% of the risk of getting addiction

based on family studies of people with alcohol use disorder.

So we don't really know it for other drugs,

but if you have a biological parent

or grandparent who is addicted to alcohol,

you are at increased risk of developing

an alcohol use disorder yourself,

even if you're raised outside of that alcoholic home.

Also in terms of nature,

if you have a co-occurring mental illness,

you are at increased risk of developing an addiction.

In terms of the nurture piece, we know that children

who are raised in an environment where parents

explicitly or implicitly condone substance use,

those individuals are at increased risk,

whereas being a helicopter parent

and knowing where your kid is

and what they're doing decreases the risk.

But I just wanna say, I have seen children

from absolutely perfect, wonderful families get addicted,

and I've seen people from really traumatic environments

who never get addicted. So this is never a one-to-one.

That last bucket of risk

is something that we seldom talk about,

and it has to do with neighborhood or environmental context.

We know that poverty increases the risk,

unemployment increases the risk,

but here's one we never talk about. Access.

Simple access to a drug increases our risk

of trying that drug and getting addicted to that drug.

And one of the big points I'm trying to push home

is that we are living in an addictogenic world.

The increased supply and access

to all kinds of reinforcing drugs and behaviors

has really increased the vulnerability profile

for all humans living in rich nations.

The most vulnerable among us are probably

poor people living rich nations,

because they have more disposable income

to more cheap sources of dopamine

without having equal access before the law to healthy forms

of dopamine that come from things like being in nature.

- Thank you. Second question.

"Is meditation effective in retraining dopamine regulation?"

- So meditation is something

that requires effortful engagement, and it has been shown

to increase dopamine levels, and I would consider it.

Although we don't think

of meditation as painful, it is effortful.

It can be painful, especially as we experience

a flooding of thoughts and emotions that we're forced

to sit with and not run away from.

And so in that sense, meditation is a potentially

healthy and adaptive source of dopamine,

as is things like prayer or other mind-body work.

- Great. Thank you.

"We all have smartphones. Our kids have smartphones.

"What can we do to curb our addiction to these devices?"

- I really recommend a 24-hour dopamine fast

from all digital devices.

If you haven't tried it, I urge you to go out and try it,

do it together with your partner,

do it together as a family.

And as you do it, make sure that you know what to expect,

which is that in the first part of that dopamine fast,

your pleasure-pain balance will tilt hard

to the side of pain, and you will experience that

as anxiety, irritability, fear of missing out,

fear of an emergency that you need

to be called on to fix, right?

That's the kind of parental piece of it.

"Well, I have to be available

"in case some disaster happens."

But as you go through the course of that dopamine fast,

notice how those thoughts and feelings abate.

Notice that the amount of mental real estate

being occupied by your phone starts to diminish

and you experience a kind of freeing

and a kind of recognition that you don't have to be

tied to these devices in the same way.

I also really recommend that if you notice that your child

is having problematic use that you discuss with that child,

especially a younger child, taking their device away

for a period of time and having the return of that device

be contingent on other types of behaviors.

I've worked with a lot of families. It's so hard to do this.

I've done it in my own family with our younger child

because he was on his phone during class,

failing his classes.

It's so hard to take that phone away, right?

They say, "everybody has a phone, I'll be cut off."

You explain why you're doing it.

You note that your child goes through

all of those horrific temper tantrums at first.

And then what I see in families and in children

is over the course of that month,

kids start to return to who they used to be.

One of the most amazing things

is how they retain their ethical compass.

They begin to care about the people

that they live with again, to notice jobs around the house

that need doing without our having to ask.

So I really urge families

to either do it together as a family,

or do it for your child who cannot help themselves,

and see what the difference is.

And the key there is once your child sees

how much better they feel and better they function

free of their device, then they're motivated

to use their device in a different way.

You no longer have to berate them and convince them of it.

- Great. It'd be great to try that. (laughs)

Maybe tomorrow, before Monday comes.

"Screens are easy babysitters these days.

"Has any research been done on screen addiction

"for children under five?"

- There's lots of research on screen addiction now.

A big problem is how exactly to quantify that,

or assess for it, or diagnose it.

Broadly speaking, again,

addiction is the continued compulsive use

of a substance or a behavior,

despite harm to self and/or others.

What I can tell you is that the early prophecy

of giving a child, a very young child,

a screen in order to make them a baby Einstein

is not scientifically validated.

And in fact, what's probably true is that

the younger we expose our kids to screens,

the harder it is going to be to have them develop

other healthier adaptive coping skills later in life.

So I really urge parents,

while you still have control over your kids,

minimize their screen time and make sure

any screen time that they have is supervised

so you know what the content is.

Do not give your unsupervised child

unlimited access to the internet.

And then when you do finally

entrust your child with their own device,

make sure you talk about digital etiquette.

Make sure you talk about the harms and risks

of addiction to these digital drugs.

- Great. Thank you.

"Can you recommend resources for parents to share

"with adolescents to explain the pain-pleasure phenomenon?

"As a parent of a gamer,

"we are not having luck explaining it to him."

- Well, I mean, at the risk of self-promoting,

I have written a book about this.

(audience laughing)

So you might read the book first

to see if it's appropriate for your younger child.

I do talk about a lot of different addictions in the book,

including pornography addiction,

but there's also a lot of good material online.

YouTube videos, I'm suggesting YouTube videos.

But there are some very good videos

talking about what happens in the brain

as we go through the process of addiction.

And I can tell you that a lot of people come to me,

and they're sort of skeptical.

"Is sex addiction real?" "Is video game addiction real?"

I can tell you in the last 20 years of practice,

I'm seeing growing numbers of people

addicted to these digital drugs, and it is very real.

The natural history of their addiction is exactly the same

as addiction to drugs and alcohol.

They increase their use over time.

They need more of the drug, more potent forms of the drug.

It starts to affect their mood, their motivation.

They become suicidal, despondent, incredible shame.

And then when they take...

Get away from that drug and abstain for long enough

to get their prefrontal cortex back online

and to reassert homeostasis, they feel so much better.

- Yeah.

"Has nicotine addiction been proven to be

"a physical dependency, or are smoking and vaping

"providing more of a dopamine trigger?"

- I think this question is,

is the nicotine itself addictive

versus the delivery mechanism? Nicotine is a stimulant.

It certainly is addictive,

but it's also been looked at as a possible agent

to help people with depression.

So at lower doses, nicotine itself may not

actually be that harmful, but it's the delivery mechanism

through the vape and through the cigarette

that makes it so incredibly harmful,

not just because of the lung health harm

from the delivery mechanism, but also because the levels

of nicotine achieved, especially through vaping,

are so incredibly high that any potential

therapeutic benefit of nicotine

is superseded by the nicotine itself.

And let me just say that nicotine is highly addictive,

and the withdrawal phase is very, very quick

many, many times through the course of a day.

People get intoxicated, go into withdrawal,

need another cigarette, get intoxicated, go into withdrawal.

And of course, when we think about nicotine intoxication,

we don't really think about that

as the way we do with intoxicants like alcohol.

But remember, what you get

is a little bit of a stimulant boost,

and then you're very quickly in withdrawal,

and then your entire being is hijacked

by the preoccupation with the next cigarette.

- Great. Thank you.

Time's gone by so quick. This will be our last question.

"What would you suggest if we suspect a friend

"or a family member is suffering from a dangerous addiction?

"What might be the conversation starter we could use?"

- The first thing that I recommend

is that you don't talk to your loved one

when you yourself are emotionally dysregulated.

So for example, don't do what I do,

which is scream at my 14-year-old

about getting off of Minecraft after I've been asking him

to get off for two hours and he's still on.

And I'm feeling like a bad parent,

I'm thinking he's a bad kid, I'm worried about his future,

I'm worried about his present.

Don't do that. Don't make that mistake.

Instead, wait till a time when you yourself

are emotionally regulated, you've thought it through.

If you're co-parenting with a partner, or it's a spouse,

or you can enlist a child,

do it together without feeling like it's an ambush,

and sit down and just reflect back

to your loved one what you are seeing.

This is a little bit like the D of the dopamine acronym,

the "data" part, where we try to reflect back to people

what we see are the negative impacts of their use,

as well as the raw data of quantity and frequency,

which they literally cannot see,

because they are chasing dopamine,

and it's hidden to their conscious awareness.

And so don't try to come up

with solutions necessarily in that first engagement.

You can express your sadness,

but really keep it kind of even keel.

"This is what I'm seeing.

"I really love you. I really care about you.

"And I'm worried about you because this is what I'm seeing."

And then don't expect immediate results.

A lot of times when I'm working with our trainees

who come and spend an extra year to learn about

how to treat addiction, God bless them, they'll say,

"Dr. Lembke, I don't feel like I helped this person."

And I'll say to them, "you never know."

I've had patients I thought I didn't help who went out,

didn't come back, and then came back two years later

and said, "Dr. Lembke, when you said that to me,

"I thought about it a year later,

"and I decided that I was gonna come back and get help."

So when we say what we need to say to our loved one,

say it and let it rest. Say it and let it rest.

Let it marinate and see if they will

then do something with that.

I will also say that contingency management works.

There's an enormous amount of data

around contingency management. What is that?

That's the use of rewards and punishments

in moderate doses to shape behavior.

So working with your family around contingency management

can be very effective.

And what that looks like is, "you can get your phone back

"or your video game console back once we see

"this type of behavior for this period of time."

- Great.

Let's thank Dr. Lembke for sharing all these wonderful tips.

(audience applauding)

(bright music)