The Art of Manliness - Do You Need to Take a Dopamine Fast？

00:00:00.000 brett mckay here and welcome to another edition of the art of manliness podcast and you probably

00:00:11.200 know someone who struggled with a severe addiction to drugs or alcohol maybe you're battling a big

00:00:15.680 addiction right now even if you don't have a severe addiction that gets in the way of your

00:00:18.820 life you might have a habit that you're not happy with like looking at your smartphone or playing

00:00:22.640 video games too much whether big or small these compulsive behaviors share a similar underlying

00:00:27.040 cause they're an attempt to assuage pain through pleasure but as my guest say argues the problem

00:00:31.680 is that relentless pursuit of pleasure only leads to more pain her name is anna limke and she's chief

00:00:36.520 of stanford's addiction medicine clinic and the author of the book dopamine nation finding balance

00:00:40.800 in an age of indulgence at the start of our conversation anna impacts the definition of 0.98

00:00:44.640 addiction why she believes it equally applies to substances like drugs as behaviors like using

00:00:49.120 porn and how it exists on a spectrum from the serious and severe to the mild and minor anna

00:00:53.920 explains why life in our comfortable pleasure-filled modern society is increasing the problem of

00:00:58.000 addiction and argues that the reason we're so miserable is that we're working so hard to avoid

00:01:01.840 being miserable she then digs into the science of why we become addicted to substances and behaviors

00:01:06.160 and how it all comes down to our mind and body trying to seek balance between pleasure and pain

00:01:10.480 we discuss dopamine's role in this seesaw dynamic and how the substances and technologies of modernity

00:01:15.600 can lead to a dopamine deficit we then walk through the process of getting a handle on your

00:01:19.600 addiction including the importance of doing a dopamine fast and how long the fast needs to be

00:01:23.440 to be effective anna then shares tactics for sticking through this abstinence period which 1.00

00:01:27.440 include counterintuitively intentionally seeking out pain she explains why dopamine fast can help you

00:01:32.400 rebalance your brain what comes after it's over and much more after the show is over check out our

00:01:36.640 show notes at aom.is dopamine nation all right anna limke welcome to the show thank you for having me

00:01:54.480 i'm excited to be here so you are the medical director of stanford's addiction medicine program

00:01:59.840 and you got a new book out called dopamine nation finding balance in the age of indulgence and this is a

00:02:05.440 it's a really easy to follow easy to understand guide through the science of addiction and then

00:02:10.720 you also walk readers through the process you use with patients that come to you with addiction

00:02:16.240 problems so let's dig into this book first question let's start with definitions how do you as a

00:02:21.120 clinician define addiction because i think a lay person that when they hear the word addiction they

00:02:25.680 think well you can be addicted to substances like alcohol or nicotine or cocaine but can behaviors

00:02:32.640 be addictions so yeah clinically how do you how do you define addiction yeah i mean so our brains are

00:02:39.040 evolutionarily designed over millions of years to approach pleasure and avoid pain and anything really

00:02:45.200 that brings us pleasure or gives us relief immediately from pain has the potential to become addictive

00:02:54.080 particularly if we have an innate vulnerability to that problem addiction broadly defined is the

00:03:00.880 continued compulsive use of a substance or behavior despite harm to self and or others

00:03:08.800 and one way to remember the diagnostic criteria for addiction shorthand is to think of the three c's

00:03:16.480 control compulsion and consequences out of control use compulsive use meaning a level of automaticity

00:03:24.080 to the use and mental preoccupation with using and then consequences and especially the continued

00:03:30.560 use of that substance or behavior despite consequences all right so i guess if there's not bad consequences

00:03:37.520 would it be would a substance behavior be considered addictive let's say you haven't you just habitually

00:03:43.280 like to i don't know drink orange juice every morning as long as that's not getting in your way of

00:03:49.440 your life or others life that's not considered addiction absolutely i mean this is not to say that

00:03:55.120 anything you enjoy is addictive or even has the potential for addiction this really is talking about

00:04:02.640 you know compulsive out of control use that is pathological meaning that it it adversely impacts

00:04:10.240 your life and possibly the lives of other people but i will say that one of the core features of

00:04:16.320 addiction is what we call denial and as one of my patients said denial isn't actually an acronym that

00:04:22.640 stands for don't even know i am lying so we can be addicted and caught up in an addiction not see the

00:04:29.680 consequences even when they're there so you mentioned behaviors can also be addictive and i i've noticed

00:04:35.840 i've kind of kept up with you know you see these magazine articles or news stories pop up about the

00:04:40.880 controversy surrounding whether or not a behavior can be considered addictive so whether shopping

00:04:46.240 whether there's a shopping addiction internet addiction sex addiction why has there been so

00:04:51.600 much controversy about whether behaviors can be addictive you know i'm not sure it's a good

00:04:57.600 question and you're absolutely right there is that controversy there but in my clinical work i really

00:05:02.560 see no difference in terms of the natural history of the behaviors whether the drug is alcohol or whether

00:05:09.360 it's pornography or whatever it is people usually start out using their drug for fun or to solve a

00:05:17.200 problem and that problem can range from depression anxiety inability to concentrate to just plain old

00:05:22.560 boredom and then if the drug works for them they naturally repeat use and over time they find themselves

00:05:30.720 using every day or in a binge pattern in greater and greater quantities and then ultimately they get to a

00:05:37.200 point where they can't stop even when they want to and many patients become depressed and anxious and

00:05:43.680 suicidal and that's as true for a pornography addiction or a gambling addiction or a gaming a gaming addiction

00:05:49.680 as it is again for drugs and alcohol so i don't know why there's this controversy because i can tell you

00:05:55.760 i've got a front seat to these problems and you can definitely get addicted to behaviors

00:06:00.960 well let's talk about the state of addiction in america today what's that like are addictive behaviors

00:06:07.280 addictive substance use is that on on the rise do we have an idea how many people have an addiction of

00:06:12.960 some sort yeah so addictions are on the rise all over the world especially in developed nations not

00:06:19.600 only are more people developing addictions but more people in demographic categories that were previously

00:06:26.320 thought to be immune to addiction are developing addiction that would include women and older people it's also

00:06:32.960 true that more people are dying from their addictions and if you look at sort of global deaths from

00:06:41.040 addiction 50 of those deaths are occurring in people under the age of 50 so we have a lot of young

00:06:48.480 people dying from addiction i would also add that more and more we're seeing minor addictions so if

00:06:55.920 addiction is a spectrum disorder mild moderate and severe and we're seeing more and more people with

00:07:01.760 with mild addictions and more and more people with either digital addictions or digitally mediated

00:07:08.720 addiction so people addicted to their their devices or addicted to a portal that the device gives them

00:07:16.560 access to so whether that could be online shopping pornography gambling etc yeah exactly so starting in the

00:07:23.680 early 2000s i started seeing more and more patients coming in specifically seeking help

00:07:29.440 for pornography gambling and gaming addictions and almost universally they reported that the tipping

00:07:36.960 point for them was getting a smartphone which made access you know 24 7 well here's a question maybe

00:07:44.800 that you might know off the top of your head do we is like a gender breakdown on addictions are there 0.79

00:07:49.280 is there one gender more likely to be addicted than the other so historically men are much more likely to become

00:07:57.520 addicted than women in a ratio that ranges between five to one and two to one but depending upon the

00:08:06.640 substance that's really changed especially among millennials so for example when it comes to alcohol

00:08:12.000 addiction millennial women are now as likely as millennial men to develop an alcohol use disorder and i would

00:08:19.680 say overall that's been the big shift gender wise that we've seen in the last couple of generations

00:08:25.360 many many more women presenting with serious addictions whereas in previous generations that was not the

00:08:31.920 case if you break it down by drug certainly video game addiction many more men play video games than

00:08:38.560 women and many more men and women struggle with video game addiction that's also true for pornography

00:08:45.360 addiction gambling addiction i mean i think you talk about this in the book the thing that's driving

00:08:49.520 is that a lot of this stuff is just it's easier to access than ever gambling you can gamble from your

00:08:54.400 computer pornography you can access it from your smartphone where before you would have to go and

00:09:00.400 move yourself physically to obtain these substances you no longer have to do that when we think about

00:09:05.600 the risk factors for addiction one of the risk factors that's often underestimated is simple access

00:09:11.680 if you live in a neighborhood where drugs are available on the street corner you're more likely to try

00:09:15.760 them and more likely to get addicted if you go to a doctor who liberally prescribes xanax and oxycontin

00:09:21.680 you're more likely to be exposed and more likely to get addicted so you're absolutely right it's the

00:09:27.200 increased access that has become one of the major risk factors for addiction in the modern world

00:09:33.280 and you make this interesting point that i didn't know about about prohibition i think typically

00:09:37.680 the way you're we learn about prohibition america is like well it was just an overzealous thing we made

00:09:43.280 we amended the constitution and then it caused the black market and we had gangster fights and

00:09:48.080 whatever and that was a mistake and we that's why we repealed prohibition but you highlight you know

00:09:53.600 the research says that actually prohibition worked to reduce alcohol consumption and it had a long

00:09:58.960 lasting effect even after it was repealed it was like wasn't until the 1950s that alcohol consumption

00:10:03.600 started increasing again in america that's right and prohibition not only decreased alcohol consumption

00:10:09.920 it decreased rates of public drunkenness it decreased alcohol related liver disease even in the absence

00:10:17.440 of new treatments for that so um you know prohibition had a positive effect on alcohol consumption and the

00:10:25.680 adverse consequences related to it and that's a piece of that history that often gets lost and really

00:10:32.240 does demonstrate a natural experiment in which access to a very addictive intoxicant namely alcohol

00:10:39.840 was decreased and as a result the harms related to use also decreased so there's an increase in

00:10:46.720 availability to addictive substances or i guess we would say portals that can encourage addictive behavior

00:10:54.080 besides that i mean what does i mean people go to these things whether it's alcohol or pornography because

00:10:59.680 they feel bad and they're trying to assuage that to feel better what is it about modern life because

00:11:07.200 you think well modern life's great like we got indoor plumbing we've got antibiotics i mean yeah

00:11:12.160 there's some stuff we got a pandemic going on but for the most part life's great so why why do we feel

00:11:17.440 like we need to turn to substances or behaviors to that can be maladaptive to make us feel better

00:11:23.600 the way that i understand this and it's a major premise of of the book is that it's essentially a

00:11:30.640 mismatch between our primitive brain and our modern ecosystem i mean our brains were evolved over

00:11:36.960 millions of years for a world of scarcity in which we would have to work very hard to obtain even

00:11:42.960 subsistence level kind of survival needs food clothing shelter a mate we now live in a time when those things

00:11:51.760 are available in a kind of horrific overabundance and technology has allowed us to make highly potent

00:12:01.040 drugified versions of all that at the same time our lives have become more much more comfortable so we

00:12:07.840 also seldom have to experience any kind of physical pain unless unless we get ill or unless we intentionally

00:12:15.280 seek it out and so it's this insulation from pain and this constant ingestion of these highly potent

00:12:22.160 intoxicants in many different forms that essentially our brains can't tolerate and as a result

00:12:28.960 we've down-regulated our own dopamine and our own dopamine receptors and are essentially

00:12:33.280 inducing a dopamine deficit state so you know to answer your question i sort of turn it on its head the

00:12:39.520 the reason that i believe that so many of us are so so miserable is because we're working so hard to

00:12:45.680 avoid being miserable that's counterintuitive because most people would say yes yeah and and

00:12:51.760 it suggests that the antidote is actually to avoid pleasure and to actively seek out challenging

00:12:58.560 uncomfortable situations well let's get into like the mechanism of addiction here and you kind of

00:13:04.880 talked about a little bit just now so you make this argument we've been so inundated with pleasure

00:13:11.520 that like we basically are desensitized to it so we have to look for stronger and stronger things

00:13:16.640 to give us pleasure walk us through that this cycle like the role that dopamine plays in the addictive

00:13:22.960 process sure so one of the most interesting findings in neuroscience in the last 75 years is that the same

00:13:30.560 parts of the brain that process the experience of pleasure also process the experience of pain and

00:13:36.720 that pleasure and pain work like a balance so for example if i do something pleasurable like eat a piece

00:13:43.120 of chocolate i get a little release of dopamine in the brain dopamine is a neurotransmitter that's

00:13:49.280 intimately associated with the experience of pleasure reward and motivation and that release of dopamine causes

00:13:56.320 my pleasure pain balance to tip to the side of pleasure but one of the rules governing that balance

00:14:02.400 is that it wants to preserve what's called homeostasis it wants to remain level so no sooner has that

00:14:08.000 happened than my brain down regulates my own dopamine transmission and my own dopamine receptors and i

00:14:14.080 imagine that as these little neuroadaptation gremlins hopping on the pain side of the balance to bring it level

00:14:19.840 again but those gremlins like it on the balance so they don't get off when the balance is level they

00:14:25.520 stay on until the balance is tipped an equal and opposite amount to the side of pain and that's what's called the

00:14:31.320 opponent process mechanism also known as the come down the hangover the after effect now if i wait long enough

00:14:39.040 those gremlins will hop off that feeling of wanting a second piece of chocolate will resolve and my balance

00:14:45.680 will be restored to the to a level balance but if i continue to eat chocolate over and over and over again

00:14:51.840 essentially that initial pleasurable response gets weaker and shorter more gremlins hop on the pain

00:14:58.800 side of the balance and that after response gets stronger and longer and ultimately i end up with

00:15:04.240 enough gremlins on the pain side of the balance to fill this whole room so i end up with a brain that is

00:15:11.960 in a dopamine deficit state and in that state i don't really enjoy anything and i have to keep eating

00:15:18.640 chocolate not to feel good but just to feel normal and that's essentially that you know long slide

00:15:25.260 into addiction now again the hypothesis is that if we wait long enough and we abstain for long enough

00:15:32.200 eventually the gremlins will hop off but it can take a really long time on the order of you know weeks

00:15:38.440 to months or in some cases for severe addiction even years well so yeah the gremlins hop on and one way

00:15:45.240 you try to counter that is you just try to increase the amount of pleasure right so you might if you're

00:15:50.760 using drugs you're gonna use a stronger and stronger drug to weigh on that pleasure side but that's not

00:15:56.640 going to work it's just going to make things worse and worse or like in the in this instance of like

00:15:59.840 with pornography you have to start looking for kinkier and kinkier stuff so you can actually feel a bit 0.76

00:16:04.580 of pleasure but in the long run you're just it's that more of those gremlin those pain gremlins are going

00:16:09.900 to hop on the other side of the this pain pleasure seesaw that is exactly right we essentially go to

00:16:15.900 war with our gremlins and they are going to win trust me whether it takes days or weeks or months

00:16:21.900 or years eventually no matter how potent the drug it eventually stops working and it puts us into this

00:16:29.420 dopamine deficit state or this balance tilted to the side of pain where when we're not using we're

00:16:35.140 experiencing the universal symptoms of withdrawal from any addictive substance and that's irritability

00:16:40.860 anxiety insomnia depression and cravings intrusive thoughts of wanting to use even when we're trying

00:16:47.640 not to and in some cases with substances it can get so you become so dependent on it like you said like

00:16:53.000 you you just need it to function there's you know people who have severe alcoholism they say i have to

00:16:58.200 have a drink or else i just can't do normal things like i can't even i might even die if i

00:17:03.800 stop drinking all of a sudden well that is factually true so some some withdrawal phenomenon for example

00:17:10.100 from alcohol or from benzodiazepines like xanax can literally be life-threatening that when we stop

00:17:17.800 that balance slams down to the side of pain we experience a neurophysiologic storm essentially and

00:17:25.640 then we can seize and die from that so and even in the absence of a life-threatening withdrawal

00:17:31.220 it's truly a physical phenomenon that is incredibly painful for people to endure they will then do

00:17:38.240 anything to get their drug to get them out of that state and another thing you talk about in the book

00:17:44.560 another problem we have that makes addiction a bigger problem now than it was say 100 years ago

00:17:50.680 is that the substances we use they're a lot stronger the alcohol stronger like marijuana the types

00:17:57.500 of marijuana people are using are a lot stronger than baby boomers were smoking at woodstock in the 0.97

00:18:02.600 60s our digital devices just a constant flux of dopamine because there's all this novelty and there's

00:18:09.420 a lot of moving images that really activate that so we have that going against us so not only is

00:18:14.300 are things accessible the things that elicit the dopamine response are a lot stronger yeah there are so

00:18:21.140 many examples of the way that technology has has impacted this progression so for example in the 1880s

00:18:28.840 prior to the invention of the cigarette rolling machine it was possible to put out about four

00:18:34.860 cigarettes per minute but the cigarette rolling machine made it possible to produce 20 000 cigarettes

00:18:40.640 per minute and now we've got you know vape pens and jewel devices which you know are as accessible

00:18:48.860 as a usb port and deliver much higher levels of nicotine and increase blood concentrations of

00:18:57.040 nicotine much higher than even the average cigarette and that progression can be seen with opioids with

00:19:02.460 cannabis with pornography you name it technology has allowed for this basically evolution of drugs to

00:19:09.840 higher and higher potency forms available you know at the tap of a screen so when someone comes to you

00:19:17.480 with an addiction problem like what what's the thing like i mean is there like a common story a common

00:19:21.760 thread like the thing that finally said i've got a problem is there a common it's like does everyone

00:19:26.840 have like a common story is everyone different you know everyone's pretty different i mean the the

00:19:32.360 natural history of the disease is very common again people start out using for fun or to solve a

00:19:38.800 problem that problem can range from depression anxiety insomnia to just plain old boredom

00:19:44.380 over time and with repeated use they need more and more to get the same effect more potent forms

00:19:50.460 eventually they get to a point where they're using every day and they have difficulty stopping even when

00:19:56.380 they want to and it's interfering with their lives but that moment when people come in asking for help

00:20:03.280 is really different for for everybody for some people it's after they've lost their jobs their spouses

00:20:08.660 their houses they're in jail that's what it takes for some people for other people it's just that look

00:20:14.200 of profound disappointment on their spouse's face when the spouse realizes that they've been lied to

00:20:20.080 so when someone comes in you walk them through this process and you've developed this acronym dopamine

00:20:26.260 because dopamine is the thing that's driving addiction uh to summarize this process and the i'd like to walk

00:20:32.660 through this i think this was really useful great you said the d stands for data so when you when a

00:20:37.100 patient comes in and you you basically the first thing you do you you want to get data from them so

00:20:42.460 what kind of data are you collecting from your patient who's got an addiction problem just really

00:20:47.880 the facts of their use how much how often in what situations what brand the point here is really to just

00:20:56.520 have a kind of judgment-free conversation about the behaviors and the reason that this is critical is

00:21:04.700 because knowing what people are using really does give a good indication as to how serious the problem

00:21:10.320 is for example if they're using all day every day that would be very concerning no matter what the drug

00:21:14.620 is but also and probably more importantly when we are forced to tell another human being what we're

00:21:22.320 actually consuming how much when it really makes it real to us in a way that it's not real when it's

00:21:30.240 just pinging around in our own heads so that's an important first step yeah i can see that i imagine a lot of

00:21:36.200 people with an addiction problem they don't even know they like how much they drink or how much

00:21:41.020 pornography they use because they never thought about it but like this would actually make them realize

00:21:46.000 oh boy this is a bigger problem than i think it is or think it was right right exactly so for example

00:21:52.800 we sometimes use this approach called the timeline follow-back method where instead of asking

00:21:58.540 patients well how much alcohol do you drink in a week which is it's easy to average things out to

00:22:03.780 a lower number we i instead say well how much alcohol did you have yesterday and how about the

00:22:09.260 day before yesterday and how about the day before that and you know it comes out then to their surprise

00:22:14.540 that well wow i'm drinking three or four standard drinks per week which puts me in the 20 to 30 drinks

00:22:21.640 per week range which puts me you know in the one percentile right like that's a lot of alcohol

00:22:27.760 and all of a sudden they're they're shocked themselves all right so d okay that's the day

00:22:33.380 you're collecting the data you're not being judgmental about it you just want to get the facts

00:22:36.720 the next part is you is o for dopamine and that stands for objective what are you hoping to get there

00:22:43.720 when you talk to your patients so all behavior no matter how irrational on the face of it has some

00:22:49.920 rational reason driving it so here's where i'm just trying to understand why the the patient uses

00:22:56.000 that drug what what it does for them what what's the reason that they they use it and that's just

00:23:02.360 really to just understand their inner life but also validate for them that they wouldn't be using it if

00:23:07.840 it didn't have some positive effect and so this can vary from person to person you give a lot of

00:23:13.800 great i would call them case studies of people who you know they started say adderall when they were in

00:23:19.440 high school because they thought they had an attention deficit disorder or they just they

00:23:23.180 felt they were struggling in school and that quickly accelerated to stronger and stronger drugs

00:23:28.080 or they started using it more and more and more and they they just kind of forgot about like why they

00:23:32.040 originally started yeah kind of forgot about it and it then became again uh you know in that in that

00:23:38.420 patient example kind of a crutch because then the adderall becomes basically a way to procrastinate

00:23:44.900 to not develop good study habits because they know they can just take it when they need it and

00:23:49.340 stay up all night and get stuff done so it can have this kind of you know paradoxical effect

00:23:54.020 where we we just come to depend on it and it seems like figuring out why you use a substance that can

00:24:01.600 go a long way in helping resolve the addiction because then you can figure out well i can do something

00:24:06.560 else to fill that hole or you know solve that problem that i'm using the drug or the behavior for

00:24:12.220 absolutely and then we can also ask ourselves honestly whether or not the reason that we're

00:24:18.680 you're using is really accomplishing our our purpose so for example i'll hear lots of patients say that

00:24:26.660 they use cannabis because it makes them more creative but then when i ask them if they've actually

00:24:31.360 created anything under the influence the answer is almost always no and then you know they're forced

00:24:36.480 to reflect on wow what's the disconnect between why i'm using this and its actual effect

00:24:41.320 all right so that's objective trying to help the patient figure out why they have the addictive

00:24:45.600 behavior using the addictive substance the p stands for problems so what are we trying to

00:24:50.020 figure out here so this is where we get at the unintended consequences because by the time folks

00:24:55.220 are in my office there's almost always an unintended consequence to their use again just using the

00:25:01.220 cannabis example they might start out using it to go to sleep or to help with anxiety but over time

00:25:07.020 that drug is sort of turned on them which happens because of the gremlins and neuroadaptation and

00:25:12.840 it's not working anymore or it's actually causing them to be more anxious and paranoid or maybe the

00:25:19.900 consequence that is unintended is their spouse doesn't like it or it's interfering with with their

00:25:25.400 professional goals so almost always there's something about using that's not working out great and it's

00:25:31.820 important to have them articulate that i'm sure this can be hard because as you said people are often

00:25:37.500 in denial like they they have a hard time seeing those unintended consequences yes exactly which is

00:25:42.960 why the next letter in the acronym a for abstinence is such a key intervention because when we're in our

00:25:50.240 addiction we don't always see the consequences but when we stop using for a period of time we can

00:25:56.120 better see true cause and effect we're gonna take a quick break for your words from our sponsors

00:26:00.780 and now back to the show well let's dig into abstinence or as you call it in the book you call

00:26:07.520 it dopamine fasting because i thought this was really interesting and you spent a lot of time

00:26:11.680 in your book talking about it and you say that you know 20 years ago if someone came to you with

00:26:17.200 anxiety or depression i mean the first thing you would have done is prescribe them an antidepressant

00:26:21.820 but now you recommend that they do this dopamine fast you know to try a period where they abstain

00:26:28.800 from their addiction and i can imagine this is a tough sell with patients because you know maybe

00:26:34.020 they're hoping for the antidepressant because you know that's just easy you take a pill they don't

00:26:37.500 want to abstain because that's really hard so why is dopamine fasting an important part of the

00:26:43.280 addiction recovery process and how long does the dopamine fast have to be to be effective

00:26:48.540 i mean so abstinence is important for two reasons the first reason is that abstaining from

00:26:54.440 our drug of choice allows time for the gremlins to hop off of the pain side of the balance

00:26:59.560 for our dopamine own dopamine regeneration to occur and for homeostasis or a level balance

00:27:07.300 to be restored which is fundamental to being able to enjoy other things which we're not able to do when

00:27:14.420 we're deep in our addiction and when our balance is tilted to the side of pain but also as i said

00:27:19.380 that period of absence is really key for seeing true cause and effect because when we're using

00:27:25.460 our drug we usually can't see the consequences as clearly or at all other people can see it but we

00:27:31.940 can't see it but when we stop using for a period of time get past the initial craving and look back

00:27:37.160 it's often a bit of a surreal moment where we're sort of shocked at how invested we were in obtaining

00:27:43.780 and using our drug and can even sort of have this bizarre experience where we don't quite quite

00:27:49.020 recognize ourselves you're right that it's a hard sell i mean many patients don't come in looking for

00:27:55.880 help with substance use or with addictive behaviors they're here for anxiety depression insomnia

00:28:01.420 they're expecting me to write them a prescription or you know give them some sort of psychotherapy

00:28:06.920 and had to be told you know first pass well i'd like you to do an experiment and try to abstain

00:28:13.420 from your drug for a month and see what's underneath that's not exactly a welcome message

00:28:18.540 but the way that i sell that message and it and i found that it's pretty convincing to people is to

00:28:24.000 basically just talk about the neuroscience the pleasure pain balance what happens to dopamine when

00:28:30.060 we chronically ingest these intoxicating drugs and why it may actually be the cause of our anxiety

00:28:38.280 and depression and and not the consequence so i hold out to people the idea that if you want to

00:28:46.160 feel better one way to do that is to abstain and i warn them that in the first two weeks they're going

00:28:52.400 to feel worse before they feel better this will be the balance tip to the side of pain before the

00:28:56.440 gremlins have time to hop off but if they can just wait long enough and get through it they'll find

00:29:02.120 that at week three and four the sun starts to come out i also importantly tell people you know if at

00:29:07.660 week four you're actually not feeling better even if you were able to abstain as as i asked then that's

00:29:15.240 also really useful information because it tells me that it's it's not your consumption of of this drug

00:29:21.700 but it's an you know an underlying psychiatric disorder other than the drug all right so just to catch

00:29:28.180 that there when you say when you ask a patient to abstain it's not just for a week you're asking you're

00:29:31.940 going like a month right so with severe addiction or you know people with more severe symptoms i have

00:29:38.780 found that a month is about the minimum amount of time and if it's you know if it's a pornography

00:29:43.800 addiction then that means no orgasms for a month with themselves or others if it's a screen addiction

00:29:49.420 that means no screens for a month it's out you know alcohol it's no alcohol for a month again the

00:29:55.360 caveat there being that that would have to be a person in whom stopping cold turkey would not

00:30:00.860 elicit life-threatening alcohol withdrawal but assuming that there's no danger of that then

00:30:05.620 it would be stopping alcohol for a month and my clinical experience has shown me again that

00:30:11.060 you need a month really to reset dopamine pathways and restore homeostasis and there's also some

00:30:18.820 scientific literature supporting that there's a study by brown and shuckett who took a men who were

00:30:25.740 addicted to alcohol and also met criteria for major depressive episode and put them on a psych ward where

00:30:32.240 they didn't have access to alcohol and otherwise gave them no treatment for depression and after a month

00:30:38.680 approximately 80 percent of those individuals no longer met criteria for depression which means that

00:30:45.300 most of those individuals the vast majority had alcohol induced depression and once they were able to

00:30:51.580 stop drinking for a month they felt a lot better it also means that 20 percent of them were still

00:30:56.620 depressed at a month and needed treatment for major depression in addition to their treatment for an

00:31:02.620 alcohol addiction likewise there are studies by Nora Volkoff from the National Institute of Drug Abuse

00:31:08.760 looking at brain scans of people who have stopped using drugs two weeks prior and comparing those brain

00:31:16.600 scans with healthy controls and finding that dopamine transmission in people who had been using drugs

00:31:22.380 who stopped two weeks prior that was still below normal hadn't yet made it back up to normal dopamine

00:31:30.820 transmission suggesting again that two weeks is insufficient and that more time is needed

00:31:36.180 i think that's an interesting point too to highlight you just i'm gonna flesh that a little bit more and

00:31:40.580 bring it to everyone's attention by abstaining so a lot of people they say they use a substance or they view

00:31:45.140 pornography because they're depressed you're saying that no it could be what that we have to abstain

00:31:50.200 to find out it could be you're depressed and you're using pornography or using drugs as or alcohol to

00:31:56.340 assuage your depression or anxiety well yeah so yeah just to clarify what i'm trying to say is that

00:32:03.460 that people feel symptoms of depression and anxiety and are using a drug and they will tell you that the

00:32:11.740 reason that they use that drug is to help with their depression and anxiety and they will also say that

00:32:17.680 in the moment when they use they briefly feel better so of course it makes sense to them and to me

00:32:25.180 that that they feel like the drug is treating their depression and anxiety but what i posit to them is that

00:32:34.700 in fact what may be happening is they're actually medicating withdrawal from the last dose of their

00:32:42.620 drug and that the use of the drug is is the underlying cause of the depression and anxiety and

00:32:48.960 is driving that phenomenon and is created by this pleasure pain balance putting them in a dopamine

00:32:55.080 deficit state to compensate for the huge surge in dopamine they're getting from the drug so it's a

00:33:01.860 little bit i don't know if i explained that okay but no that makes sense um okay yeah so it's

00:33:07.300 certainly a little counterintuitive because subjectively it in the moment it feels like the

00:33:12.200 drugs are helping but in the long run it's really making things worse or even causing the symptoms in

00:33:17.820 the first place so when you're working with a patient in this one month long abstaining process

00:33:22.980 are there any tactics that you you suggest to help them get through that so when they're having that

00:33:28.440 at week one week two and they're like oh i i really i really need i had that craving anything

00:33:34.000 you suggest that helps them get through that yeah lots of different suggestions so one of the things i

00:33:40.680 do first is just reassure them that it's time limited it's withdrawal mediated and if they can just

00:33:47.760 make it through those first couple of weeks by week three and four it really does get better

00:33:53.160 and that alone in my experience is very helpful to patients because they can just sort of wait and

00:34:00.080 endure and know that it's going to get better the other thing that i recommend is that they tell the

00:34:06.200 truth during that time period so often our addictive use is connected with lying and lying i have a whole

00:34:15.640 chapter on it can also be a trigger for relapse so one of the key things is to try very hard not to

00:34:21.660 lie about their use in the month ahead that they're trying to abstain and also not lie about anything

00:34:26.840 because i've found that that helps people maintain abstinence and then you know the other thing that

00:34:33.960 i recommend is that they do something even more counterintuitive and intentionally press on the pain

00:34:39.000 side of the balance so that they can speed along the process of restoring homeostasis and resetting

00:34:46.720 their dopamine reward pathway and that's done by things like exercise cold water immersion engaging

00:34:53.660 in intellectually challenging activities reading a hard non-fiction book for example in my case

00:35:00.340 or you know engaging in in a labor intensive intellectual creative activity yeah i'd like to dig more into

00:35:07.480 the the radical honesty and the pressing on the pain because i thought that was really it's

00:35:10.940 counterintuitive it's really interesting but also the abstain thing you also give suggestions

00:35:14.820 like on self-binding kind of taking the odysseus approach like finding ways you know when odysseus

00:35:19.960 went to go confront the sirens finding ways to basically take the the addictive substance or

00:35:25.860 behavior like get it out of your out of your environment so you because like as you as we know

00:35:32.000 when things are accessible you're more likely to do it so make it less accessible you'll be less

00:35:37.280 likely to use it yes absolutely so we talk about the ways in which willpower is a finite resource

00:35:43.740 for all humans and it lasts about a day and it wanes toward the end of the day and so it's really

00:35:49.640 important to put literal and metacognitive barriers between ourselves and our drug of choice to extend

00:35:57.580 our ability to use our willpower to resist the drug and that comes in many different forms as you

00:36:04.900 pointed out getting the drug out of the house for my patients who who travel a lot and these are all

00:36:10.880 tricks i've learned from patients they'll call the hotel in advance and ask the hotel to remove

00:36:15.020 the mini bar from the hotel room i've even had patients who ask the hotel to remove the television

00:36:20.540 set from the hotel room so that they're not inclined to you know view things that they don't want to be

00:36:25.340 viewing while they're locked in their hotel room other things are sort of yeah just setting those kinds

00:36:31.500 of barriers because the truth is we live in a very addictogenic world and it's hard for you know any of us

00:36:39.780 to resist when we're constantly getting triggered and prompted so we really have to change the

00:36:44.240 environment in able to in order to be uh you know to be able to successfully exercise our self-control

00:36:50.280 yeah the i've come across that one study about how the environment can influence addictive behaviors

00:36:56.240 it was like the vietnam and heroin right so like yeah there was after the vietnam war was over like i guess

00:37:02.880 the government was really worried that the returning soldiers i guess they started using a lot of them

00:37:06.800 started using heroin in vietnam because it's readily accessible and of course they're under a lot of stress

00:37:11.400 there and they're worried well these guys are going to come back and they're still going to have

00:37:14.880 a heroin addiction but what they found out was like actually once they came back like they didn't they

00:37:20.080 didn't have that problem anymore because they were out of that environment that encouraged the heroin use

00:37:24.180 and there was no readily available heroin yes exactly it's it's a nice corollary to the you know the

00:37:30.620 prohibition example that when people are in an environment of decreased access they're less likely

00:37:36.420 to use and they're less likely to use in an addictive way and and obviously the inverse is is true you know

00:37:42.220 when you're flooded with dopaminergic drugs and behaviors it's it's very very hard to resist so

00:37:48.420 part of our challenge in modern life is to kind of create these barriers between ourselves and all of

00:37:55.120 the the various temptations all right so let's finish up this dopamine acronym so we talked about

00:38:00.100 uh d o p a which is abstinence the next ones are m for mindfulness i for insight and n for next steps

00:38:07.380 and then e for experiment i mean can you quickly walk us through these steps like what are you hoping

00:38:11.440 the patient sees when you walk them through these things yeah so the m for mindfulness just means

00:38:17.100 that in that initial experiment of the dopamine fast or abstinence from our drug

00:38:22.920 we will experience a lot of psychological distress due to withdrawal but also due to

00:38:29.140 just having to tolerate a lot of negative feelings without escaping from those into using our drug

00:38:36.400 and this is um you know hard to do but also a really good opportunity for mindfulness defined as

00:38:43.380 observing our thoughts emotions and experiences without judgment and so i just really encourage people

00:38:50.140 to be very compassionate with themselves and to be curious about what comes up and to practice

00:38:56.360 the art of mindfulness and then insight is what often comes with this experiment again as people

00:39:03.520 get distance from their drug of choice they're much better able to see true cause and effect and that

00:39:10.280 can be a real shocking eye-opener for people you know when they realize wow i really was addicted and i

00:39:16.300 didn't realize until i tried to stop using or i didn't realize until i kind of came out of that

00:39:21.820 vortex of compulsive overconsumption and looked back at who i was when i was using so it's a it's an

00:39:28.120 opportunity for for insight and for cause and effect and when folks come back a month later and they

00:39:34.300 were successful in their month of abstinence then we talk about next steps which is the n of the

00:39:40.580 dopamine acronym and next steps is just all about what do you want to do next this you know if they

00:39:46.700 abstained and they were able to do it and it was a good outcome for them i i say to them well do you

00:39:52.540 want to abstain for another month or do you want to go back to using and almost universally people

00:39:57.460 want to go back to using but they want to use differently they want to use less they want to use

00:40:02.440 in a way that's more within their their control they want to use in a way that's more consistent

00:40:07.400 with their values so essentially then we talk again about self-binding strategies and what

00:40:12.560 moderation would look like and we get very very specific here because again the devil's always in

00:40:18.040 the details so how many days a week are you going to use or how many days a month what exactly are you

00:40:23.300 going to use what's the context in which you're going to use so for example my patient with video game

00:40:28.120 addiction he decided he would only play two or three days a week no more than two hours a day

00:40:34.160 he would only play with friends and never with strangers because once he started to play with

00:40:38.320 strangers he realized he would go down the rabbit hole that he decided there were certain video

00:40:43.060 games like league of legends that he just could never play because they're too potent for him and

00:40:47.540 he can't control himself so it's that kind of thing and then the e of the dopamine acronym just

00:40:52.980 stands for experiment that's where that folks then go back out into the world with sort of armed with

00:40:58.980 this new homeostasis and a plan for moderation and they put it to the test so i want to circle back

00:41:07.020 to this idea besides the self-binding techniques to help them when they're in that abstinence part you

00:41:11.560 also encourage your patients to what you call press on the pain side of this pleasure pain balance seesaw

00:41:18.640 and you mentioned earlier this is like doing things that are uncomfortable so could be cold water

00:41:23.960 immersion doing like reading a hard book doing exercise so what what is it about pressing on the

00:41:29.920 pain that helps that rebalance process that we're trying to get back to a good homeostasis with our

00:41:36.000 pleasure and pain the reason that pressing on the pain side is useful is because the same opponent

00:41:43.520 process mechanism that leads to neuroadaptation when we ingest intoxicants that press on the pleasure side

00:41:49.940 also can occur when we engage in activities that immediately press on the pain side so what happens

00:41:56.660 when we do something like exercise for example is that those gremlins will adapt by hopping on the

00:42:01.880 pleasure side and with repeated exposure that pleasure will be longer and stronger and so we still get access

00:42:08.860 to dopamine but it's an indirect source and therefore is less vulnerable to this problem of tolerance

00:42:16.260 dependence dependence and withdrawal gotcha and so yeah you highlight one patient who got really into

00:42:20.720 cold water immersion as a way to help him with his recovering from addiction yeah so he sort of

00:42:27.880 serendipitously discovered that these really cold showers gave him a feeling similar to vicodin and it would

00:42:34.780 last hours and so he he pursued this as part of his early recovery and continued it years later it was a way for

00:42:43.100 him to get that same feeling but in a way that was more enduring and ultimately a more manageable for

00:42:50.360 him and then another thing you encourage your patients to is to be radically honest about their

00:42:55.800 addiction and i think you talk about how the you know alcoholics anonymous have has kind of figured

00:43:02.140 this out serendipitously like they just that's part of the process but then there's also neurobiological

00:43:08.000 research that confirms that yeah there's something about being honest that helps you like be less

00:43:14.620 addicted to the stuff that you're addicted to yeah so one of the fascinating things about sort of

00:43:20.360 telling the truth which by the way is hard and which you know all of us have to exert our will to do

00:43:27.100 because we're we're all natural liars even if the lies seem innocent on their face but honesty has this

00:43:33.560 remarkable ability to basically stimulate our prefrontal cortex and i think probably strengthen

00:43:41.920 connections between the prefrontal cortex and the lower brainstem reward pathways because one of the

00:43:48.580 things that happens in addiction is that our our reward pathway starts stops talking and communicating

00:43:54.640 with our prefrontal cortex which is you know a fundamental to the problem because our prefrontal cortex is what

00:44:01.660 allows us to delay gratification make good choices narrate our lives assess future consequences and when

00:44:09.660 that gets disconnected then we um we're less able to manage our impulses and our compulsive consumptive

00:44:18.620 tendencies so radical honesty is really a way to um you know manage and be aware of uh what our what

00:44:28.000 our reward pathway is doing it also has many other potential benefits it can foster true intimacy and

00:44:36.500 we do know that social connection especially deep and honest social connections release dopamine so it's

00:44:43.200 a healthy source of dopamine it also allows us to be more authentic and and more connected to our real

00:44:50.980 selves which is key to being present in the moment and experiencing ourselves as sort of tethered to the

00:44:57.960 world i think that's an especially important aspect in this age of social media and curated online

00:45:05.460 selves when people often exist online with a persona that's wildly different from their real lives

00:45:12.160 leading to feelings of derealization and depersonalization that can make people feel

00:45:17.240 anxious and suicidal so being our you know true and authentic selves again makes us feel more real in the

00:45:25.220 world and there are you know many many other examples that i give in the book for why telling

00:45:30.500 the truth is is really not just good for recovery but important to a life well lived so another part of

00:45:37.700 the process that you you encourage your patients to go through or you you encourage in the process

00:45:42.400 which is and again it's counterintuitive this is what i love about your book is all these all these

00:45:45.220 counterintuitive things is fostering shame but healthy shame this is interesting because like we

00:45:52.800 often typically i think in our modern world we think shame is completely bad we'd rather feel guilty

00:45:57.600 right so like guilt is you feel bad for the thing you did but you're not a bad person shame is you did

00:46:03.960 something bad so it says something about you as a person right what so tell us about this like how can

00:46:09.040 we use shame in a healthy way to overcome addictions yeah so i argue that shame is one of the most

00:46:16.080 powerful pro-social emotions because shame is essentially connected with the fear of abandonment

00:46:24.640 or being kicked out of the tribe for our transgressions against social norms and we have this idea that you

00:46:34.040 we should sort of de-shame everything because the experience of shame is so painful um and certainly

00:46:40.740 it's true that shaming people can contribute to poorer outcomes but it's also true that shame can be a very

00:46:51.160 important vehicle for positive change as long as shame is accompanied by a clear pathway for change and

00:47:00.540 reassurance from the group that that individual will not be excluded from the group and this is where

00:47:06.920 i think alcoholics anonymous is such a remarkable organization because they really get shame right a lot of

00:47:13.260 patients will report that the immediate experience of joining aa is a de-shaming experience where they realize

00:47:21.020 they're not the only ones who have this problem but at the same time that joining aa is de-shaming

00:47:27.620 it's also true that many patients will report that one of the big motivators for not drinking or not using is

00:47:34.980 because they would be mortified to go back to their group and say i relapsed you know or have to start the

00:47:41.220 steps over again which is what you have to do in aa if you relapse and yet at the same time if they do relapse

00:47:48.700 they're welcomed with open arms and in fact the relapse itself represents a positive club good this is a social

00:47:56.040 behavioral behavioral economics term but it becomes a club good for the group as a whole because then

00:48:01.580 there are opportunities for example for people to sponsor that individual which is a giving back or a

00:48:07.780 service relapse also becomes part of the extended hippocampus of aa where people are reminded of what

00:48:16.060 relapse looks like and warned against relapsing themselves so so aa has really figured out how to leverage

00:48:23.540 shame in a positive direction to help people make make good behavior change so the shame can be

00:48:31.300 healthy if there's a possibility for redemption that's what it sounds like yeah yep if you can

00:48:37.620 redeem yourself within the group if you're not shunned and if your brokenness is in and of itself

00:48:45.700 of value to the group well can sometimes happen in strict religious organizations who give lip service to

00:48:52.320 helping people with addiction but actually end up not helping them is that when these kinds of

00:48:58.400 problems are discovered and not immediately resolved then these individuals are essentially shunned because

00:49:04.680 they sort of become bad advertising for the religious organization you know the idea being that if you only

00:49:10.280 believed enough you wouldn't have this problem and that becomes very problematic for people with a chronic

00:49:15.760 relapsing and remitting problem like addiction whereas in alcoholics anonymous it's the chronic relapsing and

00:49:21.900 remitting nature of it that keeps people you know coming back and again which serves as a kind of

00:49:28.440 cautionary tale for other people in the group and a reminder of how bad it can get and what's great

00:49:35.380 about this process that we just walked through is that i mean this works for like i mean you said earlier

00:49:40.160 addictions on a spectrum so you can have you know big severe addictions or even mild and minor addictions

00:49:47.120 and this process works for those minor and mild addictions as well so i mean you could try this

00:49:51.980 for example you know if you feel like you're you're checking your phone too much so you could do a

00:49:56.400 dopamine fast for a month by deleting all the apps that you waste time on from your phone don't check

00:50:02.480 those for a month and then maybe bring that stuff back but have blockers in place that limit the amount

00:50:07.860 of time you spend on them so it works for that kind of thing as well this process and for people who are

00:50:12.460 interested in learning more all about this where can people go to learn more about the book in your

00:50:15.900 work you know i'm not on social media that's good i agree i was asked by my publishers to create a

00:50:22.220 website for the book so there's a website onalemke.com but you know there's not there's not too much

00:50:28.480 information out there except for the book itself but it does come in ebook form and an audible form so

00:50:34.300 if folks are listeners instead of readers there's a way to listen to the book as well as to read it

00:50:39.760 fantastic well anna limke thanks for your time it's been a pleasure my pleasure thanks for having

00:50:44.120 me my guest here is anna limke she's the author of the book dopamine nation finding balance in the

00:50:49.680 age of indulgence is available on amazon.com and bookstores everywhere you can find more information

00:50:53.500 about her work at her website analemke.com also check out our show notes at aom.is

00:50:58.060 slash dopamine nation where you find links to resources where you delve deeper into this topic

00:51:01.660 well that wraps up another edition of the aom podcast make sure to check out our art of manless

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The Art of Manliness - October 04, 2021

Do You Need to Take a Dopamine Fast？

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