When we think of addiction, alcohol and drugs may immediately spring to mind. But we can also become addicted to digital “substances,” like Facebook, Twitter, TikTok, even video games. Today, Dr. Anna Lembke helps us uncover the nature of addiction: why we get addicted, what happens when we do, and what we can do to break its hold on us.
Anna is a professor of psychiatry at Stanford University School of Medicine. Her new book is Dopamine Nation: Finding Balance in the Age of Indulgence. Anna expounds on what happens in the brain and the body when we become addicted to a chemical substance or something virtual. She explains how intense digital addictions can be. She also uncovers how to identify addictive behavior in ourselves and its sources. She also offers hope as she tells the stories of her patients who have escaped the clutches of addiction and transformed their lives for the better.
Check out Anna’s book: Dopamine Nation
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Within the below transcript the bolded text is Hilda Labrada Gore and the regular text is Dr. Anna Lembke.
When we think of addiction, alcohol and drugs may immediately spring to mind but we can also become addicted to digital substances like Facebook, Twitter, TikTok and even video games. This is episode 357. Our guest is Dr. Anna Lembke. She is a Professor of Psychiatry at Stanford University School of Medicine. Her new book is Dopamine Nation: Finding Balance in the Age of Indulgence. Anna expounds on what happens in the brain and the body when we become addicted to chemical substances or something virtual.
It often starts with dopamine, the feel-good hormone. “We get hooked on a feeling,” as the song says, which feels great until it’s gone and then we want more of it. Anna explains how intense digital addictions can be. She also uncovers how to notice addictive behavior in ourselves and the sources of addiction. She tells stories of her patients who have escaped its clutches and transformed their lives for the better. This is the first episode in our Mental Health Track series.
Before we get into the conversation, I want to invite you to become a member of the Weston A. Price Foundation. If you are a long-time follower of the show, you’ve certainly heard me say this before. The time to act is now. The foundation is a member-supported group. It’s the only way we can continue our efforts of education, research and activism, with your help. Please become a member. Go to WestonAPrice.org, click on the Become a Member button and use the code, POD10, to join for only $30 a year. This is cheaper than some monthly gym memberships and the value will last much longer than the results from a bicep curl. Welcome to the family.
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Check out Anna’s book, Dopamine Nation
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Welcome to the show, Anna.
Thanks for having me. I’m happy to be here.
This is an important topic. I want to kick things off by diving into a story of addiction. You mentioned many in your book. Let’s talk about some young people that you’ve seen who have had a cannabis addiction.
In my book, I talk about a young woman named Delilah, who first came to me looking for help with anxiety and depression. It also happened that she was smoking cannabis every day. She assumed that my initial intervention for her would be to prescribe her a pill for anxiety or recommend some intensive psychotherapy. Instead, what I recommended is that she cut out all cannabis for a month. The reason for that is because cannabis is an addictive substance.
It releases dopamine in the brain’s reward pathway. Over time, the way that our brain compensates for that is by down-regulating our own production of dopamine, not just baseline levels but below baseline levels. With repeated use, we need more to get the same effect. We ultimately end up in a dopamine-deficit state where we don’t feel good when we’re not using. We’re experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and intrusive thoughts of wanting to use.
When you mentioned the phrase dopamine-deficit, I can’t help but think that so many people are struggling with that. You have no idea. I don’t know if you spend time on TikTok or some other social media platforms. People are always talking about their anxiety, depression, and what they do to get out of a funk. Do you think this is what they are experiencing?
Yes, exactly. That’s one of the main reasons I wrote Dopamine Nation. I wanted people to understand that by constantly bombarding our brain’s reward pathways with highly reinforcing substances and behaviors like a lot of the digital online media that we’re all consuming, what ends up happening is it’s way more reinforcing and dopamine-releasing than our brains were evolved to tolerate. To try to compensate for all of that dopamine release, what our brains do is down-regulate our endogenous or internal production of dopamine, not just to baseline levels but below baseline levels. We enter this dopamine-deficit state where we’re essentially walking around depressed, anxious, restless and craving our drug.
Real life seems boring because we’re not getting that continual dopamine hit.
That’s one of the key points to understand. I have so many people come in including young people who have everything you could want out of life. They have elite education, loving parents, plenty of money and yet, they’re restless, bored, anxious and not interested in their classes. They think it’s because they haven’t “found their passion.” What has happened is that their reward pathways have been hijacked by all of the feel-good substances and behaviors that have become so commonplace in our hyper-convenient world.
When you talk about our bodies down-regulating the amount of dopamine they produce, it reminds me of some people who try to improve their sleep patterns by taking melatonin. I know the science is out on this, but some say that the more you supplement, the less your body makes. In essence, that’s what I hear you saying happens when we take in too much of this dopamine hit from addictive patterns. It doesn’t have to be a substance necessarily but even getting our devices can lead to this issue.
I haven’t read that literature on melatonin but in general, that principle holds true for almost all biological systems, which are governed by a very intensive physiologic drive to restore what’s called homeostasis or a level baseline. Our brains and bodies will work very hard to get back to that level baseline so that if we are ingesting any chemical that gets us out of our homeostatic baseline, then our brains will have to find some way to compensate for that. That compensation can change our fundamental set point for whatever that physiologic function is, whether it’s sleep, pleasure, anxiety or whatever it is.
I can’t help but wonder as we broach this topic of addiction, doesn’t addiction serve a purpose for us? In other words, the original intent of getting a reward in our brain and then our bodies, isn’t that going to serve us in some good way? Otherwise, it wouldn’t be a part of our physiology.
Absolutely. Dopamine is fundamental to our survival. It’s what allows us to approach pleasure and avoid pain. The homeostatic balance that drives the return to whatever baseline firing of dopamine that we have is also quite genius in terms of surviving in a world of scarcity and ever-present danger. However, we no longer live in that world. We live in this world of overwhelming abundance. It turns out that our primitive wiring and fundamental physiology are not well-adapted for this new world that we have created. There’s this term called the Anthropocene, which you’re familiar with.
It’s a way of describing the way that human behavior has changed the planet. Global warming is the most obvious example of that. Another example of that is the way that we have created this hyper-convenient world where we have nearly infinite access to highly rewarding addictive substances and behaviors at the touch of a fingertip. It has messed with our brains because this wiring that we have that processes pleasure and pain is one that evolved over millions of years in a world of scarcity, and is not well-suited to a world of abundance.
With a swipe of my index finger, I can have food appear on my doorstep. I can get anything I need or think I need immediately. We weren’t made for that world.
Getting back to my patient, Delilah, what I recommended to her as a treatment essentially for her anxiety and depression was for her to eliminate cannabis for a month. I explained to her that period of abstinence or sometimes called dopamine fasting will initially make her feel more anxious and depressed. When we initially take away our rewarding substance because we have changed our set point for experiencing reward, we will immediately plummet into that dopamine-deficit state. In the book, I use the analogy of balance or a teeter-totter in a kid’s playground.
Dopamine is fundamental to survival. It’s what allows us to approach pleasure and avoid pain.
If we wait long enough, eventually, our brain and body will get the signal that incoming dopamine has been reduced and that we need to start up our dopamine factories again. We will start to make our feel-good hormones like dopamine, serotonin or norepinephrine. Our endogenous opioid and endogenous cannabinoid systems will begin to up-regulate. I usually recommend a month of abstinence because, in my experience, that’s the amount of time it takes to reset reward pathways. Eventually, what will happen is we will start to feel good again.
That anxiety and depression, which we were attributing to external causes or maybe to some fundamental brain flaw, will resolve themselves without any other intervention. That’s precisely what happened to Delilah. She came back a month later and said, “I have less anxiety and depression than I’ve had in years.” I’ve treated many patients over twenty-plus years for whom that has been the case, such that I’ve become firmly convinced that these substances and behaviors create the psychiatric symptoms that we think we’re self-medicating by using them.
It’s not unlike my own experience and that of my children and many people that I’ve spoken to in the realm of food. In other words, the Wise Traditions group promotes whole real foods for nourishment. It is great for our satiety, but also for our bodies to function on foods that don’t come with a lot of labels. At first, our palates have been so adjusted to modern foods that are full of MSG and different chemicals that taste the right way but don’t satisfy. If we withdraw from that, when we taste the real food, it seems bland in comparison. When we get accustomed and retune our palate to real food, we start to discover the amazing flavor and nourishment that comes from real food. Do you see the parallel I’m making?
Yes. It’s very clear that just as we can get addicted to drugs and behaviors, we can also get addicted to sugary, processed, over-salted and over-chemicalized food. Food addiction is real. What’s fascinating about addiction broadly in the population is that different people will have different drugs of choice. What’s highly reinforcing for one person may not be for another and vice versa. For some people, food is uniquely addictive, especially processed food and sugar. When I treat patients with food addiction, the same principles apply to treating patients with drug and alcohol addiction. First of all, we have to figure out what food they are addicted to.
Typically, it is sugar and processed food. It’s a matter of a period of abstinence where they eliminate that category of food for long enough to reset baseline homeostasis. If they decide to introduce that food back into their lives, they think in great detail about what that would look like, how often and how much, and create strategies to make sure that they don’t overconsume those addictive foods. In this day and age, we all have some level of disordered eating because food has been drugified. It’s been made to be highly reinforcing and addictive. I conceptualize disorders like bulimia as addictions rather than eating disorders per se.
I can’t help but think about the book, The Dorito Effect, and another book that my friend Diana Rogers and Robb Wolf wrote called The Case for (Better) Meat. In it, they talk about how scientists in laboratories and food manufacturers are purposely trying to make the food hyper-palatable. We’re not addicted because of a lack of willpower but it’s rather by design. That leads me to the question about our devices. You mentioned how we can have addictions to our technology and the dopamine hit we get from these things. I understand that our cellphones were designed in such a way to purposely suck us in like that. Is that true? Do you know anything about that?
That’s well known. The original creators of many of the digital products have admitted as much that they studied the motivational systems of the brain. They tested, focus-grouped and road-tested these products to be reinforcing and to keep people tapping and swiping. They do that in several ways. If you think about the four factors that make something highly reinforcing or addictive, it’s easy access. The smartphone has become the equivalent of the hypodermic syringe delivering digital dopamine 24/7. Access couldn’t be easier.
In terms of quantity, it makes the difference. The more of a drug we consume, the more likely we are to get addicted to that drug. The thing about digital products like TikTok is that they are infinite. You can run out of a line of cocaine but you will never run out of TikTok. The third aspect is potency. As you talked about, all these chemicals added to food have made them more flavorful, potent and addictive. It’s the same thing with the cannabis now is much more potent than cannabis of yesteryear.
JUUL and eCigarettes deliver more nicotine per unit puff than cigarettes ever did. Digital products were made potent in all kinds of interesting ways. One of the most common ways is to enumerate the aspects of the digital product. If we give something in numbers, it tends to be more reinforcing. For example the number of likes, tweets, retweets or our ranking in a video game. Numbers seem to elicit that dopamine response.
Another aspect that makes it more potent is combining two drugs together. For example, people with opioid addiction know that if they combine the opioid with a benzodiazepine like Xanax, they will get a higher high. The same thing happens with digital products. Within a video game, there’s a little bit of gambling. When we combine gambling with gaming, that makes both of those things more potent. If you watch YouTube or American Idol, it’s not just the music that’s in and of itself pleasurable and reinforcing. It’s that music has become gamified in a competition. You’ve taken gaming and music and made it more potent.
Our ability to minutely control our consumption contributes to the addictive potential. Unlike TV many years ago where you got what you got, now we can decide and titrate exactly what we want, how much and how fast. We can switch to something else if it’s not reinforcing enough. That also then further engages our search and explore function where we’re always looking for something a little bit better. The algorithms learn us, remember us, and then proffer that to us to suggest that we keep going.
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That’s a lot to think about, Anna. I’m grateful that you’re shedding light on the ways in which we can become addicted to our devices, and how it is by design that they were made and designed in this way and some of these apps. I wanted to flip to the opioid crisis because it is a real thing. Let’s talk about how it started. Didn’t it start innocently enough where doctors were simply trying to help alleviate their patients’ pain?
In the 1980s, with the advent of the hospice movement, there was recognition across medicine that doctors were not doing enough to help patients in pain, especially patients at the end of life who were often dying in agony. There was this idea that we could be more liberal with opioid prescribing, particularly at the very end of life when the risk of addiction seemed immaterial in contrast to the amount of time that the person had left to live.
What happened is that messaging that was originally well-intentioned got taken over by the opioid pharmaceutical industry. This incredibly influential and misleading marketing campaign convinced doctors that they could prescribe opioids for minor and chronic pain conditions, that patients were not going to get addicted to the opioids as long as they were real doctors prescribing for real pain, and that opioids were effective for long-term treatment when taken daily. None of those things is actually true.
It turns out that opioids, although effective in the short term that are less than three months for severe pain, don’t help pain when taken daily for long periods of time. At least there’s no reliable evidence to show that they do. Furthermore, it turns out that 1 in 4 patients who were prescribed an opioid for a bonafide legit pain condition will develop some opioid misuse problem, and 1 in 10 will develop a severe addiction.
The medical profession was essentially sold a bill of goods by Purdue Pharma and others, which then increased the number of opioids that doctors prescribed, which increased the number of patients exposed to high dose long-term opioids, as well as increased the number of people who are not patients but teenagers curious about what was in their parents’ medicine cabinets, kids trading pills at school, or drug dealers having more access to pharmaceuticals because there were simply more pills floating around in society. All of that led to a four-fold increase in opioid prescribing between 1999 and 2012. It’s commensurate with a four-fold increase in opioid-related overdose deaths and opioid addiction treatment admissions. It’s clear that those things are causal and not just correlative.
Why is it that this crisis has been so overlooked?
There are so many reasons. There’s so much misunderstanding about addiction and what causes it. There are so many thoughts in society that addiction is a person’s choice and within their willful control like they can just stop. Although that is beginning to shift. When polled about whether or not addiction is a disease, the majority of Americans will say that they believe that it is a disease.
That is a huge shift from years ago when the majority polled would have said it’s a willpower problem, social problem or spiritual problem. The disease model has taken hold but nonetheless, we are lacking an adequate infrastructure inside of medicine to target this huge public health problem. We have Centers of Excellence for Cancer Treatment and Centers of Excellence for Diabetes Control.
We have almost nothing like that for the treatment of addiction, with a few exceptions here and there. For a long time, insurance companies also wouldn’t pay for the treatment. It’s for all those reasons, misconceptions, lack of physicians and other mental healthcare providers, lack of training in the area of addiction, and lack of adequate medical infrastructures to treat addiction. All of those things have contributed.
Would a good place to start be to simply prescribe fewer opioids?
That is a fundamental first principle place to start. That has happened. Opioid prescribing started to decrease around 2012. Although we’re still prescribing more opioids nationally than we were in the 1990s, it has gone down by about 30% to 40%. However, there’s an enormous geographic variation with some counties way down and other counties still prescribing a lot of opioids.
If you look at what are the correlates in the counties where people are still routinely being prescribed high dose long-term opioids, it won’t surprise you to learn that those are in mainly impoverished counties where people are struggling with unemployment, poverty, multigenerational trauma, and limited access to quality healthcare, but enough access to healthcare to have some lone prescriber overwhelmed by a huge population of vulnerable people and desperate to try to do something to help them. They’re finding that continuing to prescribe a pill is all they have at their disposal. It’s a complicated problem. It’s going to take decades to address.
Can addiction to opioids or other substances such as cannabis or maybe alcohol ever be managed or overcome? I’m asking very sincerely because I feel like when the tentacles of addiction grab onto someone, it’s not a lack of willpower. It seems very difficult to extricate oneself.
One of the myths about addiction is that people don’t get better. You treat people with addiction in the healthcare system with evidence-based treatments that we have available and their biological treatments including medications, psychological treatments and social treatments. These are well-established treatments. They have been around for decades and we know they work.
If people have access to evidence-based treatment for addiction, they have about a 50% response rate. It is on par with the response rates to other mental health disorders like major depression. It’s also similar to the response rates that you see in medical disorders that have a behavioral component, so other chronic relapsing and remitting diseases like Type 2 diabetes, obesity, certain forms of asthma and heart disease.
The smartphone has become the equivalent of the hypodermic syringe to delivering digital dopamine 24/7 access.
Addiction treatment works for those who have access and actively engage in the treatment, and people get better. When people get better, their lives are transformed and the lives of people around them are transformed. There is no need to be pessimistic and yet, most people are very interesting. They have this image of you’re going to end up clutching a brown paper bag and sleeping under a bench. Addiction is certainly terminal in a small percentage of people but so is cancer. We don’t cure every case of cancer. Some people will die of their disease. That is true of every mental illness, but a whole lot of people get better.
There’s also something called natural recovery where some people get better without any medical intervention at all. They figure it out and stop using it. It’s also true that some people, after a period of abstinence, can go back to using their drug of choice in moderation. It’s a very small minority, but people who have been severely addicted probably have to abstain lifelong. Some people have been able to figure out how to go back to using in moderation.
I have a friend who was extremely addicted to alcohol. He lost his family and his job and hit rock bottom. He did not use any program like AA or seek out medical treatment or any psychological help. He simply had what you described as a natural recovery. He made a change, never went back, and then started recovering his life again. Tell us a story of one of your clients that might give us some hope too, someone who might have released themselves from the grips of addiction.
There are so many stories. My book is full of such stories. Lots of people in recovery are modern-day prophets for the rest of us and how to live in this dopamine-saturated world. The patient I spoke of, Delilah, is one good example. She did the dopamine fast and came back feeling much better. She committed to abstinence for the month after that because she wanted to maintain her improvements. She eventually decided she wanted to try to go back to using cannabis in moderation, which many people with addiction do.
It’s very hard, especially for a young person, to imagine giving up their drug of choice for a lifetime. She did that. It worked okay for a while but then she slipped back into her addictive use. She now had more experience and data. She eventually gave it up for the long haul. There are lots of stories like that. There’s no one-size-fits-all. No one path is right for everybody. I encourage anyone out there who are struggling with addiction to stay hopeful and get help. There are lots of good treatments out there that work.
I have to bring this up as we get ready to close, psychedelics. I have friends in this alternative health space who swear by them as a way to open up their minds, heal their emotions and then subsequently their bodies. How do you see them?
I believe it was George Harrison of the Beatles who said, “You only need to do LSD once.” That’s probably true. If you find yourself going back again, you might want to look hard at whether or not what you’re looking for is no longer spiritual enlightenment but some addictive pull. I generally want to try to remain open-minded about the potential utility of psychedelics in certain very rare clinical situations, administered and strictly adhering to the ways in which the data have shown that it can be helpful. As a general repeat practice, I think people are going astray.
I also think that the spiritual enlightenment that people are looking for is best obtained in other ways that involve maybe intensive spiritual practices, intensive psychotherapy, or slower medicine that leads to longer-lasting neurobiological changes, and also that requires suffering and effort. When we endure pain, that not only becomes a source of wisdom for us but it becomes a touchstone for self-confidence and self-efficacy. We can look back and say, “I made it to the top of that mountain and I didn’t take the gondola ride.” To me, psychedelics is the gondola ride.
If you don’t have legs or you don’t have enough time to walk up to the top of the mountain and that’s the only way you’re going to get there, one time is okay to see and get your spiritual awakening. I’m concerned about the level of enthusiasm for what is essentially an addictive substance. When people say psychedelics are not addictive, they do not know what they’re talking about. I see plenty of people addicted to psychedelics. Anything that’s intensely mind-altering, even if it’s occasionally dysphoric, is going to be an addictive substance.
Thank you for touching on that and giving us your opinion on that. I can’t help but think when you talked about that homeostasis that we’re seeking out between pleasure and pain. Your gondola ride was a great example of that. We can make it to the top in an easy way or we can try using our bodies and then find a joy that comes from the difficulty. I also think about my friends who are into cold therapy, including yours truly who love to get in cold water and challenge ourselves because of that euphoria. It’s a dopamine hit too when we succeed and we have done something hard, but then we get the reward of the pleasure afterward.
As I talk about in my book, when we expose ourselves to ice-cold water, what we get during the exposure is a gradual and steady increase in dopamine release that remains elevated for hours afterward, which is very different from the dopamine pattern we see after we expose ourselves to intoxicants. With intoxicants, what we see is a sudden upward spike of dopamine release followed by plummeting dopamine levels, not just to baseline but below the baseline.
Eventually, as long as we don’t continue to use that substance, a return to baseline levels. We paid an enormous price for intoxicants because we’re essentially short-circuiting what was meant to happen, which is we were meant to have to walk tens of kilometers to get a drink of water. Short-circuiting what was meant to happen is enormously stressful in the brain.
This is so fascinating. Thank you for this conversation. I want to ask you one final question, which I always pose at the end here. If our audience could do one thing to improve their health, what would you recommend that they do?
I recommend that you ask yourself whether or not you’re compulsively overconsuming a substance or a behavior, especially a digital product in your life, and that you consider a period of abstinence away from that. If you decide to do it, whether it’s a day, a week or a month, you observe in yourself how initially you feel worse as you note the dopamine-deficit state and the craving. If you can last for the full cycle and I consider 24 hours to be the minimum full cycle, what you will notice is you will get to a place where that goes away and the restlessness eases. You may even find that when you get to the end of that dopamine fast, you don’t even want to return to using that substance because you’re free.
That’s beautifully well said. Thank you so much, Anna. I enjoyed our conversation.
Me too. Thanks for having me.
Our guest was professor Anna Lembke. Get her book, Dopamine Nation: Finding Balance in the Age of Indulgence, at your favorite bookstore. You can find me at HolisticHilda.com. For a review from Apple Podcasts, Chelsea Colibri says, “Life-changing information. I discovered this podcast in 2021 while looking for accurate information among the widespread propaganda and lies regarding the public health crisis. Listening to my first episode was like stumbling on an oasis of truth, sanity and sincerity in an illogical, frightening and confusing landscape. I was hooked.”
Chelsea says, “A few months later, I attended the Wise Traditions Conference, which was a heartwarming, life-affirming and totally inspiring event, unlike anything I’ve ever attended. My favorite part was seeing all the healthy and happy babies and kids with their calm, happy and healthy mothers. The proof is in the pâté.” Chelsea, thank you for your review. You are so kind. We invite you too to rate and review the show on Apple Podcasts. Leave us a number of stars and tell us what you think of the show. You can also join us at the Wise Traditions Conference. In 2022, it’s going to be in Knoxville, Tennessee from October 21st to the 24th. I hope to see you there. Until then, stay well. Hasta pronto.
About Dr. Anna Lembke
Anna Lembke, MD is professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. Her new book, Dopamine Nation: Finding Balance in the Age of Indulgence (Dutton/Penguin Random House, August 2021), an instant New York Times bestseller, explores how to moderate compulsive overconsumption in a dopamine-overloaded world.
- Dopamine Nation: Finding Balance in the Age of Indulgence
- Become a Member
- Anna Lembke
- The Dorito Effect
- The Case for (Better) Meat
- Apple Podcasts – Wise Traditions
- Wise Traditions Conference
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