OC183 Dr Anna Lembke - Dopamine Nation: Finding Balance In the Age of Indulgence

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Hello Loves,

 

Thank you for downloading the podcast, my name is Arlina, and I’ll be your host.

 

In case we haven’t met yet, I am a certified Recovery Coach and Hypnotist. I am obsessed with all things recovery, including neuroscience, reprogramming the subconscious mind, law of attraction, all forms of personal growth and spirituality. I have been practicing abstinence from drugs and alcohol since 4/23/94, and I believe in people finding what works for them. 

 

Today I’ll be talking with Dr Anna Lembke, she is Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic at Stanford University and author of the #1 Bestseller “Dopamine Nation: Finding Balance In the Age of Indulgence”. It would be a vast understatement to say it was such an honor to interview her for the podcast. 

If you’ve been listening to these interviews for any length of time, you’ll know I love learning about ideas I can share that will help lead people out of suffering. Up til now I’ve been hyper focused on empathy largely based off of Brene Brown’s work around vulnerability and she shared that empathy is the antidote to shame. I’ve also treasured the idea that “honesty without compassion is cruelty” so I’ve been pretty focused on empathy but it felt like something was missing.

 

Then I read this by Anna: “Empathy without accountability perpetuates victimhood”. I had an absolute “holy crap” moment. Not an “aha”, a holy crap. Because, I believe that I can’t really help people who are stuck or committed to a victim mentality. Those are people who are unwilling or unable to accept personal responsibility and I actually have a visceral and negative response to that type of thinking.

 

I had to send Anna a follow up email and ask for more feedback, specifically around what to say to people who have relapsed, and this is what she said:

 

“I’m so sorry. I’m sorry for your suffering. That must be so hard.”  What this does is validate that the relapse happened, while also acknowledging the pain that person is experiencing. I think of it similar to what I would say to someone who told me their cancer which had been in remission came back.”

 

So brilliant. I just love her.

 

Anyway, that was a very long intro, but I wanted you to have that extra bit of wisdom from her.

 

I hope you enjoy this conversation as much as I did.

 

Arlina Allen  6:09  

Okay, here we go. We'll talk to you. Thank you. Thank you so much for joining me on the podcast.

 

Unknown Speaker  6:15  

Thank you for inviting me, I am very happy to be here.

 

Arlina Allen  6:18  

I'm so excited. Listen, I say that all the time. But I really, really men it this time because I have been reading your book, and actually I listened to the audio book first while I'm walking, because I sort of like the first wash of like, all these concepts. And then I get the book because I'm a students. And I like to, you know, highlight and underline and Mark things. And this book was stuff. It has some pictures. Yeah. Picture like people like me, pictures are amazing. Yeah. But I just it's called dopamine, finding balance in the age of indulgence, I'm sorry, dopamine nation. And, wow, I have so many questions to ask. But I think a good place to start might be with maybe what what is dopamine? Really, because I think there's a lot of misconceptions about what dopamine is, there isn't like a dopamine pill. But you know, when people take drugs, I think they activate dopamine, but maybe I don't really have a good understanding. So I thought maybe I could sort of clarify what it really is, and, and why it's important.

 

Dr Anna Lembke  7:31  

Yeah, so dopamine is a chemical that we make in our brain. And it's very important for the experience of motivation, reward, and pleasure, and also fundamental in this self reregulating kind of system, that's called homeostasis, that is so fundamental to our physiology, and also, you know, to our survival. So essentially, you know, in a kind of broad brushstrokes simplified form, if you imagine that there is a balance in your brain, kind of like a teeter totter in a kid's playground, when we do something pleasurable that balance tips one way, and when we do something that's painful, that balance tips the other way, or when we ingest a substance that's pleasurable, or when we have an injury, you know, we cut our finger to the side of pain. But one of the overarching rules governing that balance is that it wants to remain level or preserve what neuroscientists call homeostasis. And it will work very hard to preserve a level balance with any deviation from neutrality. So when we do something that is pleasurable, we release dopamine, the pleasure neurotransmitter in the brain's reward pathway, which is a special part of our brain that's been conserved over millions of years, and is the same across many different species, even very primitive organisms. And that balance tip slightly to the side of pleasure. But no sooner Has that happened, then our brain will try to reregulate to bring that balance level again. And it does that by down regulating dopamine production and down regulating dopamine transmission in the reward pathway. But it doesn't just bring dopamine back down to tonic baseline levels, it actually brings it below baseline. So what happens I think of that as these Gremlins hopping on the pain side of the balance to bring in level again, but they stay on until the balance is tipped and equal and opposite amount to the side of pain. Yes, and that's of course, the kind of looking at the book. There's a little graphic in there, right there. And with Gremlins, right, I'm also a visual thinker. And so I just, you know, wanted to create a simple metaphor.

 

Arlina Allen  9:52  

This is Brian, on page 52 of the book. There's like the seesaw or the teeter totter that you mentioned. And I thought That was so interesting because it when you're talking about uh when we indulge in the dopamine like you know even on the little graph is chocolate social media gaming porn shopping in my case drugs alcohol all that stuff not to say that I don't indulge in social media those other are those other things shopping that we there is that deficit it's like the equal opposite

 

Dr Anna Lembke  10:26  

yes right for every pleasure we pay a price yes price is the come down and sometimes can be very subtle outside of conscious awareness. But you know it's there. And you know if we wait long enough that feeling of wanting to buy one more thing or watch one more video or have one more piece of chocolate goes away and and homeostasis is restored. But if we continue to bombard our dopamine reward pathway with highly reinforcing drugs and behaviors, what ends up happening is that to compensate for that, let's say artificially high levels of dopamine and I call it artificial because you know, the fundamental difference between things that are addictive and those that are not are that addictive, things release a whole lot more dopamine in the reward pathway. And of course, technology has taken even things that were not addictive like food, and made them highly potent and turn them into drugs or human connection. Social media has drug A fight human connection. But as a result of constantly bombarding our dopamine reward pathways, what ends up happening is our brains are desperately trying to compensate. And so they're way down down regulate, our brains are down regulating our dopamine production, and we end up in this kind of chronic dopamine deficit state where we have, you know, 1000s, of Gremlins on the pain side of the balance, and they've kind of camped out there, right, they brought their barbecues, their tents, they're not going anywhere fast. And, and it lasts a long time, which I think is really fundamental to understanding a couple of things. The first thing is, why on earth do people with addiction, relapse, after months, or even years of recovery and abstinence and their lives are so much better? Why on earth would they go back to using the reason is because they're not necessarily walking around. With a level balance, they are potentially walking around with a balance tilted to the side of pain on a daily basis experiencing the universal symptoms of withdrawal, which can last for months to years. And those include anxiety, insomnia, irritability, depression, and craving or intrusive thoughts of wanting views. The other reason I think this is balances is really helpful, is because not only does it allow us to understand the disease of addiction and relapse and to have compassion for that. But also it might explain, and this is the fundamental hypothesis of dopamine nation. Why it is that despite the fact that we have all our survival needs met, and then some why our rates of depression, anxiety and suicide going up all over the world, especially in rich countries. And I do believe that's because we individually and collectively, are engaging in so many high reward high pleasure activities and substances, that in order for our primitive brains to compensate, we have collectively downregulated, our own dopamine transmission such that we're all more depressed and anxious.

 

Arlina Allen  13:22  

Yeah, you know, in the beginning of recovery, a lot of people talk about boredom. And I think we're so overstimulated when we're using that, when we get sober and practice that, you know, those of us are practicing practicing abstinence, I am aware that there is like harm reduction, you know, and that's the thing I totally I feel like that's totally valid. I quit drinking alcohol on my 25th birthday and continued to smoke weed for five months. I didn't know that recovery is about complete apps. That's just, they called it the marijuana maintenance program back in the day. Uh huh. Anyway, now we're calling it harm reduction, just fine. But what I thought was so interesting is and this is what I have heard over the years is that when people first get sober, they're bored. And I listened to the interview you did with Dr. Andrew Huber many we're talking about boredom and anxiety, which at first blush, you wouldn't think that those two go together. But when all your needs are met, and you really have and you don't have a passion or in my case obsessions for different things. If you don't if you don't have that you like get bored and then it's like, creates anxiety. Right? I see that in my kids.

 

Unknown Speaker  14:37  

Yeah, of course. Yeah. I mean, especially the way because we're living in a time when we're constantly able to distract distract ourselves from our own thoughts, and our own ruminations and even our own creativity really, such that when we take away those distractions, we're suddenly you know, plummeted into the abyss really existentially We are bored, and sort of then contemplate well, gee, I don't have anything to do like, What? What is the purpose of my life anyway. But I think the key really is number one to acknowledge that boredom can be an extremely painful emotion, literally, physically painful, and scary. But that if we can just sit with it, and not try to run away from it, it is also the progenitor of creativity, and a place where new things are born. And so you know, just thinking about, like, you know, open space, like, it's like, you need space before you can have a supernova, you know, you need to have that blankness in order to, you know, initiate something new. And the internet really allows us all to be in this constant state of reactivity, where we're always responding to some some kind of input, rather than, you know, sitting quietly and generating.

 

Arlina Allen  15:56  

Yeah, no, it's, I have a question for you about the neurotransmitter. So it's my understanding, like, from a chemistry perspective, that, you know, your receptors, your brain cells have receptors on them that are the uptake with Deborah allow the cells to receive the dopamine. And if you flood your cells, I'm sorry, I don't know that is your neurotransmitters? Yes, yes. Okay. So the receptor if there, there's like little receptors that allow that uptake of the dopamine, but if it's flooded too much, your cells will retract those receptors. Exactly. Right. So this is the attic mind, how long does it take the brain to heal, meaning it puts back a normal amount of receptors, because in my mind, I was thinking, I took some physiology anatomy in college, and it was like, Oh, that's why when people first stop using, they don't feel anything, it's like they can't, because their brain was trying to protect them this whole time by retracting those receptors, not allowing them to uptake the dopamine. And so because they're not there, people feel flat, like they, they feel flat, and they can't feel it. And so everybody always says, Well, how long until I start feeling good again? Like, how long does it take their brain cells to put those little receptors back out? So people start feeling good?

 

Dr Anna Lembke  17:21  

Yeah, so in my clinical experience, it takes a minimum of a month, and that's less bad, not bad. And let me just say, a minimum of a month to start to regenerate other receptors and regulate dopamine transmission. But I mean, the protracted abstinence syndrome can last many months to even years, in some cases, right? Yeah. pends on the person, it depends on the drug, it depends on how you know how much they used. But in my clinical experience, and again, this is supported by some evidence, if people totally abstain for one month, in weeks one and two, that pleasure, pain balance to transmission is below baseline, because it's exactly as you say, our neurons have retracted those dopamine receptors, so we're not getting, you know, that stimulation. And we're experiencing withdrawal. But by weeks, three or four, people typically start to feel better. And by week four, even people with some very severe addictions, will start to notice improvement. Now, one thing you have to be really careful about is cross addiction. So all addictive substances work on that same common pathway, don't mean is a universal currency for the process of addiction, at least as far as we know, at this point. So if you give up your cannabis, but you keep smoking cigarettes, you know, you're not going to get the same kind of upregulation. Because you're not going to be abstaining from nicotine, which is gonna be you know, it's not, you know, most of my patients are not willing to give up cigarettes and nicotine and alcohol and all of it at once. That's a lot to give up. So whatever they're willing to do is great. And often they will see improvements, even if they just give up one thing. But to really get the full benefit and really restore homeostasis, you kind of have to give it all up in order. What

 

Arlina Allen  19:12  

about what about caffeine?

 

Dr Anna Lembke  19:14  

Well, you know, caffeine is a stimulant. So it sort of depends on how much you're using. If you're one cup of coffee a day, it probably isn't going to make much difference and you can just keep doing that. But if you're at you know, eight cups of coffee a day, that's that's probably probably time to. And the truth is that, believe it or not, it sounds harder to give it all up at once. But it might in fact be easier. There are studies showing that people who quit drinking and quit smoking cigarettes at the same time have better outcomes than people who just quit drinking but keep smoking.

 

Arlina Allen  19:50  

Or these people who were considered pretty heavy on the alcohol use disorder spectrum or you know, I don't think alcoholic is really a A clinical term any longer Is that true?

 

Unknown Speaker  20:02  

That's true.

 

Arlina Allen  20:03  

It's alcohol use disorder.

 

Dr Anna Lembke  20:04  

Yes, that's right. So we're trying to the alcoholic comes from Alcoholics Anonymous. It's just not a medicalized term. It's a perfectly good term. But it's just not one that we're, you know, we're using in Medicine Today we're trying to use a more generic term that can crossover many different substances to now it's, we don't even use the term addiction, believe it or not in a lot. Yeah, strange, right? And that's, you know, believe it or not, it hasn't really been the term the medical term. Now, let me say I use it all the time. It's the broadly understood term for this process. It is used in neuroscience texts. It is in the name of the of NIDA, the National, its own National Institute of Drug Abuse, which is a term we don't use anymore. The language of addiction is changing. But in the Diagnostic and Statistical Manual of Mental Disorders, it's not called nicotine addiction, or alcohol addiction. It's called nicotine use disorder, alcohol use disorder, cannabis use disorder, and I'm like that.

 

Arlina Allen  21:01  

Okay. So it is specific to the whatever people are using. Okay, that's so interesting. I did not know that. Listen, I kind of came up in Alcoholics Anonymous. So, you know, but I've noticed that, and I'm sure you've noticed this too, like, and maybe not because you're not on social media. Is that true? You're not on social media? That's not true. Yeah, that's true. But you are in the social dilemma. Right? Fascinating. Like I had resisted watching it, because I'm sorry, I was sort of in the camp of, you know, I use social media for good. You know, so I don't, I didn't maybe are good. Yeah, it can. Yeah, I mean, it's that's how I communicate all everything that I do. My podcast and everything that I do is I'm trying to disseminate information, you know, solution. And he's social media. So I'm like, it's all it hits like money. It's all in how you use it, right? Like you use your powers for good. Kind of like Spider Man. But, um, where am I going with that, but but it's there's a bit of self denial because I do find I'm, you know, sort of like the typical addict, let's say, have that sort of propensity for addiction or anything obsessive anything that I like, I want more, right, I don't really have that off switch. So it's like, oh, I found something I'm passionate about is helping people recovering, Alcoholics Anonymous, and so that's all I want to do. So he says, it seems like a healthier obsession.

 

Dr Anna Lembke  22:37  

You know, putting investing our energy into things that we care about, that gives us to me meaning and purpose that serve others that make the world a better place, those are all those are all good things, they can also cross the line into addiction, we can, you know, there is work addiction. People can get, you know, caught up in that in a way that's not healthy for themselves or others. But in general, you know, when we're serving others, those are usually healthy behaviors.

 

Arlina Allen  23:06  

Yeah, I remembered my point of that little thing I just did. But with the social media, it's so interesting to see that the vernacular is changing in the world of social media, how people like me who are trying to disseminate information about recovery and sobriety, the vernacular is changing, because a lot of people, women, especially, actually are very, like anti a, because of the male dominated vocabulary. And, you know, there's this sort of patriarchal overtone, and overtures. And I kind of grew up in the church where I learned to, you know, you're supposed to read the Bible, and then you sort of decipher what it means to you. When I got sober. I was like, these people are like, Oh, you can solve that problem here. And I was like, I'm all in. And I would read the text and literature and I would just translate like, I had that ability to translate into what it means to me. So I didn't really get hung up on I was super desperate to be sober. So I didn't get hung up on terms like alcoholic or, you know, everything being in he him. There's like in the book, I'm sure you're familiar, a chapter to the lives, right? Yeah. As if we were, you know, the women were sort of secondary. And so there's all this discussion right now about how, like a lot of people I interview they talk about alcohol free, they won't even use the word like alcoholic seem shaming. Uh huh. Or have you have you experienced that and the people that come to see you.

 

Dr Anna Lembke  24:43  

I certainly have, you know, encountered a lot of people who for whom a was not useful or effective, but I've encountered an equal number or more for whom a was absolutely you know, the lifesaver for them men and women. But I think it's important to put a into its historical context, it started in the 1930s. It was started by, you know, two men who met each other and support each other. It is one of the most remarkable and robust social movements in the last 100 years, totally peer driven, takes no financial outside support takes no political stance is free is everywhere. And I do agree with you that, you know, language was important and needs to change with changing times. And I think there have been some updates to the big book, you know, more more modern, and more accessible. And certainly, I've heard of certain I'm aware of abuses in the rooms and in a, I mean, I'm glad today that there are many options, different options for me to get into recovery online, in person. abstinence oriented, moderation oriented, and I think this is great. I think there are lots of paths to the top of the mountain. But I would not throw out a you know, I know, it's a really powerful philosophy and approach. And, you know, just absolutely miraculous for, you know, for people for whom it works and who actively participate.

 

Arlina Allen  26:15  

Yeah, well, there you go, you have to actively participate. I'm a huge fan like it absolutely. There was not actually when I got sober 27 years ago, there wasn't really nothing else. Yeah, there was really nothing else, I was super grateful. And I lived in San Jose. So in the Bay Area, where you are, there are there were like 800 meetings a week. Yeah. And there were women's meetings and very specialized meetings, there was I used to go to a 6am meeting every day that attracts a certain crowd. So I was I was super lucky. And I know that's not the case everywhere. But

 

Dr Anna Lembke  26:51  

the other thing to keep in mind is that the rates of alcohol use disorder and women have gone up 85% in the last two decades, 85%, the ratio of women who are addicted to alcohol, or men who are addicted to alcohol versus women has been in the range of five to one to two to one for many generations, but in the last generation, starting with the millennials, that is approached one to one. And so now women are as likely to present with an alcohol use disorder as men, which is a brand new phenomenon. And really, you know, therefore, I do appreciate that, you know, women, who are we have more women than ever, you know, addicted to alcohol, they're also wanting new ways that are better suited to women, possibly, you know, to get into recovery.

 

Arlina Allen  27:41  

Yeah, I had a friend point out that, you know, the court system is sending people to a, who may or may not belong there, you know, predators, people with, you know, you know, violent histories or whatever that, you know, the court system is sending a lot of people there, too, I always tell women to go to women's meetings,

 

Dr Anna Lembke  28:00  

I think that's a good place place to start. Or what I say to people is that, you know, going to meetings is a little bit. I mean, maybe this isn't a great analogy, but it's a little bit like dating, you have to, you know, meet a bunch of different meetings before you find one that you like, that's a great analogy. And there's a lot of frogs. Yeah. And then the truth is that recovery is better in some meetings than others. So you want to make sure you find a meeting where there's good recovery and recovery can change. I mean, these are very organic, human gatherings, and you can have a meeting that's really unhealthy and positive, and then it loses a few key people, or there's some other disruption of location or time you lose that frame and you lose the meeting. So it's important to, you know, to just make sure you're going to Good, good meetings.

 

Arlina Allen  28:47  

Yeah, absolutely. And, you know, I've seen, like for women who have children like I, you for, so I was with my husband, and he's sober. And we didn't go to meetings together for like, 10 years when we first had kids, because number one, I never, I can't focus on funding to bring my kid to Yeah, it was just a variety mindset. Yeah, yeah. So there were so for women, when they have kids, it's like lifestyle changes, you know, affect your ability to go to, to meetings. I know. For some women, it was like, they're working full time. They have kids, it's like, you want me to go to 90 meetings in 90 days? That seems impossible. But you know, nowadays, it's a little different because we have online meetings and things like that. We have a little more, but gosh, it depends. I know the pandemic was really hard on a lot of people in a lot of ways. But it also presented has now provided new opportunities, because now women can go to meetings like we can literally, there's an international woman's meeting that goes 24 seven. Wow, that's cool. Yeah, it's been continuous for four months now. I want to ask you, I've so many questions. So we were talking about early recovery, people experiencing boredom and Takes about, you know, it takes some time for that to heal. So I think if people are aware of that that's coming that they can adapt to that. And to know that their passions for things will come back. Dr. Haberman described addiction as a narrowing of things that bring pleasure. And it's so interesting because as soon as we set it down, it's like, we start finding other things interesting again, when it comes to so I'm a mom, I know a lot of my listeners are your mom, you know, the whole video game thing, especially in this age of pandemic, where kids don't really have a whole lot to do and they're craving connection. It's been really confusing as a parent to know how to support your kids. It's like, Listen, I can't entertain their, you know, their teenagers, I can entertain them the whole time. It's like I have work to do. But I'm terrified about what's what happens to them sometimes in this in this age, and I have moms that are like, and our kids are so in touch with, like their neurosis now, like when I was coming up, we didn't know that my sister was struggling with clinical depression. We didn't know that that was the thing. The you know, whatever. 40 I don't know how overall I don't do math A long time ago. But now the kids are like, Oh, I have anxiety. I have depression. I have this. It's you know, the sex. Sexual orientation is so fluid. And it's like, as a parent, it's hard to know how to support your kids because we were kind of grew. I think you grew up with syrup. Did you grow up with like, a little bit of tough love?

 

Dr Anna Lembke  31:36  

Yeah, you know, a little bit of healthy neglect. I think it's fair to say, maybe verging on unhealthy neglect. But yeah, baby nine.

 

Unknown Speaker  31:44  

Is that a thing? benign?

 

Arlina Allen  31:45  

Yeah, so that's Yeah, my mom was a total badass. Is that was like it was the whole Go figure. Figure it out? That's right. Yeah, for yourself. And, but we don't do that to our kids now, because we are aware of like the suicide rate. So I feel like we're in a rock between a rock and a hard place, because we can't really do the hardest thing anymore. Because our kids might kill themselves. And it's like, how, as a mom, am I supposed to help my kids through the difficult times without them getting addicted to video games? Or like, even if they're home all the time, they're not doing drugs and alcohol? They can still be, you know, porn. And listen, I don't even want to know. But video, let's just say video games, just like the online stimulation. How do I, as a mom, like your mom, how do you help your kids? How do we help our kids like self regulate?

 

Dr Anna Lembke  32:44  

Well, I think an important important place to start is to talk about how pleasure and pain are processed in the brain. And how the brain really does want to assert this level balance or preserve homeostasis. And that any deviation from neutrality, whether it's on the pleasure side, or the pain side actually constitutes a stressor to the brains when we think about what's stressing kids out. Now, I would argue, as I do argue, in my book, that it's all of the feel good drugs and behaviors that's actually contributing to the stressors itself. Because when we're the kids are playing these video games, they're getting a huge bolus of dopamine in the reward pathway, then their brains need to compensate by down regulating their own dopamine transmission, bringing it bringing in those postsynaptic receptors. Such that you know, when those kids try to pull away from the video game, first of all, it's very hard to do that they will experientially describe that. And then they're depressed. So it's actually the gaming and the pornography and the social media that is causing the depression and anxiety and not the other way around. So what I counsel parents to do is to first understand something about that basic neurophysiology, explain it to their kids, talk to kids about how these online products can be great, but they can also be drugs and that they have been engineered to be drugs and to keep us clicking, and swiping and scrolling. And that we have to be really mindful of how we're using them and that in moderation, it's just fine. But just like you wouldn't get up and eat ice cream for breakfast, you probably don't want to get up first thing in the morning and, you know, be scrolling through social media and do that all day long. You know, the all all good things in moderation. Right, right. I mean, so we're all we all struggle with this. It's not just our kids. The other thing I say to parents, you know, so, as a family, talk about the dangers in talking about the good things about social media and video games and all that, but also talk about the dangers. Talk about how important it is to pay attention to not just how you feel when you're doing the activity, but also how it makes you feel afterwards. Talk about the importance of having some device free and tech free times in the day like maybe at dinner time or some other time with the family. Family, maybe taking tech free vacations, if you can do that, where maybe for a week at a time, everybody leaves their devices at home and goes and interacts in nature. These are all things that people, they just like they're horrified at the thoughts they get, right? Thinking about just leaving their phone behind, but But the truth is, that's really an indication of how addicted, we have all become. Even the thought of not bringing our phones with us, you know, generates anxiety. And you know, that's the same thing as my patients who are addicted to alcohol. And the thought of not having access to alcohol at that party, or at that gathering, or when I get home, you know, is absolutely terrifying to me. So I think we really have to, you know, conceptualize these behaviors as potentially highly addictive and, you know, be thoughtful about organizing our use around them to really respect the pathophysiology. In the

 

Arlina Allen  35:57  

first the first thought they came up here and he said, Take a tech free vacation, I was like, isn't the first week off of addiction like your worst week?

 

Dr Anna Lembke  36:06  

It is, it is. And frankly, that's why I do recommend a full month off in order to give it enough time to reset reward pathways so that you're not craving anymore. Yeah. And then and then if you want to go back to using or you have to go back to using because you need the smartphone for your work. Really, at that point, it's much easier to be intentional and thoughtful about using differently using less barriers.

 

Arlina Allen  36:31  

Like the self binding you were talking about.

 

Unknown Speaker  36:34  

Right? Okay, so

 

Arlina Allen  36:35  

I'm going to jump to that since we just talked about it. So page 93 of the book, we talk about binding and I thought that was really interesting. I loved how he used Homer's Odysseus and the sirens, the story of the sirens, how's the captain would be back on his air in time self to the boat. You know what's funny is this whole time I thought the sirens were like mermaids. They're birds.

 

Dr Anna Lembke  36:57  

They're half bird, half human creatures who spell bind sailors with their enchanting song, lure them to the rocks, and kill them that way. Kill him. I don't know. But yeah, so the story, right is that that he he but he asks his sailors to bind him to the mast, and to put beeswax in his ear so they can get through that passage without being lowered, lowered by the sirens.

 

Arlina Allen  37:22  

What are some of those? Okay, so we mentioned, let's see, I have a list of I had a list of soft binding, things you mentioned, you know, first thing that came to mind was rehab, that's kind of a soft binding thing. And it's the first 30 days gives you a chance for your brain to reset. Obviously, like changing your environment, removing all temptations around your house when you were talking about video games, you know, or other devices. You had an interesting, I don't want to spoil the book for anybody, but you had an interesting client or patient that had a machine. Right, right, machine. But anyway, he broke in her head and did all kinds of crazy things to try to avoid it. bless his heart, that must have been awful. But yeah, so we do all kinds of self binding practices or so but I kind of wanted to relay that relate that to medications, would you consider medications a self binding? practice?

 

Dr Anna Lembke  38:25  

Yeah, I think they really can be so for example, if you take a medication like now trek zone, which blocks the opioid receptor, that's been shown to help people reduce or stop opioids because obviously if the receptors blocked opioids like heroin or fake it in whatever it is, can't bind, but alcohol is also mediated through our own endogenous opioid system. So when the naltrexone is on the opioid receptor, alcohol is not as reinforcing. And so that can help people either stop drinking alcohol or reduce the number of drinks on drinking days. So it's a nice medicine to help people not only whose goal is abstinence, but also who have a goal of moderation. You know,

 

Arlina Allen  39:09  

I have a client who has a family member, let's say is probably physically addicted alcohol is naltrexone use for somebody that you're chemically detoxing or medically detoxing. Is that a is that a drug that

 

Dr Anna Lembke  39:24  

we we think of detox which is that period of helping somebody through acute withdrawal, especially potentially life threatening withdrawal and say that alcohol withdrawal can be life threatening benzodiazepine withdrawal can be life threatening that Xanax, Valium, Klonopin, advant opioid withdrawal can be life threatening. So if you're somebody who's so physically dependent on alcohol, benzos, or opioids, that you're going to go into life threatening withdrawal, you wouldn't want to just quit, you know, you would want to go see a doctor and have a medically supervised you know, medically managed withdrawal All we really think of addiction treatment or recovery as beginning, when acute withdrawal is over. Oh god, no, naltrexone is a medicine that we would use to help somebody get into and maintain recovery. It's not a medicine that we use in in acute withdrawal.

 

Arlina Allen  40:22  

Okay, so that's after acute withdrawal. That's right. Yeah, that's important. Let's talk a little bit about I like that you have dopamine as an acronym on page 88. Okay, he had it summarized in that little, and a picture. I like pictures. Can we go over the what it stands for?

 

Dr Anna Lembke  40:44  

Yeah. So the dopamine acronym is really just a framework for how to initially approach the problem of compulsive overconsumption, or in some cases, addiction. This is a framework that is good choice in people who are not so physically dependent, that they're going to go into life threatening withdrawal. And it wouldn't be a good framework for somebody who had already repeatedly tried to stop on their own and just was incapable somebody, for example, who was injecting heroin multiple times a day and just couldn't even go for a day without so that that would be somebody who would really need a higher level of care. But for those of us who have maybe mild to moderate addiction, or maybe aren't even addicted yet, but we're on our way to becoming addicted and or just engaging in compulsive overconsumption. This dopamine acronym kind of outlines a basic framework, and the D stands for data. And that's where I asked patients to describe to me what they're using, how much how often, and just by getting them to articulate to another human being what they're doing, that often brings into relief, their actual use in a way that they can be in denial about as long as it's just kind of this amorphous behavior in their heads. So I really like to start with just asking them in a non judgmental way, you know, how much are you on social media? How many hours a day? What are you doing? The O of dopamine stands for objectives. And this really gets into why why is it that you're doing that drug, or that behavior? What's positive about it for you, because I really do think that even irrational behaviors make some sense, subjectively, and so it's important for us to understand what's driving that individual's behavior. And then the P of dopamine stands for problems, that's when we get into, you know, what's problematic about your use, I understand why you do it, I understand what's good about it, what's problematic about it, and that can range to everything from you know, it's not working anymore. Like it used to do X, Y, and Z for me, and it's not doing those things, too, it costs a lot of money to it's interfering with my relationships work with my ability to do schoolwork, with my health. So there are many, many different reasons that people people will say, often, you know, in the way they do it, that it's, you know, to solve a problem, like anxiety or depression, but it may not be solving that problem anymore.

 

Arlina Allen  43:13  

Sorry. So you get them sort of in touch with specifics. Yeah. So yeah, so you're not asserting pressure? Because I think I used to be a sales grown and sales, they teach you not to pressure people because it viscerally creates resistance. Yeah, right. Right. But when you ask somebody like, what, what problems is it caused? Like, what specifically what caught? What problems? Is it causing for you? They're coming up with their own. Like, I went through that experience to specific consequences that were a problem for me,

 

Dr Anna Lembke  43:47  

right? Yeah, you basically ask them just to be objective and analytical about their own subjective experience. And just kind of, you know, go, Hey, you know, this is what I do. And this is, this is how it makes me feel.

 

Arlina Allen  44:00  

You know, what I love about science when it comes to addiction? Is it kind of depersonalized is that because we experienced so much shame and guilt? And we did terrible? Listen, I did, did some terrible and embarrassing things when I was drinking and using they caused guilt and shame, right? Well, when I started to understand the mechanics of why I fell into the trap in the first place, was sort of depersonalized it a little bit, right and took away some of the guilt and shame. And I love this approach of objective analytical sciency stuff, because it does sort of make it more easier for me to then accept the solution.

 

Dr Anna Lembke  44:37  

Yeah, you realize it's not about your it's not that you're a bad person, it's that it's a bad disease. And these are highly addictive substances and behaviors and they were engineered to hook us, right. The a of dopamine is really the the key intervention and that's where I ask patients to abstain from their drug of choice for 30 days. Why 30 days because that's an amount of time that most people can wrap their head around and I say never drink again. I'm Not going to be very persuasive, but I say, Hey, can you give it up for 30 days, please, I can, I can probably do that. The other thing again is that 30 days is the minimum amount of time it takes for those neural adaptation Gremlins to hop off the pain side of the balance for homeostasis to be restored, which is just another way of saying that's the amount of time it takes for us to up regulate our dopamine receptors and dopamine transmission so that we can widen our lens start to enjoy other things, but also look back and see true cause and effect because when we're chasing dopamine we really don't see the impact that it has on our lives.

 

Arlina Allen  45:37  

It's so we get so blind that's like the denial part, right? Yeah, we lose completely lose perspective.

 

Dr Anna Lembke  45:43  

That's right. The hard thing about getting patients to you know engage in this in this task is that many of them come in feeling bad already, right? They're looking fresh and anxiety and then I'm suggesting to do something that's going to actually make them feel worse and worse. But what I say to them it's kind of like getting you know treatment for cancer it's it's really hard when you're in it, but when you come out the other side of it, it'll it'll be worth it and potentially life saving, saving. Yeah. And then the The M is stands for mindfulness is just a way to sit with feelings, including negative, scary, strange feelings, without judgment and also without reaction without trying to get rid of those feelings. insight of dopamine acronym, just stands for how this this experiment really does give us an enormous amount of insight often into how addicted we really are. Because like I said, we were we will tend to minimize and normalize and you know, in the book, I talk about my my own romance novel reading addiction. So

 

Unknown Speaker  46:42  

funny as all I'm right there with you, girl. Until I like, Oh, yeah, right. As it is embarrassing. my

 

Arlina Allen  46:48  

mic, as

 

Unknown Speaker  46:49  

I know, it is.

 

Arlina Allen  46:51  

My boys are like sparkly vampires. What

 

Dr Anna Lembke  46:53  

is right, right, I know, two additional ways that we are sort of incontinent around our desires is always shame producing. It's interesting. Yeah. But, but you know, this is really again, just a way to gather data, do an experiment, gain insight. And it's an embodied physical experiment, I think that's really key, too, because so much of our mental health interventions are asking patients to sort of just rearrange their thoughts. But this is a really physical thing where you know, you go into withdrawal, you know, when you feel that physically, and it's painful. So kind of asking people to embrace something that's painful in the service of feeling better in the long run. And then N stands for next steps. That's when people come back after a month, if they were able to do it, I say, Okay, do you want to keep abstaining? Or do you want to go back to using and most of them say they want to go back to using what they want to use in moderation? Yeah. And sometimes

 

Arlina Allen  47:48  

disappointing for you to hear, like, does that make you nervous, you know,

 

Dr Anna Lembke  47:51  

sometimes, because sometimes my choice for them really would be absence, and I kind of know that they're not going to be able to moderate. But you know, you got to meet patients where they are. And if I try to railroad them into it, it's not going to work pressure, sometimes they just have to go out and get more data and go through that loop a couple more times. And they're like, you know, what, I think I'm better off abstaining. I that's much more persuasive than if I try to tell them, that's not really gonna work for you. The other thing I would say is I have had patients who surprised me, and actually with enormous effort, were able to abstain sometimes even when they were able to do it, though they said it wasn't worth it, it took too much effort and energy, that it was easier to abstain. But importantly, there are no drugs that we use that we can't abstain from, like food, or like our smartphones so hard. Yeah. Or sex. I mean, I think most of us think of sex as, as a part of, you know, a healthy part of a healthy life. But then that idea of Well, how do we moderate becomes important, I think, for all of us, even for those of us who are trying to abstain from our drug of choice, because, because we're just bombarded by these highly rewarding substances and behaviors. And so we're all we're all challenged with, you know, abstention, and moderation and, and I really think that people in recovery, you know, as I say, in the book, our modern day profits for the rest of us kind of can show us how to live in this token saturated world. So just to finish off, then e of dopamine stands for experiment. That's where people go back out and implement what they've learned now with a pleasure pain pathway that's at the homeostatic level place. You know, so they can go out and have a better chance of being successful with moderation, or abstinence, or whatever it is.

 

Arlina Allen  49:39  

Yeah. Thank you for going through that and being able to remember all the things you were super smart, I would not have been able to do that off the top of my head. A couple of questions came up from as you were going through that. So I just find it like such a paradox that you know, people with these use disorder. have such as high tolerance for pain on one hand like the consequences and on on the other hand we have such an in ability we have like this avoidance of emotional pain right and I just wonder I heard this I was watching this show things totally unrelated But anyway, I was watching the show called meat eater and this guy was talking about how and as a hunter, you know, human beings have something called shifting baseline syndrome. Have you ever heard of that idea? The idea is that as human evolution through human evolution or as societies change, we have good time feast and famine right? And so we have this ability to normalize lower standards of living, right and so in Alcoholics Anonymous that we talk about seeking lower companionship or like this is okay this is okay. Yeah, and so I was like that is so funny. But at the same time when it comes to paint like emotional pain tolerance, it feels like we're living in this really weird worldwide we're experiencing or we're creating all this pain for ourselves because we're you know, you drink in us you spend all your money and you're in all this pain and so what do you do you drink and use more to because you can't tolerate the pain you know, it's just such a weird place to be we have this and I feel like in all fairness that most people have an avoidance of emotional pain what are some of the ways I mean I feel like you know the great thing about a it was like we have community like it's a ready made community to help us get through emotional pain. I shared with you earlier that my mom is ill I just found out last week that she's terminally ill. And I'm not insensitive, and he might be a little bit maybe a little bit numb. But I have found I so I've been 27 years sober. It used to be if I got stood up on a date, I would go on a bender, like I couldn't tolerate it. Now I'm sober a long time. My mom is really sick. And it doesn't even occur to me to use what happened to my brain. From that, you know what I'm saying? It's like, yeah, oh, yeah. Now what happened to my brain?

 

Dr Anna Lembke  52:17  

Well, I mean, your your brain is not any longer in that addiction cycle, your brain is at a homeostatic baseline. And it might even be tipped slightly to the side of pleasure such that you have the mental calluses and the resilience to withstand even enormously painful things like, you know, the potential loss of a loved one. Well, I'm again, I just think that thinking about the balance and the neurophysiology and that what happens when people are in their addiction loop is that they're essentially walking around with a pleasure pain balance tipped chronically to the side of pain, their dopamine transmission is at chronically lower levels. And so there's an enormous physiologic drive, to get their drug and to prioritize that drug over everything else, not to get high, but just to get out of pain and to feel normal. Whereas once you and that also means that even the nearest slight is going to make you feel more pain because you're already in this painful state. And that you know, what we call natural rewards, more modest rewards, food, clothing, shelter, a good conversation with a friend will no longer be adequate, right? Because you've got all these Gremlins camped out on the pain 10 pounds. Now you need a great big bolus of a supercharged potent drug, just to bring you level again. Whereas once you're in recovery, and you start to repair all of that and the Gremlins hop off and you start to upregulate, not just your own endogenous dopamine but also your endocannabinoid system, your endo opioid system, your serotonin or norepinephrine. Now you've got a pleasure pain balance, that's subtle, right? It's homeostatic it's level its sensitive, appropriately to small pleasures. It's sensitive to small pains but resilient enough to you know, quickly restore homeostasis in both directions. And you know, that's that's great. That's exactly where we want to be. Yeah, it

 

Arlina Allen  54:10  

takes takes a lot of work takes a lot it does

 

Unknown Speaker  54:12  

it takes a lot of vigilance and where it's you know, when you when I think about that pleasure, pain balance, it's sometimes I say it's like a teeter totter and a kid's playground, but really, it's more like a piece of plywood on a ball and you're standing on that piece and you're constantly having to move in order to keep in balance it's not a static process it's a really dynamic process that takes constant small adjustments

 

Arlina Allen  54:37  

Yeah, and I'm glad you talked about that you're you know talking about balance and and and we only have a couple minutes and so I did want to touch on the scent. Thank you so much for writing this book. This was so such such an important book for people like me, who need to know why and need to know how and what to do about it right like we can we know ruminate on the problem. All day long, but I need to know what to do. Right? There are practical steps, tangible, practical, understandable, things to do to get better. And the idea is that and you did talk about like we can break our dopamine reward system, but you also said we can heal it. And that is the hope that this will give provides so much hope and like a real concrete, practical way that doesn't require like a you know, religion or you don't have to do like, like, I'm not knocking that at all right? Because I found that to be super helpful, but I don't know I'm a science girl at heart and I need to know why. I write I need to me, to me kind of girl at the end of the day, and at the end of the book on page 231 we're talking about your conclusion, which is the lessons of balance and you know, I've, you know, heard people say I think of balance is sort of a wide path that's not a razor's edge and I just gonna read under read you something that you wrote, you're like I already know. We all desire a respite from the world, a break from the impossible standards we often set for ourselves and others. It's natural that we would seek a reprieve from our own relentless ruminations. Oh, my God, the whole obsessive thinking, why did I do this? Why can't I do that? Look what they did to me? How could I do that to them? And then your question you pose is what if, instead of seeking oblivion by escaping from the world, we turn toward it? That is the challenge, right? That is the challenge is to, you know, Sheryl Sandberg said lean in, right, you know, but it's in the leaning in that, it we, you know, I'm always talking about let's process her resolution, right. And that requires leaning in,

 

Unknown Speaker  56:55  

it does, yeah. And I think, you know, I mean, we're all seeking transcendence, and that loss of self, that non being where we're not ruminating and thinking about ourselves in the world, and, you know, escaping with drugs, or in my case in into fantasy novels, you know, is one way to do that, but not ultimately, a very adaptive way to do that, a better way to do that is actually to do the opposite. And really engage with the people around us with the life that we've been given, immerse ourselves in it. And when we invest in and immerse ourselves in, you know, in our real lives, they do become, you know, transcendental, they do take on a kind of luminous and numinous quality that's really enhancing that releases dopamine, but in a way that is enduring, and healthy. And so yeah, that's, I think, really the antidote to to to addiction, you know, instead of trying to run away, turn around, and immerse yourself in it.

 

Arlina Allen  57:57  

That is the antidote simple, but not easy.

 

Unknown Speaker  57:59  

That's not easy to do. Yeah, well, listen,

 

Arlina Allen  58:03  

at the end of the day, that's why we all need each other. Right? You know, and, and I know from reading the book that you did your own work, and I really appreciated that about you, thank you for sharing those for your transparency and your vulnerability in the book of sharing your own, you know, struggles that you did your own work. So thank you. Thank you so much again, for this time, I'm so honored and and this was such an amazing book and where do people find? Find out more about you?

 

Unknown Speaker  58:32  

Well, the book is available where books are sold, that's probably the best source of finding my work. It's also available on on Audible, as you mentioned, for people who'd rather listen than then read a physical book or a Kindle version. And then there's more about me on on Olympia calm or dopamine nation calm a website that was created for the book.

 

Arlina Allen  58:56  

Listen, thank you so much for idea, tell Andrew I said “Hey”.

 

Unknown Speaker  59:03  

All right. Yeah. Thank you so much.