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A

Welcome to the Huberman Lab podcast, where we discuss science and science based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. Today, I have the pleasure of introducing Doctor Anna Lemke. Doctor Lemke is a psychiatrist and the chief of the Addiction medicine dual diagnosis clinic at Stanford University School of Medicine. She's a psychiatrist who treats patients struggling with addiction. She has successfully treated patients dealing with drug addiction, alcohol addiction, and behavioral addictions such as gambling and sex addiction, as well as other types of addiction. In fact, during our discussion, I learned that there are a huge range of behaviors and substances to which people can become addicted to, and that there is a common biological underpinning of all those addictions. I also learned that there is a common path to the treatment and recovery from essentially all addictions. Doctor Lembke explained that to me and explained how to think about and conceptualize our own addictions, as well as the addictions of other people who are struggling to get treatment, move through treatment, and stay sober from their addictions in addition to treating patients. Doctor Lembke is an author and was featured in the 2020 Netflix documentary the Social Dilemma. I'm excited to tell you that she has a new book coming out called Dopamine finding balance in the age of Indulgence. The book comes out August 24 and is an absolutely fascinating read into addiction and ways to treat various types of addiction. I've read the book cover to cover, and all I'll tell you is that at the very first chapter and throughout, you are going to be absolutely blown away. The stories about her patients are extremely engaging. It brings forward the real struggle of addiction and the incredible, I think it's fair to say, heroic battles that people fight in order to get through addictions of various kinds. And all of that is woven through with story, with science, in ways that make it very accessible to anyone. Whether or not you have a science background or not, I can't recommend it highly enough. So again, the book is dopamine finding balance in the age of indulgence. It comes out August 24 of this year, 2021, and you can pre order that book by going to Amazon. We will provide a link to that in the show. Caption before we begin, I just want to mention that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero cost to consumer information about science and science related tools to the general public. In keeping with that theme, I'd like to thank the sponsors of today's podcast. Our first sponsor is Athletic Greenshouse. Athletic Greens is an all in one vitamin mineral probiotic drink. I've been taking athletic greens since 2012, so I'm delighted that they're sponsoring the podcast. The reason I started taking athletic greens, and the reason I still take athletic greens once or twice a day is that it helps me cover all of my basic nutritional needs. It makes up for any deficiencies that I might have. In addition, it has probiotics, which are vital for microbiome health. I've done a couple of episodes now on the so called gut microbiome and the ways in which the microbiome interacts with your immune system, with your brain to regulate mood, and essentially with every biological system relevant to health throughout your brain and body. With athletic greens, I get the vitamins I need, the minerals I need, and the probiotics to support my microbiome. If you'd like to try athletic greens, you can go to athleticgreens.com huberman and claim a special offer. They'll give you five free travel packs plus a year's supply of vitamin D three, k two there are a ton of data now showing that vitamin d three is essential for various aspects of our brain and body health. Even if we're getting a lot of sunshine, many of us are still deficient in vitamin d three and k two is also important because it regulates things like cardiovascular function, calcium in the body, and so on. Again, go to athleticgreens.com huberman to claim the special offer of the five free travel packs and the year supply of vitamin D three k two. Today's episode is also brought to us by element. Element is an electrolyte drink that has everything you need and nothing you don't. That means the exact ratios of electrolytes are an element and those are sodium, magnesium and potassium. But it has no sugar. I've talked many times before on this podcast about the key role of hydration and electrolytes for nerve cell function, neuron function, as well as the function of all the cells and all the tissues and organ systems of the body. If we have sodium, magnesium and potassium present in the proper ratios, all of those cells function properly and all our bodily systems can be optimized. If the electrolytes are not present and if hydration is low, we simply can't think as well as we would otherwise. Our mood is off, hormone systems go off. Our ability to get into physical action, to engage in endurance and strength and all sorts of other things is diminished. So with element, you can make sure that you're staying on top of your hydration and that you're getting the proper ratios of electrolytes. If you'd like to try element, you can go to drinkelement. That's lmnt.com huberman and you'll get a free element sample pack with your purchase. They're all delicious. So again, if you want to try element, you can go to elementlmnt.com Huberman todays episode is also brought to us by waking up. Waking up is a meditation app that includes hundreds of meditation programs, mindfulness trainings, yoga, Nidra sessions, and NSDR non sleep deep rest protocols. I started using the waking up app a few years ago because even though ive been doing regular meditations since my teens and I started doing yoga Nidra about a decade ago, my dad mentioned to me that he had found an app, turned out to be the waking up app, which could teach you meditations of different durations, and that had a lot of different types of meditations to place the brain and body into different states and that he liked it very much. So I gave the waking up app a try, and I too found it to be extremely useful because sometimes I only have a few minutes to meditate, other times I have longer to meditate. And indeed, I love the fact that I can explore different types of meditation to bring about different levels of understanding about consciousness, but also to place my brain and body into lots of different kinds of states, depending on which meditation I do. I also love that the waking up app has lots of different types of yoga Nidra sessions. For those of you who don't know, yoga Nidra is a process of lying very still but keeping an active mind. It's very different than most meditations. And there's excellent scientific data to show that yoga nidra and something similar to it called non sleep deep rest, or NSDR, can greatly restore levels of cognitive and physical energy, even with just a short ten minute session. If you'd like to try the waking up app, you can go to wakingup.com huberman and access a free 30 day trial. Again, that's wakingup.com huberman to access a free 30 day trial. And now for my discussion with doctor Anna Lembke. All right, great to have you here.

B

Thank you for having me. I'm excited to be here.

A

Yeah, I have a lot of questions for you. I I and many listeners of this podcast are obsessed with dopamine. And what is dopamine? How does it work? We all hear that dopamine is this molecule associated with pleasure. I think the, uh, the term dopamine hits like, I'm getting a dopamine hit from this, from Instagram or from likes, or from praise or from whatever is now, um, commonly heard. What is dopamine? And what are maybe some things about dopamine that most people don't know? And probably that I don't know either.

B

So dopamine is a neurotransmitter, and neurotransmitters are those molecules that bridge the gap between two neurons. So they essentially allow one neuron, the presynaptic neuron, to communicate with the postsynaptic neuron. Dopamine is intimately associated with the experience of reward, but also with movement, which I think is really interesting because movement and reward are linked, right. If you think about, you know, early humans, you had to move in order to go seek out the water or the meat or whatever it was. And even in the most primitive organisms, dopamine is released when food is sensed in the environment. For example, C. Elegans, a very primitive wormhood. So dopamine is this really powerful, important molecule in the brain that helps us experience pleasure. It's not the only neurotransmitter involved in pleasure, but it's a really, really important one. And if you want to think about something that most people don't know about, dopamine, which I think is really interesting, is that we are always releasing dopamine at a kind of tonic baseline rate, and it's really the deviation from that baseline, rather than, like, hits of dopamine in a vacuum, that make a difference. So when we experience pleasure, our dopamine release goes above baseline, and likewise, dopamine can go below that tonic baseline, and then we experience a kind of pain.

A

Interesting. So is it fair to say that one's baseline levels of dopamine, how frequently we are releasing dopamine in the absence of some, I don't know, drug or food or experience just sitting being. Is that associated with how happy somebody is, their kind of baseline of happiness or level of depression?

B

There is evidence that shows that people who are depressed may indeed have lower tonic levels of dopamine. So that's a really reasonable thought, and there's some evidence to suggest that that may be true. The other thing that we know, and this is, you know, really kind of what. What the book is about, is that if we expose ourselves chronically to substances or behaviors that repeatedly release large amounts of dopamine in our brain's reward pathway, that we can change our tonic baseline and actually lower it over time as our brain tries to compensate for all of that dopamine, which is more really, than we were designed to, to experience.

A

Interesting. And is it the case that our baseline levels of dopamine are set by our genetics, by our heredity?

B

Well, I think if you think about sort of the early stages of development in infancy, certainly that is true. You're kind of born with probably whatever is your baseline level. But obviously your experiences can have a huge impact on where youre a, your dopamine level ultimately settles out.

A

So if somebody's disposition is one of constant excitement and anticipation or easily excited, I think about the kind of people where you say, do you want to check out this new place for tacos? They're like, yeah, that'd be great. And other people are a little more cynical, harder to budge, like my bulldog Costello, very, very stable, low levels of dopamine with big inflections, in his case. Do you think that's set in terms of our parents? And obviously nature and nurture interact, but is dopamine at the core of our temperament?

B

I don't really think we know the answer to that, but I will say that people are definitely born with different temperaments. And those temperaments do affect their ability to experience joy. And we've known that for a long time. And we describe that in many different ways. One of the ways that we describe that in the modern era is to use psychiatric nomenclature, like this person has a dysthymic temperament or this person has chronic major depressive disorder. In terms of looking specifically at who's vulnerable to addiction, that's an interesting sort of mixed bag, because when you look at the research on risk factors for addiction, so what kind of temperament of a person makes them more vulnerable to addiction? You see some interesting findings first, you see that people who are more impulsive are more vulnerable to addiction. So what is impulsivity? That means having difficulty putting space between the thought or desire to do something and actually doing it. And people who have difficulty putting a space there who are, who have a thought to do something and just do it impulsively, are people who are more vulnerable to addiction.

A

Interesting in terms of impulsivity, is this something that relates literally to the startle reflex? Like I, for instance, as a lab director, I'm familiar with walking around my lab and when I decide, deciding I'm going to talk to my people, of course, when they knock on my door, it's always like, wait, why am I being bothered right now? Even though I love to talk to them. But I walk around my lab from time to time, and some people I notice, I'll say, do you have a moment? And they'll slowly turn around and say, yeah or no, in some cases. And other people will jump the moment I say their name. They actually have a kind of a heightened startle reflex. Is that related to impulsivity, or is what you're referring to an attempt to withhold behavior? That's very deliberate, under very deliberate conditions.

B

Yeah. So I don't think that that startle reflex is necessarily related to impulsivity. That can be related to anxiety. So people who are high anxiety, people will tend to have more of a startle reflex. Impulsivity is a little bit different. And by the way, impulsivity is not always bad. Right. Impulsivity is that thing where there's not a lot of self editing or worrying about future consequences. You have the idea to do something, and you do it. And, of course, we can imagine many scenarios where that's absolutely wonderful. You know, there can be a sort of, let's say, intimate interactions between people where you wouldn't really want to be super inhibited about it. Right. You would want to be disinhibited and impulsive. I can also imagine, like, sort of fight or flight scenarios, like battle scenarios. Right. Where it would really be good to be impulsive and just go, rah, you.

A

Know, where hesitation can cost, right.

B

Yes, that's right. That's right. But, you know, and I think this brings up a really something that I've come to believe after 25 years of practicing psychiatry, is that what we now conceptualize in our current ecosystem as mental illness are actually traits that in another ecosystem might be very advantageous. They're just not advantageous right now because of the world that we live in. And I think impulsivity is potentially one of those, because we live in this world that's like, you have to constantly be thinking rationally about the consequences of x, y, or z. And it's such a sensory rich environment that we're being bombarded with all these opportunities, these sensory opportunities, and we have to constantly check ourselves. So impulsivity is something that right now can be a difficult trait, but isn't in and of itself a bad thing.

A

I see. Yeah. And I'm beginning to realize it's a fine line between spontaneity and impulsivity. What is pleasure, and how does it work at the biological level? And if it feels right at the psychological level, and if you don't mind painting a picture of sort of the range of things that you have observed in your clinic or in life that people can become addicted to. But just to start off really simply, what is this thing that we call pleasure?

B

Well, I think it's actually really hard to define pleasure in any kind of succinct way, because certainly there is the seeking out of high or a euphoria, or, I think, the kind of experience that most anybody would associate with the word pleasure. Also, the seeking out of those same substances and behaviors is often a way to escape pain. So, for example, when I talk to people with addiction, sometimes their initial foray into using a drug is to get pleasure. But very often it's a way to escape their suffering, whatever their suffering may be. And certainly as people become addicted, even those who initially were seeking out pleasure are ultimately just trying to avoid the pain of withdrawal or the pain of the consequences of their drug use. So I think it's, you know, very hard to actually, you know, define it as this unitary thing. And it's certainly not just getting a high. There are so many ways in which people sort of want to escape, which is not the same thing as sort of this hedonic wanting to feel pleasure.

A

So someone could decide that they want to go out and dance or get up and dance because of the pleasure of dancing. I can imagine that. And maybe it's very difficult for them to stay seated when a particular song comes on, for instance. But seeking what we would call pleasure in order to eliminate pain, that evokes a different picture in my mind, that evokes a picture of somebody that feels lost or depressed or underwhelmed. I definitely want to get into the precise and general description of addiction and what that is. But in a previous conversation we had, you said something that really rung in my mind, which is that many people who become addicted to things, let's call them addicts, have this feeling that normal life isn't interesting enough, that they are seeking a super normal experience, and that the day to day routine balance, which is actually in the title of your book, Dopamine Nation, finding balance in the age of indulgence, that the word balance itself can sometimes be a bit of an aversive term for people. And I'm struck by this idea, and the reason I want to explore it is because so much of what I see online is about generating a lack of balance, about being tilted forward at all times, really leaning into life hard, experiencing life, living a full life. Even the commencement speech given by Steve Jobs on this campus was really about finding passion digging. That's so much in the narrative. Now, maybe you could just tell us a little bit about your experience with this association, if it really exists between people's sense of the normalcy, or maybe even how boring life can be and their tendency to become addicts of some sort.

B

Yeah, well, I mean, I think that life for humans has always been hard, but I think that now it's a harder in unprecedented ways. And I think that the way that life is really hard now is that it actually is really boring. And the reason that it's boring is because all of our survival needs are met. We don't even have to leave our homes to meet every single physical need, as long as you're of a certain level of financial well being, which, frankly, we talk so much about the income gap. And certainly there is this enormous gap between rich and poor, but that gap is smaller than it's ever been in. Like the history of humans. Even the poorest of the poor have more excess income to spend on leisure goods than they ever have before in human history. If you look at leisure time, for example. So people without a high school education have 42% more leisure time than people with a college degree. My point here is that life is hard now in this really weird way, in that we don't really have anything that we have to do. So we're all forced to make stuff up, whether it's being a scientist or being a doctor, or being an Olympic athlete or climbing Mount Everest. And people really vary in their need for friction. And some people need a lot more than others. And if they don't have it, they're really, really unhappy. And I do think that a lot of the people that I see with addiction and other forms of mental illness are people who need more friction. Like they're unhappy, not necessarily because there's something wrong with their brain, but because their brain is not suited to this world.

A

And do you think they have that sense? My brain isn't suited to this world? Or they simply feel a restlessness and they're constantly seeking stimulation?

B

I think that's right, yeah, I think it's not really knowing what's wrong with me? Why am I unhappy? How can I be happier? And of course, as you talk about, what's so pervasive in our narrative now is like, find your passion, find your, you know, whatever it is to save the world. And in a way, that's good because it has people out in the world and seeking. But in a way, it can also be misleading in the sense that I think people aren't entirely aware that the world is a hard place and that life is hard and that we're all kind of making it up. Do you know what I mean?

A

Yeah. Well, there's a book by Cal Newport. I don't know if you know Cal Newport's work, but you guys are very symbiotic in your messages. Hes a professor of computer science at Georgetown. Yes, at Georgetown. And wrote a book some years ago, really ahead of its time called so good they cant ignore you, which is about not meditating or doing much work to try and figure out what ones passion is by thinking, but rather go out and acquire skills and develop a sense of, of passion for something by your experience of hard work and getting better and feedback, a little bit of the growth mindset thing of our colleague Carol Dweck. But he's gone on to write books, deep work, which is all about removing yourself from technology and doing deep work. Yes.

B

Right.

A

And he's been a big proponent of the evils of context switching too often throughout the day for sake of productivity, mostly. His new book is called a World without email. I'm beginning to realize, as I cite off these books and your book, Dopamine Nation, finding balance in the age of indulgence, that maybe the reason why you two don't know about one another is because neither of you are on social media.

B

That's it.

A

Right. And yet you're two of the most productive people that I know, including productive authors. So that's a discussion unto itself. But I find this fascinating. So let's talk about the pleasure, pain, balance and addiction. And I've heard you use this seesaw, or balance scale, um, analogy before, and I think it's a wonderful one, uh, that really, for me, clarified what addiction is, at least at the mechanistic level.

B

Yeah. So to me, one of the most significant findings in neuroscience in the last 75 years is that pleasure and pain are co located, which means the same parts of the brain that process pleasure also process pain. And they work like a balance. So when we feel pleasure, our balance tips one way. When we feel pain, it tips in the opposite direction. And one of the overriding rules governing this balance is that it wants to stay level. So it doesn't want to remain tipped very long to pleasure or to pain. And with any deviation from neutrality, the brain will work very hard to restore a level balance, or what scientists call homeostasis. And the way the brain does that is, with any stimulus to one side, there will be a tip, an equal and opposite amount to the other side.

A

It'S like you have principal laws of physics.

B

Yes. Right, right. So, like, I like to watch YouTube videos. When I watch YouTube videos of American Idol, you know, it tips to the side of pleasure, and then when I stop watching it, I have a comedown. Right. Which is a tip to the equal and opposite amount on the other side. And that's that moment of wanting to watch one more YouTube video. Right.

A

Yeah. And I just want to project there. So this moment of wanting to watch another that is associated with pain, I think is, are we always aware of that happening? Because you just described in a very conscious way.

B

Right.

A

But when I indulge in something I enjoy, I'm usually thinking about just wanting more of that thing. I don't think about the pain, I just think about more.

B

Right. So really excellent point. Because we're mostly not aware of it, and it's also reflected. So it's not something that consciously happens or that we're aware of unless we really begin to pay attention. And when we begin to pay attention, we really can become very aware of it in the moment. Again, it's like a falling away, like that you're on social media and you get a good tweet of something, and then you can't stop yourself because there's this awareness, a latent awareness, that as soon as I disengage from this behavior, I'm going to experience a kind of a pain. Right. A falling away, missing that feeling, a wanting more of it. And of course, one way to combat that is to do it more. Right. And more and more and more. So I think that is really what I want people to tune into and get an awareness around. Because once you tune into it, you can see it a lot. And then when you begin to see it, you have. And if you keep the model of the balance in mind, I think it gives people kind of a way to imagine what they're experiencing on a neurobiological level and understand it. And in that understanding, get some mastery over it, which is really what this is all about. Because ultimately we do need to disengage. Right. We can't live in that space all the time. Right. We have other things we need to do, and there are also serious consequences that come with trying to repeat and continue that experience or that feeling.

A

So if I understand this correctly, when we find something or when something finds us that we enjoy that feels pleasureful, social media, food, sex, gambling, whatever happens to be, we will explore the full range of these. There's some dopamine release when we engage in that behavior. And then what you're telling me is that very quickly.

B

Yes.

A

And beneath my conscious awareness, there's a tilting back of this scale where pleasure is reduced by way of increasing pain.

B

Right.

A

And I've heard you say before that the pain mechanism has some competitive advantages over the pleasure mechanism, such that it doesn't just bring the scale back to level, it actually brings pain higher than pleasure. Could you tell us a little bit more about that?

B

Yeah. Yeah. So what happens again? So the hallmark of any addictive substance or behavior is that it releases a lot of dopamine in our brain's reward pathway. Like. Right. Like, broccoli just doesn't release a lot of dopamine. Just doesn't. Right.

A

I'm trying to imagine. I was about to say maybe, and I stopped myself because, no, broccoli is good. It can be really good. But broccoli is never amazing, right?

B

Broccoli's never amazing.

A

Never like this.

B

Honestly, we can probably find somebody on the planet for whom broccoli is amazing. And of course, if I'm starving, broccoli is amazing.

A

Rich roll. Rich roll is big on plants, and he has a good relationship to plants. Rich, tell us how to make broccoli amazing. If anyone could do it, it'd be rich.

B

But what happens right after I do something that is really pleasurable and releases a lot of dopamine is, again, my brain is going to immediately compensate by down regulating my own dopamine receptors, my own dopamine transmission, to compensate for that. And that's that come down or the hangover, that after effect, that moment of wanting to do it more. Now, if I just wait for that feeling to pass, then my dopamine will reregulate itself and I'll go back to whatever my chronic baseline is. But if I don't wait, and here's really the key, if I keep indulging again and again and again, ultimately I have. I have so much on the pain side, right, that I've essentially reset my brain to what we call like an anhedonic or lacking in joy type of state, which is a dopamine deficit state. So that's really the way in which pain can become the main driver, is because I've indulged so much in these high reward behaviors or substances that my brain has had to compensate by way down regulating my own dopamine such that even when I'm not doing that drug, I'm in a dopamine deficit state, which is akin to a clinical depression. I have anxiety, irritability, insomnia, dysphoria, and a lot of mental preoccupation with using again or getting the drug. And so that's the piece there. There's the single use which easily passes, but it's the chronic use that can then reset, really, our dopamine thresholds, and then nothing is enjoyable. Right. Then everything sort of pales in comparison to this one drug that I want to keep doing.

A

And that one drug could be a person, right? I mean, I. I know people in my life that are still talking about this one relationship, this one person that was just so great, despite all the challenges of that thing, that it's almost like they're addicted to the narrative. Yeah, they were, maybe still are addicted to the person. So it could be to any number of things. Video game, sex, gambling, a person, a narrative to me. And because of the way you describe this mechanism, this pleasure, pain balance, that all speaks to the kind of generalizability of our brain circuitry. And this is something that fascinates me, and I know it fascinates you as well, which is that nature did not evolve 20 different mechanisms for 20 different types of addiction. Just like anxiety is a couple of core sets of hormones and neurotransmitters and pathways, and one person is triggered by social interactions, another person is triggered by spiders, but the underlying response is identical, it sounds like, with addiction as well. There may be some nuance, but that they're sort of a core set of processes. So it doesn't really matter if it's gambling or video games or sex or a narrative about a previous lover or partner or whatever. It's the same addictive process underneath that. Is that correct?

B

Yes, exactly. And that's where this whole idea of cross addiction comes in. So once you've been addicted to a substance, severely addicted, that makes you more vulnerable to addiction, to any substance.

A

And when you say substance does the same, is what you just said also true for behaviors?

B

Yes. So when I do, when I use the word drug, I'm talking about substances and behaviors, really? And I'm talking about behaviors like gambling, sex, porn. Gaming, porn. Absolutely shocking work you've accused me, just.

A

For the record, Anna, doctor Levge has accused me, not accused me, has diagnosed me outside the clinic in a playful way of being work addicted. You're probably right. The first thoughts I have when I wake up are typically about work, certainly within 50 milliseconds or so of waking. And probably the last thoughts I have, I would hope, are not about work. But yeah, I work constantly. I don't. I do other things, but I have to actively turn that off.

B

Yes, that's exactly right. And you're certainly not alone in that. And of course, at Stanford.

A

No, no, no.

B

I mean here in Silicon Valley. Right. It's highly rewarded. Right. So that kind of.

A

That kind of embedded in the culture. Absolutely, yeah. Yeah. And there's this other city, I think it's called New York, where they also work a lot out here, and it's heavily rewarded. I once said, and I'm sure that I'm not the first person to say it, but I was thinking about addiction, and I was thinking about the underlying circuits, and I posted something to social media which said that addiction is a progressive narrowing of the things that bring you pleasure. That was the way that I crystallized the literature in my mind. And then we met, and you, of course, came and gave these amazing lectures in the neuroanatomy course for the medical students, and the rest is history. But I tossed out a kind of mirroring statement for that as well, which was a bit overstepping, I admit, which I said, addiction is a progressive narrowing of the things that bring you pleasure. And dare I say, enlightenment is a progressive expansion of the things that bring you pleasure. Not that anybody knows what enlightenment is, but it was my attempt to take a little bit of a jab at the fact that nobody knows why not. Why wouldn't I throw a neurobiological explanation just to just kind of sample the waters? And people had varying levels of response. But the reason I bring that up is that I would imagine that being able to derive pleasure from many things would be a wonderful attribute. We know people like this that can experience pleasure in little things and in big events, not just the big milestones of life, but also the subtle, as the yogis would say, the subtle ripples of life, if such an ability exists, do you think that that reflects a healthily tuned dopamine system, one that can engage and enjoy but then disengage? Is that what we should be seeking? And to underscore, I know nothing about enlightenment, meditation or any of it, I just. I use these as opportunities to explain.

B

Yeah, so it's a great question. I mean, and I understand the question as, so where. What should we be striving for? Right. Where. Where should we settle out? And, you know, in my book, I really hold out people in recovery from severe addiction as sort of modern day prophets for the rest of us, because I do think that people who have been addicted and then go get into recovery do have a hard won wisdom that we can all benefit from. And the wisdom, I guess, to distill it down. I mean, it's many things, but in terms of dopamine, the wisdom is there are adaptive ways to get your dopamine, and there are less than adaptive ways. And in general, you could describe the adaptive ways as not too potent, so not tipping that balance too hard or too fast to the side of pleasure.

A

So does that mean never allowing myself to be absolutely in complete bliss or does it mean not allowing myself to stay in that state too long?

B

The latter, I think the latter. And then that gets to temperament. So I'm going to get that to a second. So in general, what we want is some kind of flexibility in that balance and the ability to easily reassert homeostasis. We don't want to break our balance, which is possible if we overindulge for enough period of time and end up with a balance tip to the side of pain. This dopamine deficit state we've been talking about. We want a flexible, resilient balance, right? Which can be sensitive to things going on in the environment, which can experience pleasure and approach, which can experience pain and recoil. Right. This is all adaptive and healthy and necessary and good. We would never want a balance that doesn't tilt.

A

Right.

B

That would be a disaster. We wouldn't be human and we wouldn't want that. It would be really, really boring. On the other hand, what people in recovery from addiction talk about is to some extent, having to learn to live with things being a little boring a lot of the time, right? So trying to avoid some of this intensity and thrill seeking and escapism that really is at the core of addictive tendencies.

A

Sorry to interrupt, but when you say boring, can we add stressful and boring?

B

Yes.

A

Because there are days where I'm not. I have to, I'm one of these people, have to remind myself to have fun because I sort of forgot what the term means because I've. I like to think that I experience a lot of pleasure in little things, but I'm pretty hard driving guy. I like goals and big milestones, all that stuff. Anyway, the point being that many days, I'm not bored thinking, oh, there's nothing to do, but I am kind of overwhelmed by the number of things that are really not pleasureful that I have to do. I won't mention what they are. I don't want my colleagues. That's why you don't respond to emails. No, just your emails, not yours. But there's, in any event, so anxiety and boredom can hang out together, right? Am I correct?

B

Oh, for sure. I mean, actually, boredom is highly anxiety provoking.

A

Okay, that's good to know because I think people hear boredom and they think like, oh, there's nothing to do here, right? There's nothing. I feel like we have a ton to do. We just don't really want to do it.

B

Right.

A

As opposed to something that we're excited to do.

B

Right. Okay, so this gets to sort of some of the core things. Also, we were talking about earlier about finding your passion. So I'm going to try to link it all together. But basically boredom. First of all, boredom is a rare experience for modern humans because we're constantly distracting ourselves from the present moment and we have an infinite number of ways to do that. Right? But boredom is really, I think, anh important and necessary experience. But it is scary because when you allow yourself to be bored, let's say you had that list of all the things you hate to do when you actually got them all done. Imagine that. And you got your forthcoming book done, and you did all your interviews.

A

It could happen.

B

Lightning could spike, and you walked your dog and you cleaned your house and you went shopping. Imagine that for a moment you would be sitting in your house and my guess is you would be terrified because, wow, what am I supposed to do now, right? There's nothing I really have to do. And that is really, really scary. That can feel like free fall, and yet that's really an important and good experience to have. And I think that is an experience out of which we can have a lot of creative initiative, but also really consider our priorities and values. Okay, here I am on planet Earth. What the hee haw am I going to do with my life? What do I really care about? How do I really want to spend my time when I'm not distracting myself, you know, in order to spend it? And then this gets back to our conversation a little bit earlier about finding your passion. So I think that one of the big problems now that's very misguided about this idea of finding your passion. It's almost as if people are looking to fit the key into the lock of the thing that was meant for.

A

Them to do, and then everything will feel like a natural progression, right.

B

Will be wonderful.

A

I can attest to the fact that is not how it works in any endeavor, right.

B

And that you'll have all this great success or, you know, but. And here, here's where I really think the answer lies. And I really, really believe this. Stop looking for your passion. And instead, look around right where you are. Stop distracting yourself, look around right where you are and see what needs to be done. So not what do I want to do, but what is the work that needs to be done. And more importantly, it doesn't have to be some grandiose work like, does the garbage need to be taken out? Right? Is there some garbage on your neighbor's lawn that someone threw there that you could actually bend over and pick up and put into the garbage can? Look around you. There is so much work that needs to be done that nobody wants to do that is really, really important. And if we all did that, I really think the world would be a much better place. And this is what people who have severe addiction, who get into recovery realize. They're like, it's not about me and my will and what I'm going to will in my life or in the world. It's about looking around what needs to be done, what is the work that I am called to do in this moment, which also is incredibly freeing because I don't have to search for the perfect thing. There's a lot of burden now on young people that they have to find that perfect thing, and until they found that perfect thing, they're going to be miserable. You don't have to do that. Look at the life you were given. Look at the people around you. Look at the jobs that present themselves to you and do that job simply and honorably, one day at a time, with a kind of humility. I think this is really what, what's so striking to me about the wisdom of people in recovery. There's this incredible humility that comes out of that experience. You feel so broken, so ashamed, but you pick yourself up one day at a time and you build a life that's around. What can I do right in this moment that might benefit another person and thereby benefit me?

A

It's a really important point. And if you're willing, I'd like to actually stay on this issue of passion because I think the dopamine systems, if I understand them correctly, the dopamine systems merge with this work that you're referring to, this immediacy of things calling to us, like taking out the trash, which sounds, frankly, really boring, to be honest. I hate taking out the trash, but I do it because I like a clean home, and I like a home that smells good, or at least doesn't smell bad. So we do these things. And not that we want to offer some larger carrot as a consequence of doing those things, but if I understand correctly, what you're saying is in the act of looking at one's immediate environment, acting on that immediate environment, we cultivate a relationship to these circuits in our brain about action and reward. That, at least to my mind, span the range of small things being rewarding and then lead us to bigger things being rewarding. It's not like all we're going to do is take out trash and tend to house. We eventually will venture out and we, and eventually we'll find careers and work on those. But if I understand correctly, you're talking about getting into a sort of functional or adaptive action step. And it's the action step that these days we tend to overlook because most of our mindset is in things that are truly outside of the, our immediate reality. Do I have that correct?

B

Yeah, that was beautifully said. And I would just add to that, I see a lot of young people who, for example, spend most of their waking hours playing video games. And they come to me and they say, I am anxious and depressed. I'm majoring in computer science. I hate it. I thought I would like it, you know, if I could only find that thing that I was really meant to do, my life would be better. And my first intervention for the many, many people like that, that I see in clinical care is you have it backwards. I don't say it quite like that. You are waiting for that thing to pull you out of the video game world and you're never going to find it as long as you're playing video games. Because video games are so powerfully dopaminergic that you have this distorted sense of really pleasure and pain and you, you will not be able to find that thing that you enjoy. And so of course the intervention is abstain from video games, reset your reward pathways, start with a level balance and what invariably happens, and I've just seen it over 20 years, so many times I've become really a believer in this. All of a sudden it's like, oh, wow, my computer science class is interesting this quarter. It's like, okay, you know, you have a receptivity then to experiencing pleasure and reward in a way you just don't have when you're bombarding your reward pathways with these high dopamine drugs.

A

Very interesting. And just to underscore this notion that tending to the immediate things can lead to super performance, I may have mentioned it earlier this episode, but if I didn't, I'll mention now, which is I have the great privilege of having some close friends that were in the SEAL teams and doing some work with those communities. And it's a remarkable community for reasons I think most people don't understand. People think they see the images carrying logs down the beach and all the blowing stuff, all the, all the stuff that's fun for guys like that. But all of the guys I know who are in the seal teams have this sense of duty about immediately things, and not just holding the door and doing the. Helping with the dishes and moving things around. They are constantly scanning their environment for what can be done. They essentially conquer every environment they're in. They are also, some of them, the most competitive human beings in the world. And they do it unless they're in the act of war, fighting, which is their real job. They do it in every environment in a very benevolent way. And it's a remarkable thing because I think it's what is part of what they're selected for. And, you know, there's a range there. But I think when we hear about tending to the immediate things, or this phrase, you know, how you do one thing is how you do anything. That's a tricky one for me, because there are certain things I just don't do well. But should we always be trying? I think that the tending to setting the horizon in closely and tending to things in one's immediate environment, I think is very powerful and translates, because again, I think the nervous system, it performs algorithms, it has action steps. The brain doesn't evolve to do one thing. It evolves to be able to use the same approach to doing lots of different things.

B

Yes, I just want to add so even beyond that, because that totally resonates for me and is very consistent with people in recovery from addiction who learn to take it one day at a time, which is one of the standard lingo from Alcoholics Anonymous and other twelve step groups. But I think also, as you say, our brain is really wired for the 24 hours period. We're not very good at sort of the, you know, ten year 20. I mean, we have these huge frontal lobes. And yes, we're great planners, and we can. But if we live too much in that space, we can really get very anxious and depressed and lost and either catastrophize or get grandiose. But if you can chunk it down to a day, what people in recovery talk about is how, if I can just do today, right, then I will get a chain of days that seem insignificant in their individual units. But after six months or a year or two years of those good days, I've got two very good years, right? And I look back and it's like, oh, wow, I guess I did all that, but I think that's really one of the keys, is really taking it one day at a time, which your seals, and also this connecting with the environment, right? So being awake and alert to your environment and connecting with your environment, not trying to escape it. And of course, escapism is what we all want and desire, that experience of non being. And we get it from the Internet or from drugs or whatever it is, but it is, it's the booby prize, because ultimately it takes you further and further away from your immediate environment, which is where we really have to connect to, to get that sense of groundedness and authenticity and like, of being in our own lives.

A

Well, I think the unit of the day is something that comes up again and again in my discussions with colleagues who are extremely successful and who also have balanced lives. This actually came up in the discussion with Carl Dyseroth, who is also a successful scientist and clinician and manages a family, et cetera. So the unit of the day, I think, is fundamental. And those stack up, as you mentioned. So, along those lines, I've heard you say that in order to reset the dopamine system, essentially, in order to break an addictive pattern, to become unaddicted, 30 days of zero interaction with that substance, that person, etcetera. Is that correct?

B

Yeah. And 30 days is, in my clinical experience, the average amount of time it takes for the brain to reset reward pathways for dopamine transmission to regenerate itself. There's also a little bit of science that suggests that that's true. Some imaging studies showing that our brains are still in a dopamine deficit state two weeks after we've been using our drug. And then a study by Shuckett and Brown, which took a group of depressed men who also were addicted to alcohol, put them in a hospital where they had received no treatment for depression, but they had had no access to alcohol in that time. And after four weeks, 80% of them no longer met criteria for major depression. Again, this idea that by depriving ourselves of this high dopamine, high reward substance or behavior, we allow our brains to regenerate its own dopamine for the balance to really quilt. Right? And then we're in a place where we can sort of enjoy other things.

A

So that progressive narrowing of what brings one pleasure eventually expands. So I'd like to dissect out that 30 days a little more. Finally, and I also want to address, how does one stop doing something for 30 days if the thing is a thought. So we'll kind of put that on the shelf for a moment. So days one through ten, I would imagine, will be very uncomfortable. Yes, they're going to suck, basically, to be quite honest. Because the way you describe this pleasure pain balance, to my mind, says that if you remove what little pleasure one is getting, or a lot of pleasure from engaging in some behavior, that's gone. The pain system is really ramped up and nothing is making me feel good. I'll just use myself as an example. I'm not in recovery, but that ten days is going to be miserable. Anxiety, trouble sleeping, physical agitation, to the point where, you know, maybe impulsive, angry.

B

Should.

A

Should one expect all of that? Should the family members of people expect all of that?

B

Yeah. So what I say to patients, and it's a really important piece of this intervention, is that you will feel worse before you feel better. For how long?

A

Yeah, this is probably the first question they ask. Right.

B

And I say, usually in my clinical experience, you'll feel worse for two weeks. But if you can make it through those first two weeks, the sun will start to come out in week three. And by week four, most people are feeling a whole lot better than they were before they stopped using their stubborn substance. So, um, yeah, you have to. It's. It's a hard thing. Like, you have to sign up for it. And I will say, obviously there are people with addictions that are so severe that as long as they have access to their drug or behavior, they're not able to stop themselves. And that's why we have higher levels of care or residential treatment. This is not going to be for everybody, this intervention. But it's amazing how many people with really severe addictions to things like heroin, cocaine, very severe pornography addictions. I posit this and I do it as an experiment. I said, let's try this experiment. I'm always amazed. Number one, how many of them are willing, and number two, how many of them are actually able to do it? They are able to do it. And so that little nudge is sort of just what they need. And the carrot is, you know, there's a better life out there for you and you'll be able to taste it in a month. You really will be able to begin to see that you can feel better and that there's another way.

A

So the way you describe it, it seems like it's hard, but it's doable for most people, not everybody. And we'll return to that category of people who can't do that on their own. Well, then days 21 through 30, people are feeling better. The sun is starting to come out, as you mentioned, which translates in the narrative we've created here and support biology that dopamine is starting to be released in response to the taste of a really good cup of coffee, for instance.

B

Exactly.

A

Whereas before, it was only to insert, you know, addictive behavior.

B

Right.

A

Whichever it is.

B

Of course, coffee can be addictive, too, but. But we'll leave that aside. Yeah.

A

I feel like coffee has a kind of consumption limiting mechanism built in where at some point, you just can't ingest anymore. Yeah, but maybe that's wrong. Sorry to give lift to the caffeine addicts out there as I. As I clutch my mug. So days 21 through 30, I've seen a lot of people go through addiction and addiction and treatment. I've spent a lot of time in those places, actually, looking at it, researching. I've got friends in that community. I'm close with that community. One thing I've seen over and over again, sadly, often in the same individuals, is they get sober from whatever they're doing great. These are people with families. These are people that you discard your normal image of an addict and insert the most normal, typical, whatever, healthy person you can imagine, because a lot of these people you wouldn't know were addicts. And then all of a sudden, you get this call. So and so is back in jail. So and so, his wife is going to leave him because he drank two bottles of wine and took a Xanax at 07:00 a.m. crashed his truck into a pole. It's got two beautiful kids. Like, how did this happen again, to the point where by the fourth and fifth time, people are just done? I mean, maybe people. You might be able to detect the frustration in my voice. I'm dealing with this with somebody that's like. But I don't even know that I want to help this time. It's been so many times to the point where I'm starting to wonder, is this person just an addict? This is just kind of what they do and who they are. And I. And you never want to give up on people, but. And I'm hanging in there for them, but I will say that many people have given up on them. And so what I'd like to talk about in this context is what sorts of things help other people that we know that are addicted? What really helps, right. Not. Not what could help, but what really helps? And are there certain people for whom it's hopeless? I mean, I don't like to hold the conversation that way, but I wouldn't be close to the real life data if I didn't ask. Is it hopeless? Are there people who just will not be able to quit their substance use or their addictive behavior despite, I have to assume, really wanting to?

B

Yeah. Yeah. So there. There are people who will die of their disease, of addiction, you know, and I think conceptualizing it as a disease is a helpful frame. There are other frames that we could use, but I do think, given the brain physiologic changes that occur with sustained, heavy drug use and what we know happens to the brain, it is really reasonable to think of it as a brain disease. And for me, the real window of, let's say, being able to access my compassion around people who are repeat relapsers, even when their life is so much better, when they're in recovery. Yeah. It's like a no brainer is to conceptualize this balance and the dopamine deficit and a balance tilted to the side of pain and to imagine that for some people, after a month or six months or maybe even six years, their balance is still tipped to the side of pain that on some level, that balance has lost its resilience and its ability to restore homeostasis.

A

It's almost like the hinge on that.

B

Balance is messed up. Exactly. And so, I mean, for someone who's never experienced addiction like yourself, maybe one way to conceptualize it is why I didn't say that. Okay.

A

To be clear, I was not referring to myself, but in this example I was given, if I were, I would come clean. I would reveal that. But I think that especially after hearing some of your lectures and descriptions of the range of things that are addictive, I think I've been fortunate. I don't have a propensity for drugs or alcohol.

B

Right.

A

I'm lucky in that way that, frankly, if they remove all the alcohol from the planet, I'll just be relieved because no one will offer it to me anymore. So don't send me any alcohol. It won't go to me. But I don't have that. I like to think I have the compassion, but I don't have that empathy for, you know, taking a really good situation and what, from the outside, looks to be throwing it in the trash.

B

Yeah. So, okay, so this is really, I think, important because I also had to come to an understanding of this, and I feel that I have, in my 20 years of seeing these patients. And, of course, addiction is a spectrum disease. Right. And so you've got the severe end of things. Imagine that you had an itch somewhere on your body, okay? And it was. I mean, we've all had that, like, you know, whatever the source, it was super, super itchy. You can go for, you know, if you really focus, you could go for a pretty good amount of time not scratching it. But the moment you stopped focusing on not scratching it, you would scratch it. And maybe you do it while you were asleep. Right. That. And that is what happens to people with severe addiction. That balance is essentially broken. Homeostasis does not get restored despite sustained abstinence. They're living with that constant specter of that pull. It never goes away. So let me see. There are lots of people with addiction for whom that does go away, and it goes away at four weeks for many of them. But in severe cases, that's always there and it's lingering, and it's the moment when they're not focusing on not using. It's like a reflex. They fall back into it. It's not purposeful. It's not because they want to get high. It's not because they value using drugs more than they do their family. None of that. It's that really, they cannot not do it when given the opportunity. And that moment when they're not thinking about it. Does that make sense?

A

That's a great description. And actually, in that description, I can feel a bit of empathy because the way you describe scratching an itch in your sleep.

B

Yeah.