The Peter Attia Drive - #321 – Dopamine and addiction： navigating pleasure, pain, and the path to recovery ｜ Anna Lembke, M.D.

00:00:00.000 Hey, everyone. Welcome to the Drive podcast. I'm your host, Peter Atiyah. This podcast,

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00:01:04.200 My guest this week is Dr. Anna Lemka. Anna is the chief of the Stanford Addiction Medicine

00:01:10.600 Dual Diagnostics Clinic, the medical director of addiction medicine and professor of psychiatry

00:01:15.320 and behavioral sciences at the Stanford University School of Medicine, where her clinical focus is

00:01:20.460 addiction medicine. In 2021, she published her book, Dopamine Nation, Finding the Balance in an Age of

00:01:27.640 Indulgence. And on October 1st of this year, she's releasing the official Dopamine Nation workbook,

00:01:35.140 a practical guide, which I actually can't wait to indulge in myself. In my conversation with Anna,

00:01:40.540 we begin by laying the foundation for understanding addiction and understanding the biochemistry and

00:01:45.800 neurobiology of dopamine, explaining the various functions of, for example, the prefrontal cortex

00:01:51.260 in all of this. Anna explains the framework she uses to address patients with addiction. And we talk

00:01:56.560 through some examples of addiction and how this framework would be put into practice for, say,

00:02:01.600 alcohol and gambling addictions. And we also speak about addictions to cannabis, sex, social media,

00:02:07.140 and exercise. Anna outlines the risk factors for addiction, including inherited and nurture-based

00:02:13.580 risks, and why different individuals are more susceptible to specific and different addictions.

00:02:19.220 We then dive into the rise of addictions in the younger generation, particularly the addiction to

00:02:24.760 pornography in young men, and how to have conversations with your children about these

00:02:29.360 subjects. From there, we discuss healthy coping strategies, the famous marshmallow experiment,

00:02:34.600 and how it has been revised. We talk about cross addiction, and also Anna's experience and

00:02:39.360 knowledge around GLP-1 agonists and whether or not they may be a tool for treating

00:02:43.420 addictions. Lastly, we speak about 12-step programs and Anna's perspective on their benefits

00:02:48.920 and impact, as well as how she personally copes with the intensity of her work. So without further

00:02:54.940 delay, please enjoy my conversation with Anna Lemka. Anna, thank you so much for making time to sit

00:03:06.400 down with me today. I've been looking forward to this for quite a while, months actually. So thank you

00:03:11.520 for humoring me and talking about a subject that you, I know, talk about a lot.

00:03:15.520 Well, thank you for inviting me. I'm delighted to be here. I actually hadn't realized that you were

00:03:20.500 a fellow Stanford grad, so that was fun to learn.

00:03:23.720 I know. I feel like we were passing each other briefly, right? Because I think you graduated two

00:03:29.540 years before I started, but then you were in your residency while I was in med school. So the

00:03:35.380 probability that we ran into each other in the cafeteria or going through the hall is probably

00:03:40.920 pretty high. Yes, it's perfectly possible that I scutted you out as a medical student and made you

00:03:46.820 go do things that I didn't want to do.

00:03:50.960 I always tell people I have the fondest memories of medical school, but there are certain things

00:03:55.460 that I still remember and I can't believe they were the case. And one of them is that for a school

00:04:00.320 as fancy and prestigious that, do you recall, we didn't have a bathroom in the library?

00:04:06.660 Ah, I didn't.

00:04:07.840 Do you remember that fact?

00:04:08.640 Yes. It could be I did not spend as much time in the library as I should have.

00:04:13.960 I do remember that we had our anatomy classes in trailers.

00:04:17.620 In trailers. Yep.

00:04:18.240 Right.

00:04:18.520 I remember that.

00:04:19.440 Yes.

00:04:20.280 Well, we ended up studying mostly in the business school library, which was really fancy,

00:04:24.800 had bathrooms and didn't have business students in it because of reasons that are probably obvious.

00:04:31.340 So anyway, great to sit down with you. There's actually a lot I want to talk about with you.

00:04:35.080 Some of it is the substance of what you've written about in Dopamine Nation. And I'd love

00:04:39.140 to probably start there, but there's so much other material I'd love to cover with you if our time

00:04:42.980 permits. But obviously, one of the things that anyone who's familiar with you thinks about is

00:04:47.840 this role of dopamine and understanding addiction. This clearly plays into a big part of your

00:04:53.800 clinical practice as a psychiatrist. But I also realized that terms get thrown around quite

00:04:59.180 loosely, and sometimes it can just be helpful for people to understand a little bit of what

00:05:03.620 we describe as the semantics. So I'd like to actually start with an understanding maybe of

00:05:08.100 some of the biochemistry and the neurobiology of dopamine. And then I want to actually talk about

00:05:12.380 what an addiction really is. But this word dopamine is something everyone has heard of.

00:05:17.620 But tell us a little bit about the molecule, how it works, and maybe even some of what the

00:05:22.980 supporting cast of other neurotransmitters look like that factor into these pathways that

00:05:28.100 obviously play an important role in our evolution and our existence.

00:05:31.860 Yeah, great place to start. Thank you for setting the stage. So dopamine is a neurotransmitter.

00:05:38.860 So it's a chemical that we make in our brains. Neurotransmitters are the chemicals that allow for 0.98

00:05:44.800 fine-tuned modulation of the neural circuits that make us who we are. You might think of the brain

00:05:50.420 as a collection of wires. Those wires are neurons. They send electrical impulses one to the other,

00:05:56.500 but the neurons don't actually touch end-to-end. There's a little gap between them called the

00:06:01.700 synapse, and that gap is bridged by molecules called neurotransmitters. There are many different

00:06:08.460 neurotransmitters in the brain. They have many different functions, but dopamine has become

00:06:14.460 kind of the common currency for measuring pleasure, reward, and motivation. It's not the only

00:06:22.480 neurotransmitter involved in that process, obviously, but it is the final common pathway

00:06:27.700 for all reinforcing substances and behaviors. So whether the substance is primarily modulating

00:06:34.540 our serotonergic system or norepinephrine or the nicotinic system or the endogenous opioid

00:06:40.420 system or the endogenous cannabinoid system, the final common pathway for all of those chemical

00:06:46.960 cascades is to release dopamine in a dedicated part of the brain called the reward circuitry,

00:06:53.080 which consists of the prefrontal cortex. That's that large gray matter area right behind our foreheads,

00:06:58.420 and then these deeper limbic or emotion brain structures like the nucleus accumbens and the

00:07:03.440 ventral tegmental area. We're always releasing dopamine at a baseline tonic level,

00:07:09.080 but when we do something that's pleasurable or reinforcing or that our brains consider salient

00:07:15.000 or important for survival, in some cases it might even be an aversive stimulus, then temporarily we

00:07:21.180 will increase dopamine firing above baseline. That generally feels good to us, which is how we tell

00:07:28.620 our brains, oh, this is important. I should approach, explore, and consider doing this again.

00:07:35.420 So broadly speaking, that's dopamine's function. It's not its only function, by the way. So dopamine is also

00:07:41.440 really important for movement. As you know, Parkinson's disease, which is a movement disorder,

00:07:47.160 is characterized by a decrease or a depletion of dopamine in a different part of the brain called

00:07:51.640 the substantia nigra. And one of the ways that we treat Parkinson's is to actually give people

00:07:56.620 L-dopa, which is a dopamine precursor. Why do we give them L-dopa and not dopamine? Because dopamine

00:08:02.560 itself actually can't cross the blood-brain barrier, so we give them a precursor that crosses the blood-brain

00:08:07.460 barrier and then binds to dopamine receptors in the substantia nigra, allowing for more fluid 0.97

00:08:13.480 movements in people with Parkinson's. Unfortunately, L-dopa transformed to dopamine also binds dopamine

00:08:20.860 receptors in the reward pathway, which is why about a quarter of folks with Parkinson's who get treated

00:08:25.720 with L-dopa end up with addictive disorders that are usually reversible when you stop the L-dopa and

00:08:33.760 tend to be dose dependent. So the more L-dopa, the more likely the sex addiction, shopping addiction,

00:08:39.480 or whatever the compulsive behavior. Okay. A lot there and many questions, but one of them is the role of

00:08:47.140 the prefrontal cortex. Now, again, I think people listening to us probably have heard about the

00:08:51.840 prefrontal cortex. It comes up a lot when we talk about dementia. It comes up a lot when we talk about

00:08:57.100 higher order cognitive function, judgment centers, but it is also something that I believe, and I could

00:09:03.500 be wrong on this, but I believe this is a part of the brain that is more developed in our species than

00:09:07.840 in others. So I guess a question then would be around the addictive potential of our species versus

00:09:16.000 others. Are we more susceptible to what we're about to talk about as addiction with a larger

00:09:21.160 prefrontal cortex, or is it not as simple as just the anatomic size of this part of the brain?

00:09:26.940 I guess to back up for a second, the prefrontal cortex has many roles, but when we think about

00:09:32.740 its role in addiction or other appetitive disorders, it actually has a stop function. So if you analogize

00:09:41.980 to a car, the prefrontal cortex acts like the brakes on the car. It allows for delayed gratification.

00:09:48.740 This is where we have the control centers. It allows for appreciating future consequences.

00:09:54.560 It lights up when we're engaged in autobiographical narrative. And of course, narrative is part of the

00:09:59.660 ways that we actually create metacognitive awareness to inform future decisions. So having a very robust

00:10:09.480 prefrontal cortex is potentially protective against addiction. People who have cognitive or attentional

00:10:17.760 disorders who are thought to have a disorder of the prefrontal cortex, for example, attention deficit

00:10:23.420 disorder, are at higher risk to develop addictive disorders. So essentially, again, if you think of

00:10:30.020 this as like the car analogy, the prefrontal cortex is the brakes, the nucleus accumbens is the accelerator,

00:10:36.000 the nucleus accumbens is deep in the brain, is rich in dopamine-releasing neurons, and that acts like

00:10:40.900 the accelerator on the car. So addiction is a problem either with too little on the brakes, too much on

00:10:47.600 the accelerator, or some combination thereof. In terms of whether or not humans are more likely to

00:10:55.680 get addicted than animals, I would say no. What's remarkable about this reward circuitry is how

00:11:04.720 incredibly conserved it is over millions of years of evolution and across species. So neuroscientists

00:11:12.340 used to talk about the lizard brain or the triune brain. They're not typically using that phraseology

00:11:18.320 so much anymore. But what they were getting at was that if you look at the nucleus accumbens

00:11:23.160 ventral tegmental area, it's amazingly unchanged across species over millions of years of evolution.

00:11:30.920 It's really our reflexive approaching pleasure and avoiding pain is what has kept us alive for so

00:11:39.480 many, many generations on the planet. And so it's a very basic primordial structure that all living

00:11:47.060 organisms, even primitive organisms have. Even the most primitive nematode or worm will release dopamine

00:11:53.220 in response to food in its environment, which then dopamine allows it to locomote toward food.

00:11:57.780 It's probably no coincidence that the same neurotransmitter involved in movement is also

00:12:02.780 involved in pleasure, reward, and motivation. Because prior to about 500 years ago, if you wanted

00:12:08.160 to get a reward, you had to work for it. That's no longer true, which is one of the reasons our brains

00:12:13.460 are so confused today. So I would say, again, to just sort of try to answer your question, you could

00:12:20.400 almost make the opposite argument that because we have these large frontal lobes that can sort of reason

00:12:26.800 and appreciate future consequences, human beings might be even more capable of getting out of the

00:12:33.280 cycle of addiction than other organisms. I mean, it is miraculous that even people deep in the most

00:12:43.700 severe addiction can find somewhere within themselves the capacity to stop using. It's really,

00:12:52.340 really remarkable. It seems to me almost a miracle in my clinical work when I get people who have been

00:12:57.440 in severe addictions for decades who somehow find it within themselves, either through some logical

00:13:03.680 reasoning or some spiritual surrender or some combination to actually get into recovery.

00:13:10.040 There's so much I want to talk about on that front, but I think I'll still try to get some of the more

00:13:16.240 basic stuff out of the way just to make sure when we get there, we have the foundation to understand

00:13:21.460 some of the incredible stories you've shared. So let's take a moment to now maybe technically define an

00:13:26.280 addiction. I'm sure everybody once in a while has said, man, I'm addicted to Netflix and I'm addicted to

00:13:31.940 chocolate and I'm addicted to this. But how does one truly define an addiction in a clinical setting?

00:13:37.820 So when I use the term addiction, I'm referring to a form of psychopathology, not the more common

00:13:45.180 colloquial casual use of I'm addicted to Netflix. Although you could argue that we actually are

00:13:50.960 addicted to Netflix. We'll probably get there. So the diagnosis of addiction is based on what we call

00:13:56.900 phenomenology. These are patterns of behavior that repeat themselves across individuals with unique

00:14:02.780 temperaments, demographics, time periods, geographic locations. There is no brain scan or blood test to

00:14:10.400 diagnose addiction. Although we know that addiction is characterized by distinct brain changes, we're

00:14:16.240 just not at a state of the art where we can diagnose it based on that. So it's still based on patterns of

00:14:21.820 behavior that can broadly be summarized as the four C's plus tolerance and withdrawal. So the four C's are

00:14:29.520 out of control use, compulsive use, cravings, and continued use despite consequences. Now, as you can

00:14:38.520 imagine, that phenomenology is going to be a judgment call. And it's going to be based on both that

00:14:46.980 individual's subjective endorsement of having those kinds of issues, plus the observation of other people

00:14:55.220 around them. Which is to say, if you went to 10 different psychiatrists, you might get 10 different

00:14:59.840 diagnoses. And that is true for all mental health disorders. We don't have any brain scans or blood

00:15:05.200 tests to diagnose any mental health disorder. The entire DSM or Diagnostic and Statistical Manual of

00:15:11.060 Mental Disorders, which is our codification of different buckets that we put people in for different

00:15:16.780 forms of psychopathology, is completely based on phenomenology. So you have the four C's, and then you

00:15:22.220 have tolerance and withdrawal. So those are very clear evidence of physiologic changes. Psychological

00:15:29.200 changes are also physiologic changes. But here we're talking about more obvious manifestations

00:15:34.560 of it being, say, a physical, chemical body reaction. Tolerance is the phenomenon of finding that the drug

00:15:42.320 stops working over time, and that we need more and more to get the same effect or more potent forms.

00:15:48.540 And tolerance is overcome by using more, using more often, or overcoming tolerance by changing the

00:15:54.700 delivery mechanism instead of orally ingesting, maybe smoking or injecting, or overcoming tolerance

00:16:02.020 by changing slightly the chemical combination or moiety or combining drugs together so that the brain

00:16:07.800 sees something that's similar but slightly novel. And then in addition to tolerance, there's the phenomenon

00:16:13.180 of withdrawal, which is to say, when I cut back or stop using, my body reacts in a very predictable

00:16:19.400 fashion, which is most often the opposite of whatever the intoxicant causes. So if I'm taking a

00:16:26.700 stimulant like cocaine or meth or nicotine or caffeine, and I try to stop using, my withdrawal

00:16:32.000 phenomenon will feel like sedation, lethargy, inattention. If I'm using a sedative like alcohol,

00:16:38.880 then my withdrawal phenomenon will be restlessness, jitteriness, maybe even seizures, maybe even

00:16:45.200 life-threatening seizures in the case of alcohol and benzodiazepines. And also keep in mind that the

00:16:50.620 universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia,

00:16:56.260 dysphoria, and craving. And I always like to mention that because I'll have cannabis users,

00:17:00.820 your alcohol users come in and say, well, I don't have any withdrawal, so therefore I'm not addicted.

00:17:05.480 Well, did you feel anxious? Did you feel restless? Were you unable to sleep? Were you in craving mind?

00:17:13.340 Because those are all the actions, so to speak, that our brain takes to get us to try to use again.

00:17:19.680 So I want to use just two examples and walk viewers and listeners through them. So let's start with a

00:17:25.460 chemical one and let's just pick alcohol because of its ubiquity. So let's go through how a person might be

00:17:31.920 evaluating the four C's and tolerance withdrawal. So I come to you and I say, I'm here because people

00:17:40.320 around me think I drink too much. What are sort of the questions we go through to probe that?

00:17:45.280 Yeah, great. So we've developed a kind of framework that relies on gathering data in a way that's not

00:17:52.340 threatening and sort of factually based, starting simply with data. So we would ask people,

00:17:57.920 what do you drink, how much and how often? When we try to quantify that specifically with alcohol,

00:18:04.700 we bring it down to what we call the standard drink. A standard drink is one 12-ounce bottle of beer,

00:18:09.380 a five-ounce glass of wine, or one to one and a half ounces of hard liquor. So that's one standard drink.

00:18:15.820 We use something called the timeline follow-back method because it tends to be more reliable than a

00:18:20.220 sort of general gestalt where we say, okay, how much did you drink yesterday? How much did you drink

00:18:25.600 the day before that? And the day before that? And the day before that until we get seven days,

00:18:28.860 we add it all up. And then the person goes, oh, wow, I'm drinking 21 standard drinks in a week.

00:18:35.820 That's very useful information for me as a healthcare provider, but also for that individual

00:18:41.480 themselves. Because when we're chasing dopamine, we have a funny way of not being very good self-observers

00:18:47.060 and losing track. So we simply gather the data. Then we ask people to tell us why they drink.

00:18:54.020 What is the positive thing that they get out of it? As well as trying to hint a little bit at

00:18:58.840 tolerance, which is to say, is it still working for them the way that it used to? I should also

00:19:04.460 mention when we're gathering data, we're also looking for binge patterns. So some people can go

00:19:08.700 a long time without drinking, but then they'll have, let's say for an adult male, a binge is

00:19:12.800 considered five or more standard drinks in a sitting. A sitting is a single day. For an adult female, 0.78

00:19:18.400 it's four or more standard drinks in a sitting. And when we find that pattern, that's also very

00:19:23.120 concerning. Let me just say that the really nice thing about alcohol is that these questions are

00:19:27.820 based on epidemiologic studies showing that for an adult male who drinks more than 14 standard drinks

00:19:35.860 per week or more than four on any given day, or an adult female who drinks more than seven standard

00:19:41.080 drinks per week or more than three on any given day, there's a much higher risk not only of having

00:19:46.840 an alcohol addiction, but also developing all cause morbidity and mortality. So pancreatitis,

00:19:53.240 heart disease, cancer, injury, accident, and death. So it's very nice to have that data to back that up.

00:20:00.980 But we start there. Then we probe. And why do people drink? People drink for all kinds of reasons,

00:20:06.160 but broadly speaking, they drink to have fun or to solve a problem. That problem can be anything from

00:20:10.540 social anxiety to loneliness to boredom and everything in between. So we really explore that with

00:20:14.840 patients. And then next, we ask about problems. What are the problems that you have noticed?

00:20:20.680 Interpersonal problems, work problems, health problems, the simple problem of tolerance that

00:20:26.360 it's not working for you the way that it used to. Are you having mental health problems, depression,

00:20:31.440 anxiety, insomnia, and attention? And we kind of go through those. And then based on that, we begin to

00:20:39.600 see a picture that nudges us toward thinking that, yes, this person has what we call an alcohol use

00:20:46.660 disorder. And again, you can see it's quite judgmental and contextual, depending upon the

00:20:52.740 culture. But one of the things that often happens is people will normalize their use by affiliating with

00:20:58.180 other people who drink heavily. So they'll say, well, you may think that's a lot, but my fraternity

00:21:02.780 brother Joe drinks way more than I do. It's like, well, yes. But in the general population,

00:21:06.920 you're in the one percentile in terms of even just the amounts that you drink. And we know that just

00:21:12.980 based on amounts, you're at higher risk for all-cause morbidity and mortality, even separate

00:21:17.600 from our diagnosing an addictive disorder. Okay. So you also already addressed the withdrawal. And of

00:21:23.980 course, I'm sure many people are quite familiar with the medical complexity of alcohol withdrawal

00:21:29.160 and how things like DTs can become an actual physiologic risk to mortality if a patient isn't

00:21:37.940 withdrawn safely from alcohol using things like benzodiazepines. And as discussed earlier, of

00:21:43.760 course, tolerance is clear with alcohol. What if we talk about something like gambling? How does the

00:21:50.240 framework work for something like that? In other words, for a person to have a gambling addiction,

00:21:57.040 is the sin qua non of that, that they basically must be financially creating chaos in their lives?

00:22:05.260 Or if a person loses a million dollars a year in gambling, but they make 10x that and it's not

00:22:11.820 actually impacting their life in other ways, how do you ferret out whether or not this is pathologic?

00:22:19.480 Great question. And I would say when you think about the four C's, control, compulsion,

00:22:23.160 craving and consequences plus tolerance and withdrawal, none of those is a sine qua non. And in fact, you can

00:22:30.160 have no tolerance and no withdrawal and still meet criteria for an addiction. Just a little footnote there,

00:22:37.260 people can actually have physical withdrawal from behavioral addictions like gambling, where they have

00:22:41.460 headache, nausea, vomiting, insomnia. But for gambling disorder, theoretically, you could have somebody who was

00:22:48.900 gambling a lot and had no control issues, meaning that they could set a certain amount that they were

00:22:56.260 going to spend. And even if that was a very large amount, they adhered to that amount. When they decided

00:23:01.220 to cut back or abstain for a period of time, they were able to do that. They could have no craving,

00:23:06.360 no reported cravings. Although again, we're not the best judges often of ourselves when it comes to this

00:23:11.940 disease process. They could have, as you highlight, no consequences because they're making money. Although

00:23:17.640 generally with pathological gambling, that almost never works out that way. The house wins. So then

00:23:23.560 you have to get into the more subtle factors of compulsive use. So what does it mean, compulsive

00:23:27.760 use? It means a lot of mental real estate occupied with thinking about using, getting the drug,

00:23:34.620 maybe covering up drug use because other people don't approve, finding that other things are less

00:23:41.420 salient. So a kind of narrowing of our focus on that particular activity, a loss of joy in other

00:23:47.440 things that we used to find pleasurable. So this kind of, and a level of automaticity, right? Like I'm

00:23:52.980 just immersed in this. And then I think a kind of a qualitative judgment about the attachment, which is to

00:24:02.040 say, feeling like if I don't have this activity as an outlet, I can't function, even on just a mental

00:24:09.740 level, even if objectively everything looks great on paper in terms of my life. Like I'm so deeply

00:24:16.020 immersed in this kind of addiction vortex that I'm thinking about it all the time. I'm organizing my

00:24:21.500 life around it. I don't feel like there are other things that I can do or take joy in. When I try to

00:24:27.060 decathect or remove some attachment, I get anxious. I get irritable. I can't sleep. The interesting thing

00:24:34.000 for me about treating addiction is that it is a biopsychosocial disease. There's a biological

00:24:40.140 component, psychological, and a deeply embedded social and cultural component, such that, for

00:24:46.020 example, workaholism is really celebrated in our culture. And we have many, many workaholics, and you

00:24:52.400 and I might even be in that category. And yet there are so many social rewards, monetary, social validation,

00:24:59.120 you name it, that this compulsive engagement in the work that we do, we may not ever identify as problematic

00:25:07.180 unless we begin to look at more subtle manifestations or harms like opportunity costs. Like because I'm spending

00:25:14.860 all this time working, I really don't know my children. Or because I'm spending all this time working, I'm not

00:25:20.460 cultivating friendships or not investing in my partner or in my health or whatever it may be.

00:25:27.360 A big part of what I wanted to chat about,

00:25:29.120 was actually this idea of why different individuals become addicted to very different

00:25:35.940 stimuli, even if the final common pathway is comparable, right? So even if you could put all

00:25:41.760 of us into whatever it is we use, fMRI or whatever type of scan that we might use to pick up on the

00:25:48.020 areas of the brain that undergo excitation, why is it that for one individual, alcohol becomes the thing,

00:25:56.780 whereas for another person it becomes an opioid. And by the way, are there clusters where for certain

00:26:01.300 people chemicals really are the problem, whether it be opioids, alcohol, cocaine, and yet for others

00:26:06.860 it's more behaviors. And I'll share with you just as an example of why this is a question that is on my

00:26:11.780 mind so often. I've shared this story publicly before, but when I was actually in medical school,

00:26:16.840 I suffered a really, really debilitating back injury. And to make a very long story short,

00:26:22.860 through some errors in the part of the medical system, I ended up on a really, really, at the

00:26:28.140 time, very high doses of oxycodone and oxycontin. And predictably went through the escalation of those

00:26:36.300 doses until at one point I was up to 300 milligrams a day of oxycontin. So I'm sure you can put that in

00:26:44.220 the context of the patients that you see, and I'm sure you've seen patients higher, but that's a pretty

00:26:49.420 staggering dose. It's a dose that if you or I split it right now, we would be dead, just for context to

00:26:54.860 people. So after several, oh, I don't know, probably six months of being on enough oxy to kill a horse,

00:27:03.480 I just decided I wanted off. It was a very strange wake up moment where I realized I wasn't even taking

00:27:09.580 it because I was in pain anymore. I was taking it because I wanted to escape how depressed I was

00:27:14.840 that I was debilitated. I just decided to stop cold turkey. And I, at the time, was dating an

00:27:21.220 anesthesiology resident, and she was like, you are effing crazy. You're going to die. We need to put 0.99

00:27:29.300 you on nortriptyline and 10 other drugs to taper you off. And I said, no, I'm doing this cold turkey,

00:27:35.240 which I did. And I proceeded to spend the next two weeks in hell. But this is the point of the story.

00:27:40.840 It's nothing that I said so far. The point of the story is I'm no more inclined to struggle with an

00:27:49.680 opioid than any other person for reasons I don't understand. In other words, after that experience,

00:27:55.760 I was quite afraid of opioids and I assumed I was addicted. But maybe 10 years later,

00:28:01.480 when I had a really bad tooth condition and nothing was touching the pain, I finally succumbed

00:28:07.360 and took Percocet. And then after two days, when the tooth was addressed, I stopped taking the

00:28:12.800 Percocet and there was no issue. I concluded from that experience that this was not a willpower thing

00:28:19.120 that allowed me to quit. This was just a luck thing. There's something physiologically about

00:28:24.900 me that was not becoming addicted to that substance. And that's why I was able to stop cold

00:28:30.860 turkey. In other words, I wasn't morally superior to the opioid addict. I was lucky. And my question

00:28:37.600 is why? What explains this difference? Because there are clearly areas like work where I'm not so

00:28:44.660 lucky, where the addiction is indeed real and where the struggle is daily.

00:28:51.480 Okay. So a lot there to unpack. Why don't we just start with your interpretation of your

00:28:58.680 experience, which is, yes, I got physiologically dependent on opioids in medical school, but

00:29:05.100 ultimately, I'm not a person who's going to be addicted to opioids.

00:29:09.020 Well, I thought I was, but it didn't appear to be the case based on subsequent use patterns.

00:29:12.980 Yes, yes. You ultimately decided, oh, this is not an inevitable problem for me. But I recognize

00:29:19.500 that, especially given what you went through, that it could be an inevitable problem for somebody else,

00:29:24.600 right? Right. Yeah.

00:29:26.140 So let's start with risk factors for addiction. So risk factors for addiction can broadly be

00:29:32.200 placed into three separate buckets, which I call nature, nurture, and neighborhood.

00:29:37.260 The inherited or inborn risk for addiction based on family and twin studies is about 50 to 60%.

00:29:46.320 So this is, for example, based on studies showing that if you have a biological parent or grandparent

00:29:51.700 addicted to alcohol, you are at increased risk of getting addicted to alcohol than the general

00:29:57.660 population, even if raised outside of that alcohol using home. So these are really nicely

00:30:02.500 carefully done studies. So high heritability is determined by twin concordance, basically.

00:30:08.880 Yeah. And family studies, looking back in family trees, looking at kids who were adopted into non-alcohol

00:30:16.320 using homes who developed alcohol use disorder at higher rates because they had a biological parent

00:30:22.100 or grandparent. Those are those studies. And for a long time, people have talked about the

00:30:27.500 quote-unquote addictive personality. I have an addictive personality. Whatever I do, I take it

00:30:32.600 to the extreme. I'm going to get addicted. That's a kind of colloquial use. But it gets to the heart of

00:30:37.380 this idea that, yes, people come into the world with different vulnerability to this tendency to

00:30:45.780 take to the extreme the pursuit of certain types of highly reinforcing substance behaviors once

00:30:52.400 discovered in the environment. It's also probably true that we each have different what are called

00:31:01.680 drugs of choice. So even with people who are poly substance users, which by the way is more common

00:31:08.020 than not today, people use a lot of different substances and behaviors. They'll still tell you,

00:31:12.560 but my preference is opioids or the thing I really want to do is smoke a cigarette or alcohol is my go-to.

00:31:17.980 Interestingly, there's very little science on the concept of drug of choice. I looked pretty hard for that

00:31:24.760 and I couldn't find very much. But it is a really important one because what it means is that here we have

00:31:32.120 the phenomenon of access intersecting with drug of choice to increase the risk for certain individuals.

00:31:42.080 Let me explain what I mean. Let me back up. So we've got the nature, the inherited risk. By the way,

00:31:47.400 it probably goes along with co-occurring mental health disorders. People with mental health disorders

00:31:51.320 are at increased risk of developing addictive disorders. And addiction is probably a complex

00:31:56.300 polygenic phenomenon. Then we have risk factors based on nurture. So this is the way that we are

00:32:02.300 raised, early childhood development, parents that model maladaptive addictive behaviors or that

00:32:10.180 explicitly or implicitly condone substance use or other addictive behaviors. Those kids are more likely

00:32:16.360 to develop addiction in adulthood, especially if there's trauma, if there's negative attachment.

00:32:21.860 Whereas kids who are raised in a home where patients are modeling healthy, adaptive coping

00:32:27.260 strategies, where they have a good attachment to their kids, where there's not sexual, physical,

00:32:32.200 or emotional abuse, those kids are protected or relatively protected. Nobody's completely protected.

00:32:38.060 You can have the perfect childhood and still end up addicted. And then we have what I call

00:32:42.320 neighborhood risk factors. And these get to the key of access. So one of the biggest risk factors

00:32:48.820 for addiction is simple access to that drug. If you live in a neighborhood where drugs are sold

00:32:54.100 in the street corner, you're more likely to try them and more likely to get addicted. If you go and get

00:32:58.180 medical care at a place where people liberally prescribe opioids, benzodiazepines, stimulants,

00:33:04.400 your brain will be exposed to those drugs, will change in response to those drugs, and you are at increased

00:33:09.760 risk of getting addicted to those drugs. Now, in your case, the risk of access was ultimately what got

00:33:17.960 you initially hooked. But probably other innate protective factors that you have allowed you to

00:33:26.520 not end up with a serious addiction, probably in terms of genetic protective elements, maybe having to

00:33:33.620 do with the way that you were raised. I don't know you, so it's hard for me to judge. But essentially,

00:33:37.940 that's how we think about it. But what's interesting, and I guess this is the part that's most curious to

00:33:44.660 me is, I mean, if I'm being brutally honest and take an honest stock of my life, there are clearly

00:33:50.040 things where I behave in very addictive ways today. And let's just acknowledge that the neighborhood for

00:33:57.160 those things is high. Online shopping. My wife describes me as an e-shopaholic, and she can tell my

00:34:05.840 stress level by the number of Amazon packages that come to the door. So when I'm under low stress,

00:34:12.660 we'll go a week without a package. When I'm under high stress, three packages a day. To be clear,

00:34:20.180 it's not breaking the bank. I'm buying stupid, irrelevant trinkets. But it's this dumb little 1.00

00:34:25.960 escape I have where, oh my God, I need a keychain. I wonder what kind of keychains they have on Amazon. 0.79

00:34:30.780 Oh, look, I fully acknowledge that that is a true addiction. Now, I'm fortunate in that the

00:34:36.700 consequences of that addiction are minimal. But I'd like to believe I'm at least wise to the fact

00:34:43.980 that there's just a general good luck that is permitting Amazon to be my pusher, as opposed to

00:34:52.920 someone selling illicit drugs. And I wonder why. That's the thing. I wonder why, because

00:34:59.840 this to me speaks to, we're all addicts potentially. Why are some people unlucky in that the addiction

00:35:07.780 turns out to either kill them or destroy the quality of their life and their relationships?

00:35:14.560 Let me answer that in a couple of different ways. First of all, thank you for sharing the online

00:35:18.700 shopping addiction. As you know, in my book, Dopamine Nation, I talk about how I got addicted

00:35:23.660 to romance novels. Now, granted, it was a minor addiction. And I was able to, once I recognized it,

00:35:30.120 change those behaviors without having to get professional help. Which, again, brings us back

00:35:36.100 to this concept of drug of choice and how it intersects with access. Because what's so challenging

00:35:42.420 about the world today is that not only do we have more access to more potent forms of traditional

00:35:48.220 drugs, including alcohol, but all the other drugs that have been around for millennia, but we also

00:35:53.760 have brand new drugs that didn't exist before. All of the online digital media, online shopping,

00:35:59.820 pornography, the drugification of the romance novel, et cetera, et cetera.

00:36:05.040 You described this, Anna, sorry to interrupt, in a way that I loved so much. I wrote it down.

00:36:09.120 We are cacti living in a rainforest. I mean, it's just such a beautiful way to describe

00:36:15.360 the bizarre existence of the human in this condition relative to 10,000 years ago and for

00:36:24.140 millennia. Yes. And I'd love to take credit for that metaphor, but I can't. That's Dr.

00:36:28.960 Finnecane from Johns Hopkins. It's a fantastic metaphor. That's right. We weren't evolved for the

00:36:34.640 world that we live in now. So again, just to go back to my own example, I thought that I hadn't

00:36:40.540 inherited this so-called addiction gene because alcohol was never reinforcing for me. Caffeine

00:36:46.900 doesn't wake me up. These are the legal and easily accessible drugs that people who do find those

00:36:54.000 drugs reinforcing are going to be vulnerable to because they're legal and accessible. Why do nicotine

00:37:00.100 and alcohol kill more people every year than any other drug because they're legal and they're

00:37:07.320 accessible? So I think that's a really important first thing to say. Now that we have drugs like

00:37:12.260 online shopping and romance novels, people like you and me who maybe thought, well, I didn't inherit

00:37:17.260 this addiction gene. Maybe it's not true at all. Maybe we just hadn't yet met our drug of choice.

00:37:22.540 And now that we have new drugs proliferating, we are discovering we are just as vulnerable

00:37:27.120 as the next person, given the key that fits into our neurobiological lock. I am going to get to the

00:37:36.080 heart of your question a second, but I just want to make one more point before I do. When I think

00:37:39.780 about this from an evolutionary perspective, it makes a lot of sense that mother nature would want

00:37:46.120 there to be inter-individual variability in terms of drug of choice, right? So if we're living together

00:37:51.440 in a tribe, in a world of scarcity and ever-present danger, which is the world that humans have existed

00:37:57.360 in for most of the time that we've been around, it's very good if we're not all going for the same

00:38:03.720 exact berry bush. It's very good if you like the red berries and I like the blueberries and somebody

00:38:08.960 else wants to hunt meat and somebody else wants to look for people. That way, we as a tribe can be

00:38:15.000 pretty well guaranteed that together, we're going to be able to get all of the scarce resources that

00:38:21.060 we need to survive. So I think when you think about it from an evolutionary perspective, that's

00:38:25.700 important. But I really think the heart of your question is not so much why is it that some people

00:38:32.000 get addicted and others don't because we've just explored the fact that really we're all vulnerable,

00:38:37.340 especially in the modern ecosystem. But why is it that some people can self-correct? That as we

00:38:44.440 progress on this road of compulsive overconsumption, why is it that some people can see it and make an

00:38:50.400 adjustment? Which by the way, I just want to make sure, I know you know this, but I want to make sure

00:38:54.720 the listener understands. When I tell that story about me with the opioids, I'm not claiming to have

00:39:00.500 self-corrected. I'm simply saying it was not the lock and key for me. So it was actually quite easy

00:39:09.000 to stop. And the only suffering I went through was the physiologic withdrawal, which is dramatic,

00:39:15.140 but it's a chemical reaction that after a few weeks was gone. And now, I mean, even as I sit

00:39:20.840 here now, we have a bottle of Percocet in our, it's in my bathroom. It's 10 feet from me and it's

00:39:25.340 been there for 10 years and I've never looked at it and it wouldn't occur to me to. But if I was in

00:39:29.680 significant pain, I would go and take two of them and not think twice about it and it would be fine.

00:39:33.020 So just to be clear, it wasn't through any self-discipline that I stopped taking it.

00:39:38.120 That was quite easy once I just decided and made the observation that I shouldn't be taking it.

00:39:43.160 If I was truly one of willpower, I would never step foot on Amazon again. Or if I did,

00:39:49.000 it would only be for something that I needed. So in that sense, I am a junkie and I don't seem to

00:39:54.980 possess the tools or at least innately to stop it. Okay. So good clarification. You really don't

00:40:02.240 think that you have a vulnerability to opioid addiction, but you really do think you're

00:40:06.120 addicted to online shopping. Is that fair? That's fair.

00:40:10.680 Okay. So yeah, but I think you're too hopeless about your online shopping. I think that that is

00:40:18.380 an addiction that if you decided you wanted to, you could work on and make progress in that regard.

00:40:25.760 Clearly, there are not financial consequences for you to buy key chains. Now, in my book,

00:40:31.340 I do talk about a patient of mine who did get addicted to online shopping on Amazon to the point

00:40:35.660 where his house was full of partially opened boxes. He was in credit card debt, approaching

00:40:41.600 financial ruin. He didn't even get pleasure from the things he ordered anymore. It was just the

00:40:46.720 anticipation and then it would come. And as soon as he opened the box, he would have an immediate

00:40:50.600 come down. Which by the way, I can relate to that. I can really, really relate to that. And it's with

00:40:56.760 great empathy that I read that story because I can imagine how painful that is as the size of

00:41:04.220 the purchases goes up and up. And again, for whatever reason, and I attribute it solely to

00:41:10.380 luck and good fortune, maybe it's just a tolerance thing. I haven't had to get to the point of that

00:41:16.360 patient. Right, right. Exactly.

00:41:18.660 But that would be awful if you're spending all of that energy on something and you open the package

00:41:24.980 and you're like, yeah, great. Okay. What's next?

00:41:28.480 Yeah. And I think it's great for people to hear that you have some degree of incontinence around

00:41:34.320 this behavior. Aristotle talked about what he called wide-eyed incontinence. Why is it that I do what I do

00:41:41.080 not want to do? Because really that's at the heart of addictive behaviors. And I'm guessing that people

00:41:46.960 look to you as a sort of paragon of self-discipline. So it's very nice, I think, for people to recognize

00:41:53.080 that even you have arenas in which you are incontinent in this regard. Which, by the way, is really hard

00:41:59.100 to admit in our culture because we're all supposed to be, you know, have it together and have all this

00:42:05.120 kind of self-control. But really, almost all of us now have some space in our lives where we're

00:42:11.220 over-consuming either a substance or behavior, even if it's only mildly problematic, that we'd like to

00:42:17.480 change. And I guess since I have seen people with very severe and life-threatening addictions be able

00:42:24.940 to get into recovery and maintain recovery for decades, I think that we can all look to those

00:42:31.540 individuals as guides for the rest of us and not be overly fatalistic about our own capacity to change

00:42:40.420 these behaviors. I think we can change these behaviors. And I would also suggest that to do so

00:42:46.100 is not just important for our own mental health, but it's also important for the planet. So our

00:42:50.420 consumptive behaviors really do affect everything around us.

00:42:54.780 Some of the stories in your book, Dopamine Nation, as I'm reading them, I'm thinking to myself,

00:43:00.720 well, if she included this person, there must be a happy ending. But as I'm reading it, I'm thinking,

00:43:06.160 there's no way this person is getting out of this alive. I mean, some of the clinical stories that you

00:43:12.320 write about, and I assume outside of changing names and maybe genders in a few places, these are probably

00:43:18.700 very accurate accounts of the individuals you worked with. I mean, I really had a lot of empathy for

00:43:24.680 these people.

00:43:25.720 Yeah, good. That's good.

00:43:27.020 Maybe because anybody reading it who themselves has an addiction, even a quote unquote benign one,

00:43:32.040 realizes that that's devastating. But there are a couple that I think are interesting and worth

00:43:37.380 talking about. So let's talk about the young woman whose parents sort of talk her into coming to see

00:43:42.220 you because she's basically smoking pot around the clock or not even smoking it. I mean, she's consuming 1.00

00:43:47.480 it in every form that THC is imaginable. And now, of course, by her own reckoning, this is

00:43:54.000 purely a logical coping tool for her anxiety. There's nothing pathologic about it. She's not

00:44:00.900 suffering any ill consequences of it. Maybe tell her story and kind of a little bit of the work you

00:44:05.600 did with her. And the reason I want to use that as one of the examples is you talked about

00:44:10.180 neighborhood a second ago. And it's a very controversial topic right now, which is, for example,

00:44:16.320 the legalization of marijuana. And truly, it's something I find myself divided on. Because on the one

00:44:21.940 hand, I think the criminalization of marijuana has led to a lot of destruction in people's lives.

00:44:29.880 But at the same time, it's hard to avoid the knowledge that you've shared, which is, look,

00:44:34.480 the more available and ubiquitous a substance is, the more likely it is to be abused. Case in point,

00:44:41.000 alcohol and tobacco. So I'd like to kind of explore that a bit with you and also explore this idea of

00:44:47.360 marijuana as a gateway drug, that the so-called gateway drug to drugs that maybe people would

00:44:53.540 argue are quite harmful, even if they believe that THC consumed in any amount is not. So maybe

00:44:59.540 we'll start with the story of that young woman and kind of explore that a bit more.

00:45:03.400 Yeah. So this young woman, first of all, all of the patients that I talk about in the book are

00:45:08.480 patients who were very longtime patients of mine, who I knew very well and who I asked for their

00:45:14.320 permission to share their stories using a pseudonym. This was a young woman, very typical for the types 0.99

00:45:21.040 of patients that we will see now, who came in not looking for help with her cannabis use, but

00:45:26.540 looking for help with her anxiety and her depression. 20 years ago, the first thing I would have done

00:45:32.920 for a patient like this was prescribe an antidepressant or an anxiolytic, maybe even some Xanax or some

00:45:39.000 clonopin and referred her for psychotherapy. My practice has changed very much in the last two

00:45:46.060 decades because of what I've learned from patients in recovery and the ways in which repeated use of

00:45:52.720 highly reinforcing substances and behaviors actually changes our hedonic or joy set point and creates,

00:46:00.280 exacerbates and drives depression and anxiety such that now the first intervention that I'll do with

00:46:06.440 a patient like this is to actually ask them to abstain from their drug of choice for four weeks

00:46:12.120 as a way to reset those reward pathways to see whether or not that alone will address the anxiety

00:46:19.440 and depression. And in the majority of my patients, if they are willing and able to do that, they feel

00:46:26.420 so much better after that abstinence trial or dopamine fast that there's not even an indication after that

00:46:34.260 to prescribe an antidepressant or an anxiolytic or necessarily do psychotherapy. I'm happy to talk

00:46:40.660 about how that hedonic set point gets changed from the perspective of neuroscience if that would be

00:46:44.880 helpful. Yeah, I think that would be great. Okay, so to me, one of the most interesting findings in

00:46:50.780 neuroscience in the past 75 years is that pain and pleasure are co-located in the brain and work like

00:46:56.820 opposite sides of a balance. So if you imagine that deep in these limbic structures in nucleus accumbens,

00:47:02.540 the area that's rich in dopamine-releasing neurons, there's something like a teeter-totter,

00:47:08.040 a central beam on a fulcrum that in a very simplified way represents how we process pleasure

00:47:13.520 and pain. When we experience pleasure, it tips one way. Pain, it tips the other. There are certain

00:47:19.440 rules governing this balance, and the first and most important rule is that the balance wants to remain

00:47:24.380 level. And that level balance is what neuroscientists call homeostasis, such that with any deviation from

00:47:32.200 that level position, which is the definition of biological stress, our brains will work very hard

00:47:37.720 to restore a level balance. So for example, my patient uses cannabis through the endogenous opioid

00:47:44.020 system that ultimately leads to the release of dopamine in the reward pathway. Her pleasure-pain

00:47:48.620 balance tilts to the side of pleasure, and then her brain says, oh, that was good. Let's do that again. 0.59

00:47:54.800 But remember, the balance wants to return to the level position, so it does that by adapting to that

00:48:00.340 increased dopamine by down-regulating dopamine transmission and production, not just at baseline

00:48:05.380 levels, but below baseline levels. I like to imagine that as these neuroadaptation gremlins

00:48:11.240 hopping on the pain side of the balance to bring it level again, but the gremlins like it on the

00:48:15.480 balance, so they stay on until the balance is tilted an equal and opposite amount to the side of pain.

00:48:21.000 That's the hangover, the come down, the blue Monday, or just that state of craving. Now, if after that

00:48:27.060 initial use, my patient doesn't smoke again, those neuroadaptation gremlins get the message that their

00:48:33.500 work is complete, they hop off the balance, and homeostasis is restored. Craving goes away, and

00:48:40.080 she goes on with her day. But if she continues to use that substance, in her case cannabis, repeatedly

00:48:46.780 over time, ultimately what happens is those gremlins on the pain side of the balance start to accumulate.

00:48:52.080 They get bigger, they get stronger, now they're camped out there. And now, essentially, we're entering

00:48:56.920 addicted brain. Now, when she uses cannabis, that initial deviation to the side of pleasure 1.00

00:49:02.140 is weaker and shorter in duration, but that after response to pain gets stronger and longer. And

00:49:08.780 ultimately, she ends up in a kind of chronic dopamine deficit state, below her natural dopamine

00:49:14.900 baseline, where she is experiencing the universal symptoms of withdrawal from any addictive

00:49:20.320 substance, which are, again, anxiety, irritability, insomnia, dysphoria, and craving. When she uses

00:49:27.380 cannabis, that temporarily counteracts those gremlins on the pain side of the balance, and she feels better.

00:49:34.500 So she thinks to herself, I'm self-medicating my anxiety with my medical marijuana. But in truth,

00:49:41.880 all she's really doing is just adding more gremlins to the pain side of the balance. So the intervention 0.98

00:49:47.060 is to have her abstain from her cannabis long enough so that those neuroadaptation gremlins get the 1.00

00:49:54.300 message they need to hop off the pain side of the balance so that healthy levels of dopamine firing can

00:49:59.240 be restored. This is obviously a vast oversimplification of a very complex process, but it gets to the heart of

00:50:06.120 homeostasis, a level balance, and allostasis, which is our brain's attempt to adapt to these highly

00:50:14.540 reinforcing stimuli, for which it was not evolved. And the definition of an intoxicant is that it

00:50:20.300 releases a lot of dopamine all at once in the brain's reward pathway. Our brains were evolved for us to

00:50:24.960 have to work very hard to find a tiny little jolt of dopamine, and then essentially do that again and

00:50:31.440 again to stay alive. So the intervention for her is to ask her to abstain and to let her know that she's

00:50:39.040 going to feel worse before she feels better, more depressed, more anxious. Maybe she'll have other

00:50:44.200 signs of physiologic withdrawal, which indeed in her case she did. She had vomiting, which really

00:50:49.320 shocked her because she thought that was a sign for her, a physical sign that she had become dependent

00:50:55.560 on or addicted to the cannabis. But as I say to patients, if you can just get through about the

00:51:00.600 first 10 to 14 days of feeling worse after you give up your drug of choice, by the time you make it to

00:51:09.040 feel better, less craving, less anxious, less depressed, better able to sleep. And that's so

00:51:14.320 often a revelation for people because they have become convinced that their drug of choice is

00:51:20.540 quote unquote self-medicating their depression or whatever it is. So that was the intervention with

00:51:25.940 her. That's our general early intervention that we do. Just a couple of questions there, Anna,

00:51:30.540 before we go on, which drugs or chemicals, I suppose, can you not safely just do that with?

00:51:40.000 So for example, in the case of cannabis, the pain that she experienced was not life-threatening and

00:51:45.220 therefore she didn't need anything to cope with withdrawal. We've already discussed how that would

00:51:50.000 not be the case with ethanol. So if somebody came into your office and they're having six drinks a day

00:51:54.940 and they go through the steps to acknowledge, hey, this is problematic and they agree to want to stop,

00:52:00.580 you wouldn't be able to just say, hey, leave your office, don't drink and I'll see you in four

00:52:04.580 weeks. There's a very good chance they would be dead due to the cardiovascular side effects. So

00:52:10.040 there you would have to put them on other drugs. What are the other dependencies for which you

00:52:15.500 wouldn't just have the liberty of stopping cold turkey? Let me just say that that's a very good point

00:52:21.020 to qualify this intervention, but it's not necessarily true that for somebody with an alcohol

00:52:27.900 addiction, you couldn't do this intervention. It would depend on how severely physiologically

00:52:33.160 dependent they were and whether or not they were at risk for life-threatening withdrawal or

00:52:38.600 delirium tremens or seizures. Most people who are addicted to alcohol actually won't have life-threatening

00:52:45.100 withdrawal and could do this. How do you determine that? By the way, we used to be very blunt about this

00:52:50.500 in residency because I was a surgical resident. When we operated on people who appeared to drink

00:52:56.220 a lot based on our intake assessment, which is subjective, we would just usually run an ethanol

00:53:02.220 drip in them for safety. I don't think there was any real insight into whether that was really

00:53:07.620 necessary or not. So how would you evaluate that with a patient?

00:53:11.880 The biggest predictor of how someone is going to withdraw from alcohol is past withdrawal. So we will

00:53:17.400 ask them, when was the last time you stopped drinking? For how long? And what was your

00:53:21.760 symptomatology? It's not fail-safe. Of course, as people age, they lose neuroplasticity. Their risk of

00:53:29.720 having some kind of more difficult or even potentially life-threatening withdrawal increases. It also increases

00:53:35.380 over the drinking career, especially as their liver is compromised or pancreas is compromised. But really,

00:53:41.780 you look at past withdrawal, how long ago was that? It is really interesting, and we don't understand why

00:53:50.320 this is, that some people who drink enormous quantities for decades can stop and have minimal

00:53:56.780 withdrawal. And other people who have had much shorter drinking careers will go into delirium tremens or have

00:54:02.620 life-threatening seizures. So we're not at all cavalier about it. And for any patient that we remotely

00:54:08.580 suspect might have a serious withdrawal, we would recommend medical monitoring or possibly inpatient

00:54:17.360 monitoring. So we take it very seriously. And we don't just recommend this early intervention for

00:54:23.240 somebody who was at risk. But I can tell you, most people who are addicted to alcohol will not have

00:54:29.640 life-threatening withdrawal from alcohol. The other major category is basically benzodiazepines,

00:54:34.280 which is alcohol in pill form. They work on the same or similar GABA receptors. And so people can

00:54:39.780 have life-threatening withdrawal from benzodiazepines, which is why for many individuals, we will

00:54:45.460 recommend a medically monitored slow taper or a more rapid inpatient detox. We used to think that

00:54:52.820 opioid withdrawal, although extremely painful, was not life-threatening. But in the last 20 years,

00:54:58.220 as we've been helping people decrease the very large doses of prescription opioids they've been given

00:55:03.500 by their doctors, we have noticed that especially in older people and people with serious medical

00:55:09.100 comorbidities, cardiac comorbidities, for example, the stress is just too much. And that those

00:55:15.160 individuals, again, need to be slowly tapered down. But the general ones that we worry about and have

00:55:21.620 to screen for is alcohol, benzodiazepines, and now concern for opioids. I would say the other category

00:55:29.020 of individual in which we would not recommend this dopamine fast or abstinence trial is individuals

00:55:34.140 who have repeatedly tried to stop on their own and been unable to. That would just be a lesson in

00:55:39.060 frustration. Those are individuals that we would recommend to a higher level of care, like a day

00:55:43.380 treatment program or a residential treatment program. Also, especially with opioid use disorder,

00:55:49.660 opioid addiction, we are finding that some people, even with long periods of abstinence,

00:55:55.900 never get out of that state of craving and really can't move on with their lives. Which is why we

00:56:02.160 will prescribe opioids to treat opioid addiction in some cases. And for example, medications like

00:56:07.860 buprenorphine or methadone maintenance are evidence-based interventions for opioid addiction.

00:56:12.740 Seems counterintuitive to give a patient with an opioid addiction an opioid, but they're very unique

00:56:18.340 opioids. They have a long half-life, which means it gets people out of this repeated cycle of

00:56:22.760 intoxication, withdrawal, drug seeking, et cetera, gets them out of that state of craving. And if you

00:56:28.240 think back to this pleasure-pain balance, we're not getting folks with opioid use disorder high by

00:56:33.220 giving them opioids. We're just allowing them to level their pleasure-pain balance, go back to

00:56:38.540 baseline homeostasis, which then frees up their energy and creativity to engage in other aspects of

00:56:44.960 their recovery.

00:56:45.660 If someone's listening to us now and by the end of this podcast, they've become convinced that

00:56:51.300 maybe they're drinking too much and they'd like to try this dopamine fast, do you recommend that

00:56:56.940 they speak with their doctor before doing it? Is this something that a person can safely try

00:57:01.920 if they're aware of what side effects might prompt medical attention? We certainly don't want to

00:57:06.800 discourage people from reducing their alcohol intake if that is indeed problematic, but at the same

00:57:11.940 time, we want to be responsible in how we do that. So what advice would you have for somebody listening

00:57:15.220 who's saying, hey, you know what, these three or four drinks I'm having every single day,

00:57:20.180 I'd be better off without?

00:57:21.740 I think if the individual has any concern about a serious medically dangerous withdrawal from alcohol

00:57:30.200 or from benzodiazepines or from opioids, they should consult a medical specialist. But the majority of

00:57:36.460 people who use these substances have taken periods on the order of days or maybe even weeks when they

00:57:43.340 have stopped. So they have a pretty good sense of, number one, whether they can do it, and number two,

00:57:48.720 what kind of reaction their body will have. So I do think that this is an experiment that most people

00:57:55.760 can try without medical supervision, especially if they're in a position to either not be able to afford

00:58:01.360 it or have access to somebody who's trained in addiction medicine. We have far fewer addiction

00:58:07.240 medicine providers in this country than we have the need to address the problem. So I think as an early

00:58:13.700 intervention, it can be a nice experiment even just to see if they can do it. Sometimes we think we have

00:58:20.620 some degree of control and then it turns out we don't have the degree of control that we thought we had.

00:58:26.080 It's also just a very interesting experiment for those who are not addictive to get a sense of deep

00:58:35.640 understanding and empathy for the problem of addiction. Because even just giving up something

00:58:40.320 like online shopping or romance novels or video games or what have you, and to observe ourselves going

00:58:47.120 through withdrawal can be enlightening. And as you experience with the opioid withdrawal in that medical

00:58:54.360 setting, give you a great deal of empathy and healthy respect for the phenomenon of addiction.

00:59:01.720 Yeah, going back to that, the point about neighborhood again is really, really clear,

00:59:05.960 which is it's very difficult to kick a habit if you go right back into the environment in which that

00:59:12.320 habit was rife. So in the case of this patient, for example, she comes back after four weeks. It's been

00:59:18.920 a transformative experience in that she's gone through very painful withdrawal. You prepared her for it by

00:59:25.500 telling her it was going to hurt a lot and that she needed to sit in the pain effectively. And when she

00:59:30.780 comes back, the anxiety is gone. So one, how do you now help her with this next phase of recovery? And how

00:59:40.840 difficult a set of choices does that person need to make if indeed their social circle basically fed into

00:59:48.260 that addiction? I mean, to me, as hard as that four-week abstinence program is, it might be what

00:59:54.140 follows that's actually harder. Yeah, you're absolutely right. So if the patient is able to abstain for four

01:00:01.540 weeks, they come back, we ask them how it went, and we kind of make a pros and cons list. What was good

01:00:07.620 about not using? What was bad about not using in those four weeks? When the patient feels better,

01:00:12.940 and again, about 80% of folks feel better, 20% don't. And that's also really useful information

01:00:17.620 because it tells us that something else is driving this, and then we explore that.

01:00:21.620 For this case, the feeling better, on the pros side, people will talk about,

01:00:26.380 I was more productive. I had more time. I was able to be more present. I felt physically better. I was less

01:00:32.620 anxious, less depressed, slept better, et cetera, et cetera. So there's really a nice long list of

01:00:38.320 things that they gained from stopping using. And what I think is so powerful about this intervention

01:00:45.560 is that the person has their own experience. I'm no longer in the role of having to persuade them

01:00:51.940 that not using or using less will make them feel better. They have experienced it for themselves.

01:00:58.160 On the cons list, like what was bad about not using, you already anticipated pretty much the

01:01:03.920 top one, which is I couldn't hang out with my friends because all my friends use, and I would

01:01:08.980 really like my friends. I want to go back to hanging out with them. So that poses a serious dilemma.

01:01:13.840 The other major con that people endorse is just simple boredom. All of a sudden, people are left with

01:01:19.420 lots of time and wondering what to do with it. But I like to talk a lot with patients about boredom

01:01:25.180 being kind of the midwife of creativity. And then we essentially talk about next steps.

01:01:32.500 And the first time around, most patients want to go back to using their drug of choice,

01:01:37.660 but they want to use differently. They want to use in moderation. So I support them in that goal,

01:01:42.880 even if I'm thinking to myself, this is a really bad idea. I don't think they're going to be

01:01:46.360 successful. Why do I support them in that goal? Because again, this is experiential learning.

01:01:50.820 I can talk to the cows, come home until they experience it for themselves. It's not really

01:01:55.760 going to take. But also, I've discovered that I'm a very bad predictor of who's going to be

01:02:00.500 successful and who isn't. I've had patients who definitely meet criteria for alcohol use disorder,

01:02:06.640 serious alcohol addictions, who have been able to go back to using alcohol in moderation after an

01:02:14.220 extended period of abstinence. What fraction do you think fits that description? Again, we'll talk about

01:02:19.880 it through the lens of chemicals maybe as opposed to just behaviors, but is that a minority of people

01:02:24.620 who are able- Oh, absolutely. It's a small minority. It's a small minority. It's definitely

01:02:28.960 less than 10%, maybe even hovering closer to 1%. So these people are clearly anomalies, but just

01:02:36.760 out of the curiosity of exploring the end user, what is it about an individual that allows them

01:02:43.000 on the one hand to have met complete criteria for a true addiction, whether it be to alcohol or

01:02:49.820 another substance, to go through a period of detoxification and emerge from that and say,

01:02:55.460 you know what? It's true. I used to drink six drinks a day and I would blackout drink and binge

01:03:00.200 drink and it was ruining my life. DUIs all day long, like all of the above. But now I'm going to become

01:03:07.080 a social drinker. I'm going to have a glass of wine with dinner every night. That's it. If there's

01:03:11.040 the one in a hundred who can do it, how are they doing that?

01:03:14.840 They're doing it with a lot of hard work. It doesn't come just like that. It's not like you

01:03:23.280 staying for a while, you reset your reward pathways, you're good to go. In fact, quite the contrary.

01:03:29.500 Once we've created those kinds of addiction circuits, even though we can get them to quiet down,

01:03:34.300 they're very easily reignited, not just by exposure to our drug of choice itself, but to reminders of

01:03:41.300 the drug of choice. So what I talk a lot with patients about is the specificity of the plan

01:03:48.020 for how they will consume. The more specific, the better. And this is all in the spirit of

01:03:53.360 self-binding strategies. Self-binding strategies are very, very important in a world where we're

01:03:58.960 constantly being titillated and invited to consume and told that that's the good life.

01:04:04.300 What do I mean by self-binding strategies? Those are both literal and metacognitive barriers that

01:04:09.560 we put between ourselves and our drug of choice so that we can press the pause button between

01:04:14.780 desire and consumption. So for a patient with a drinking problem, that might look like not having

01:04:22.280 any alcohol in the house, right? A very simple and obvious self-binding strategy. That might look like

01:04:28.520 pledging to never drink alone, but only with friends on special occasions.

01:04:33.340 Making sure that I don't now fill my schedule up with many different special occasions, which

01:04:38.700 happens. That can look like making sure that I am very cognizant of how much I'm drinking and keep

01:04:45.840 it to no more than two standard drinks on any given occasion and track it carefully and write it down

01:04:51.860 so that I don't get into that state of blurry denial where I can tell myself it was only one drink when

01:04:57.660 it was really five. That might even look like taking medications. So we have medications like

01:05:03.000 naltrexone, which is an opioid receptor blocker. Alcohol works in part through our endogenous opioid

01:05:08.820 system. And by blocking the opioid receptor, we essentially make alcohol less reinforcing.

01:05:14.760 So people who will take naltrexone will say, when I'm taking naltrexone, at least the ones for whom

01:05:19.080 it works, I can look at a six-pack of beer and I just want to drink two. I don't want to drink the whole

01:05:24.940 six-pack. And that's really a revelation for these people because before, you know, it would just be

01:05:30.120 like, I really want to drink the whole six-pack. Self-binding strategies can be, again, at the

01:05:35.140 literal physical barrier level. It can be at the chemical barrier level. It can be at a kind of

01:05:42.100 interpersonal accountability level. It can be at a spiritual level. So wanting to live in accordance

01:05:48.800 with one's values or a greater good and seeing their use or their excessive use as contrary to

01:05:57.140 living according to those values. So really getting at it from all different angles. And people with the

01:06:03.380 most severe addictions ultimately really need to get a totally different orientation on their lives

01:06:12.180 in the sense that they really need to inculcate a philosophy about life that allows them to maintain

01:06:23.080 their recovery. And by that, I mean like living recovery principles in all aspects of their lives.

01:06:29.140 So that's things like telling the truth in all situations. A lot of people in recovery have taught

01:06:34.400 me that if they start to lie, even about little things like why they were late for a meeting,

01:06:39.180 that is a potential for them to tip over and relapse. So it's a very interesting, it's like a

01:06:46.760 recovery mindset slash lifestyle slash philosophy. It has to become bigger than just the substance

01:06:54.320 itself. One of the things that strikes me as noteworthy as you describe the effort that would have to go

01:07:01.740 into dipping your toe back in the water is at least maybe having the patient consider the cost of that

01:07:08.860 in terms of look, if you really want to go back to having a couple of drinks here and there, then the

01:07:15.040 systems you have to put in place to do that as opposed to the systems you might have to put in place to

01:07:20.760 just adhere to complete abstinence. Think of the opportunity cost of doing that. That's a lot of energy that

01:07:26.800 could go into living a fuller life in other ways. Is it really worth having a couple of drinks a week or

01:07:34.160 whatever it is that you've agreed to? Do you sort of ever have that discussion or do you think that

01:07:38.840 that's just up to them to figure out? Oh, no, no. So that's a very common discussion. So basically

01:07:45.640 the typical outcomes that we see after the dopamine fast or the abstinence trial is first the abstinence

01:07:52.220 violation effect where people say, I'm going to go back to using in moderation and immediately they're

01:07:56.120 plunged into a binge episode, even worse than what was there before. And then, you know, then there's the

01:08:01.360 discussion of, gee, maybe moderation is really not possible. Or people who are able to achieve

01:08:06.860 moderation but who ultimately decide it's so effortful and so much work that it's essentially

01:08:12.080 not worth it. There's this famous AA lingo, one drink is too many and two is never enough,

01:08:19.240 which kind of captures that very well. This idea that stopping at two doesn't actually get me what

01:08:25.060 I'm looking for, but does in fact reignite those addiction circuits such that it's very difficult

01:08:32.400 to stop at two and I want to keep drinking. And those people will often ultimately decide that

01:08:37.700 abstinence is not only better for them, but also easier. Yeah. Let's talk a little bit about some of

01:08:43.780 these behavioral addictions as well. I think of all the stories in your book, the one that I'm not sure

01:08:49.040 what it is about the character, but he certainly invites enormous sympathy is, I think his name is Jacob.

01:08:55.140 Yeah. Everybody's heard of sex addiction and sort of has an understanding of what it is, but

01:09:00.540 it's not necessarily what you describe in Jacob. His sex addiction is not the one that you would

01:09:06.520 think of when you're watching a TV show that features someone who's a sex addict. So maybe tell 0.78

01:09:11.940 briefly the story about Jacob and describe the pathology there and what is the addiction giving him

01:09:18.200 that maybe a gambling addiction wouldn't give a gambler or an alcohol addiction doesn't give the

01:09:23.700 alcoholic. What was the pleasure he was seeking relative to maybe what I would normally think of

01:09:28.880 as a sex addict is seeking many partners, for example? Ah, interesting. Okay. So there are,

01:09:35.660 I mean, many different ways that sex addiction can manifest. Sometimes when people get addicted to sex,

01:09:42.340 they compulsively seek out partners, but many people addicted to sex now are addicted to pornography and 0.88

01:09:50.100 compulsive masturbation. It's very hard to get numbers on any of this, but I would say the majority

01:09:55.800 of cases that we see are not in fact people who are having sex with other people. There are people

01:10:01.800 who are spending enormous amounts of time looking at pornography, masturbating, and of course that's

01:10:07.620 so easy to do now given the advent of the internet and online pornography. In the case of my patient,

01:10:13.220 Jacob, he started out with pornography and compulsive masturbation, but he is an engineer and ultimately

01:10:20.200 built a masturbation machine that escalated over time as his addiction progressed, as addictions will progress,

01:10:30.240 such that he was ultimately hooking himself up to the internet, letting strangers in chat rooms manipulate

01:10:35.880 this machine in a way that was really very dangerous and potentially life-threatening, which he was fully aware of,

01:10:42.460 and yet struggled to stop the behavior. Ultimately, you know, when the behavior was discovered by his

01:10:47.880 wife, she left him and he considered ending his life. When people say, oh, you can't really get addicted

01:10:54.600 to sex the way you can with drugs and alcohol, I would just invite them to be a fly on the wall in the 0.68

01:11:01.000 work that we do. We are seeing more and more men of all ilk coming in with really devastating,

01:11:08.040 what we broadly classify as sex addictions. This is compulsive masturbation or the pursuit of 0.97

01:11:14.260 orgasm in many different ways. You mentioned this is primarily a male problem. Why do you think that 0.94

01:11:20.800 is? Well, I think there's enough evidence to show that men in aggregate have a higher sex drive than

01:11:30.720 women. Any teenage boy, the joke about how much of a teenage boy's brain is occupied with 0.82

01:11:36.280 thinking about sex. It's a 99%. I mean, you know, I'm sort of loathe to kind of speculate

01:11:42.580 too much about that, but it's just the truth. I mean, that's what we're seeing. We're not seeing

01:11:48.120 women coming in with sex addictions the way we are as with men. Occasionally, we'll see that, 0.95

01:11:54.600 but it's quite rare. Although there are data emerging showing that more and more women are consuming 1.00

01:12:01.100 pornography. So what's been interesting to see in the modern era, the ways in which certain

01:12:08.540 demographic groups that were previously relatively immune to certain types of addictions, that's no

01:12:14.280 longer the case. So for example, with alcohol use disorder, for generations, the ratio of men to women

01:12:19.920 with an alcohol addiction was five to one. 30 years ago, it was two to one. Today, among millennials,

01:12:25.560 it's one to one. We are now seeing young women presenting with alcohol use disorders pretty much

01:12:31.340 as often as we see men. So who knows? With enough time, it could well be that this is not necessarily

01:12:38.240 a biological phenomenon and really just a sociocultural one. Certainly in part, it's probably

01:12:43.920 sociocultural. Are men in general more prone to addiction? Because obviously you've stated now that

01:12:50.400 men effectively make up all of the or most of the patients who suffer from various forms of sex

01:12:56.280 addiction. I'm just going to guess, knowing nothing about it, that the same is probably true with

01:13:00.460 gambling. What are the addictions, maybe stated the other way, where women disproportionately make up

01:13:05.400 the patients? The only one that I have seen data for where women outstrip men is for benzodiazepines,

01:13:13.140 so sedatives like Xanax, Valium, Klonopin. Okay. So if we take all addictions together,

01:13:20.820 men have a greater problem with addiction than women, I would guess, just based on the simple 0.50

01:13:25.580 fact that in most cases, men outstrip women. The one sort of new wrinkle there is just social

01:13:31.780 media addiction where we're seeing more women and girls. Okay. So do you think that that fits more

01:13:39.240 into nature, nurture, or neighborhood as the driver? We have three things. So I guess it's

01:13:44.180 a combination of all three things, I think. Very interesting. So let's go back to maybe some

01:13:52.640 of the things that, some of the itches that are being scratched with these different addictions.

01:13:57.540 So you talk about, I think it's called loss dysphoria. Is that what you referred to? Or no,

01:14:02.780 no, I'm sorry, loss chasing. Oh yeah. Is that what the gambler is looking for? Now that was a very,

01:14:07.320 I had never thought of that before. Can you explain what that is? And does that phenomenon

01:14:12.100 expand beyond the gambling addiction? Is there an analog to that in other forms of addiction?

01:14:17.720 So loss chasing is a phenomenon that's been observed in pathological gamblers,

01:14:23.520 where they will report that when they are deep in an episode of gambling, they actually want to lose.

01:14:31.740 And the reason they want to lose is because the losing allows them to justify staying in the game

01:14:38.800 longer, which is, I think, very revealing because it shows that on some level, a gambling addiction

01:14:45.720 isn't really about being addicted to money. It's about being addicted to the pursuit of money or the game

01:14:51.860 itself or the trance-like state that people can get into when they're deep in their addictive

01:14:57.320 behaviors, which I would argue applies to every single addiction under the sun. So for example,

01:15:03.180 sex addiction is not really about sex. It's about self-soothing. It's about escape. It's about

01:15:09.540 numbing. It's about relieving tension. And I would say that that's true for all addictive behaviors.

01:15:17.100 Interestingly, there's been some work using brain imaging, looking at dopamine levels

01:15:21.920 in pathological gamblers' brains compared to healthy control subjects who are gambling.

01:15:28.300 And what the researchers found is that when pathological gamblers are winning,

01:15:34.260 there will be an increase in dopamine transmission in the reward pathway. And the same will be true

01:15:38.820 for healthy control subjects. But the difference comes when they're losing. When healthy control

01:15:45.120 subjects lose, there's no increase in dopamine transmission. But pathological gamblers will

01:15:50.460 actually have an increase in dopamine transmission when they're losing, which maps very nicely on

01:15:56.440 to this subjective experience of loss chasing. And it looks like the dopamine in a pathological

01:16:04.220 gambler, dopamine is released at the highest level when the chances of winning and losing are equal.

01:16:09.200 So it's that place of uncertainty in the gambling state that is, on some level, the most appealing state

01:16:18.060 for the pathological gambler.

01:16:20.480 Is there, just from a population prevalence standpoint, you've already alluded to the fact that

01:16:26.040 addictions to social media are probably really, really on the rise for the obvious reason that

01:16:31.520 didn't exist 20 years ago. We certainly know from an availability, i.e. neighborhood access phenomenon,

01:16:37.840 that opioid addiction is clearly on the rise. I would assume that marijuana is also on the rise

01:16:43.800 for the same reason. Is that a fair assumption? I haven't looked at the latest data. So certainly

01:16:51.200 overall, in the last 20 years, Americans are using a lot more cannabis than they were previously.

01:16:59.280 And they're using more potent forms of cannabis. And what we're seeing in particular is that there's

01:17:04.920 a subset of individuals who use cannabis who are using very, very large quantities. So a generation 0.95

01:17:11.060 ago, 20, 30 years ago, people who used cannabis were still mostly using it recreationally on the

01:17:17.480 weekends with friends. Now what we're seeing is a very hardcore group of individuals who use cannabis

01:17:23.660 every day, all day, dabbing, highly potent forms, vaping, getting very high levels in their brains. So

01:17:32.300 these are the kinds of trends. In other words, the increased access is going to harm

01:17:39.620 a subset of the most vulnerable individuals who will be most likely to use it in very potent forms

01:17:47.440 in very large amounts. Which really raises kind of a challenging societal question, which is,

01:17:53.180 do you punish all of the people for whom the increased access has potentially made life better,

01:17:59.980 both in terms of the actual use of the drug and certainly the decriminalization of it,

01:18:04.580 which has probably made many lives better. But it's clearly made some lives worse. And I'm glad

01:18:11.080 I'm not the person responsible for making those decisions because those are very difficult decisions.

01:18:14.980 I don't know how one makes a decision if you're trying to put the good of society at the top of

01:18:22.140 the priority list when there are these conflicting outcomes. What about other things like, well,

01:18:27.800 I guess you've alluded to the fact that it sounds like sex addiction is also on the rise.

01:18:30.900 Very hard to get numbers on sex addiction. But I can tell you, based on 25 years of clinical

01:18:37.760 practice, it's on the rise, at least in terms of help seeking individuals. And my sense is that

01:18:43.840 since the advent of the internet, especially the smartphone, which makes online pornography and chat

01:18:49.480 rooms, et cetera, so easy to access dating apps, I would put in the category of sex addiction.

01:18:54.300 I think that we are dealing with an enormous problem in ever younger age groups. And that 0.94

01:19:03.080 what we see is really just the tip of an iceberg of kind of a rampant compulsive consumption of

01:19:11.020 pornography among men and boys. I want to come right back to that. But just to close the loop on

01:19:16.420 this, what about gambling, benzos, cocaine, things of that nature? Where is the trajectory and trend

01:19:22.220 line on those things? So with gambling... I assume online gambling is just another thing that's...

01:19:29.620 Right. The online sports betting, as you know, has now become legal in many different states.

01:19:35.660 And in the states where it has become legal, we've seen a 300 to 500% increase in calls to

01:19:44.180 pathological gambling hotlines, which is just one metric. Again, these are difficult to get numbers on

01:19:50.220 these. But it does suggest that the old bugaboo of increased access leading to increased harms in

01:19:56.120 a subset of the populations, raising, as you point out, very difficult policy questions. Do we as a

01:20:02.140 society have a responsibility to protect those vulnerable individuals? And how do we do that?

01:20:07.920 And do we do it at the expense of individuals who maybe can use those substances and behaviors

01:20:12.660 recreationally without too much harm?

01:20:14.480 So online sports betting is on the rise. And just the portability of these devices, the ability to

01:20:22.340 place a bet without a mediator anywhere, anytime, has really created a very difficult situation for

01:20:30.600 individuals who are vulnerable to pathological gambling. In terms of cocaine and meth...

01:20:36.640 Meth and, I mean, yeah, benzos.

01:20:37.920 Yeah. We're seeing a rise in recent years in addictive use and harmful use of cocaine and

01:20:44.500 methamphetamine. And it's hard to know exactly why that is or where it's coming from. Again,

01:20:50.400 accessibility may be partially related to the decreased access in recent years to prescription

01:20:55.300 opioids, people switching to stimulants or finding that when they combine a stimulant with an opioid,

01:21:00.600 they can overcome tolerance and get more of a high. So these are all the trends. Overall,

01:21:06.160 if you look at like all drugs of abuse, what we're seeing is a gradual, not even gradual in some

01:21:13.160 cases, what almost appears an exponential rise in drug overdose deaths. And I would attribute that

01:21:18.720 again to sort of ubiquitous access. There's probably no corner of the world anymore that you can go to

01:21:25.480 where you can't get drugs.

01:21:27.780 I mean, this is a little bit depressing, Anna, because I didn't hear you say that anything is

01:21:31.500 going down. In other words, you can't even argue that the increase in some of these addictions

01:21:36.140 is due to the substitution effect of some things are going down. Like, well, we're just, there's so

01:21:42.080 much less alcohol abuse today. And that's why some of it is shifting over to this. I'm just hearing

01:21:47.360 that on mass, everything is in aggregate, at least it's just going up. In other words, in 1980,

01:21:53.900 the percentage of the population that had an addiction was X. And today it's three X. I'm making

01:22:00.520 that up, but you get the point. Is that assessment shared by both the data and your clinical experience?

01:22:06.140 The data show that, for example, cigarette use has gone down in the last 20 to 30 years. And that

01:22:13.080 you do get a kind of a whack-a-mole effect, you know, as prescription opioids became less available,

01:22:18.360 illicit fentanyl came in to replace it. So it's not that everything is going up. We are seeing

01:22:25.480 some trends. But on the other hand, as cigarette use went down...

01:22:28.080 E-cigs go up, yeah.

01:22:29.500 Right. The point I try to make in Dopamine Nation is that I do think that we are living in 1.00

01:22:36.200 a drugified world where we all have more access to highly reinforcing substances and behaviors,

01:22:44.500 and that even so-called healthy behaviors like exercise and playing chess and reading novels

01:22:50.760 have been made addictive through the advent of the internet and social media and

01:22:56.080 all the comparisons and what have you. We've really fine-tuned our understanding of how to

01:23:03.060 get people hooked on just about anything, which you could argue is a natural byproduct of a

01:23:08.420 successful capitalist system. In the most successful capitalist system, we would all be addicts.

01:23:14.720 Addicts are the ultimate consumers. I'm not arguing for a system other than capitalism, but I am 1.00

01:23:20.020 suggesting that this is problematic and that we've reached some kind of tipping point where if we

01:23:25.400 don't put some guardrails and measures in place to guard against this extreme version of consumption,

01:23:31.240 we are all of us liable to suffer the harms of addictive behaviors.

01:23:36.300 Okay. I want to go back to what you talked about with respect to porn and young kids,

01:23:41.540 young boys in particular. So anybody listening to this who has

01:23:44.360 young boys is probably aware of and concerned about this. I always think Bill Maher does the best job

01:23:51.640 talking about this. He says, look, for people of our generation, pornography was like finding a

01:23:57.700 raggedy old Playboy magazine in the woods. And there's no question that you were obsessed with

01:24:02.640 looking at that, but it didn't warp your sense of sex. It didn't pervert you to the point of

01:24:09.620 potential pathology. And yet today, anything on your smartphone can basically do just that.

01:24:16.320 Is there an argument to be made that the impact of that is differentially worse in a prepubescent

01:24:24.360 slash in puberty brain than it is in an adult? I mean, is there a difference in the impact? What

01:24:31.280 are the data on that? And then ultimately what I'm really asking is what can parents do to educate

01:24:38.180 their kids? Because I think it has to come down on some level to education. If you think about

01:24:43.280 this through the lens of alcohol, what a parent says and does probably matters more in terms of

01:24:49.840 modeling, I would hope, than just a draconian rule set. So tackle those questions in any order you see

01:24:56.940 fit. Basically, what is a parent to do in this day and age to try to raise boys in particular to be

01:25:05.220 sexually healthy people when they get older? Okay, great. So let me start at the beginning

01:25:10.340 of your series of questions. So first of all, one of the things that's been very interesting to me

01:25:16.680 in treating patients with sex addiction is to see how tolerance manifests. Many of these

01:25:24.760 individuals start out with kind of run-of-the-mill legal types of engagement with pornography or what

01:25:30.840 have you. But over time, as their brain adapts to those rewards, they develop tolerance, they need

01:25:35.760 more potent forms to get the same effect. And they find themselves a year, two years, five, ten years

01:25:41.460 later, then engaging in highly deviant or violent or pedophilic pornography or engaging with sex workers,

01:25:50.620 illegal activities. And so I think that is important because when we're trying to distinguish like

01:25:57.100 a paraphilia from a sex addiction, I think many psychiatrists are not recognizing that the way

01:26:03.860 that that person presents at sort of their end stage sex addiction might really be 100% due to

01:26:09.620 tolerance. And if you can get them out of that addiction cycle, their preference for this illegal

01:26:15.820 activity really might not be there. In terms of the developing brain, we do believe that children

01:26:22.980 and adolescents are more vulnerable to these highly reinforcing stimuli and that the earlier that

01:26:29.340 folks are exposed, the more likely they are to develop an addictive process. We base that on

01:26:34.540 analogy with substances because we know that the earlier that kids start using substances, the more

01:26:39.760 likely they are to develop a substance use disorder in their lives. We speculate that that is because

01:26:47.540 adolescence, adolescents still are developing the connectivity between the frontal lobe and those

01:26:54.060 deep limbic structures, the emotion part of the brain, and that adolescence is characterized by a

01:27:00.900 period of pruning where the brain essentially cuts back on those neuronal circuits and dendrites and

01:27:07.840 axons that are being used least often and myelinates those circuits that are used most often.

01:27:15.000 Myelination is what makes the conductivity faster and more efficient such that by the time we're about

01:27:21.900 age 25, we've essentially created the neurological scaffolding that will serve us for our adult lives.

01:27:28.360 So that means if young people are engaging in maladaptive coping strategies and strengthening those

01:27:33.980 circuits, it's not impossible, but it's harder to change once they reach 25 or early adulthood.

01:27:40.840 So the key for parents to realize is that while they still have some modicum of control over how

01:27:47.320 their children and adolescents are engaging with the internet, I recommend that they exercise that

01:27:53.060 control to limit access as well as educating and having open discussions about the potential harm there.

01:28:01.840 What is the potential harm? Again, these images are highly reinforcing. We were wired to find mates and

01:28:09.840 partner, and that's what allows us to propagate the species, which is how we've been able to survive.

01:28:15.940 But what pornography essentially does is it hijacks these reward pathways with very potent images

01:28:21.720 that are made all the more reinforcing by the fact that the individual can control them in the moment.

01:28:27.740 So with very little work that is required in real relationships, they can now just go right to the

01:28:32.960 money, so to speak, or the reinforcing aspect. Plus, orgasm is the release of a bunch of neurotransmitters 0.98

01:28:39.580 all at once, which feels really good for many people. I want to highlight that not every boy or man

01:28:45.700 is actually drawn to pornography or sex. Again, we have this inter-individual variability. But for boys

01:28:51.720 and men for whom that is a potent reinforcer, it is the medium itself of the internet, the easy access,

01:29:00.340 the potency, even dating apps. The idea of dating apps is that we're going to be matched with a

01:29:06.260 partner. But what can happen is people get just addicted to the match, the confetti of the match,

01:29:11.020 and then they want to have the pursuit and the match again. And it's not even necessarily leading

01:29:15.240 to any kind of intimacy beyond that. Or if it is, it's just leading to hookups, which are about the sex.

01:29:21.920 So for parents out there, really recommend that a child under 13 not have unsupervised access to

01:29:29.520 the internet. If they must have some kind of phone device, have it be a light phone or a flip phone.

01:29:35.140 And then once they get to the point where they do have data and access to the internet,

01:29:39.980 have a lot of open discussions about pornography. And they can be really, really awkward discussions.

01:29:46.160 I'm a mother to two boys and both of my sons. We have tried to have open, quite awkward discussions

01:29:54.000 about pornography.

01:29:54.660 Tell me about that because it's been really easy to have discussions with our daughter

01:29:59.660 about illicit drug use because it's a biochemistry discussion and the risk is really obvious. In

01:30:07.560 other words, I had a guy by the name of Anthony Hippolito on the podcast, who's a local sheriff

01:30:12.660 here in the Austin area, whose work focuses entirely around fentanyl toxicity and fentanyl

01:30:18.800 laced drugs. So there are kids all over here that are dropping dead from laced Ambien, laced Xanax,

01:30:26.560 cocaine, whatever the drug is that seems to be spiked with fentanyl. So having the discussion

01:30:30.420 with our daughter about that is really quite easy. What are your coaching points for, and I'm asking this

01:30:36.480 honestly for myself, just as much as the listeners, right? My boys are pretty young, seven and 10.

01:30:42.400 That's going to be a discussion to have soon. Well, how are you making the case to a 13 year

01:30:47.120 old or 14 year old that, Hey, you're going to be over at your friend's house one day and you're

01:30:51.500 going to be playing sports. And all of a sudden he's going to say, Hey, come and look at this.

01:30:55.460 Cause maybe in their household, that's not going to be as policed as it is in our household.

01:30:59.500 What's the case you're making?

01:31:00.600 So this is where I really encourage parents to try as much as possible to just be curious.

01:31:10.160 One metaphor I heard once, which I thought was really good is pretend like you're a journalist

01:31:14.180 and you're just trying to get the story. Just ask them, you know, what did you think about that?

01:31:19.980 It's very easy as a parent to get dysregulated in even speaking about these things or imagining our

01:31:26.100 child engaging with these images, but it is the reality. So we have to go there. What did you

01:31:31.760 think about that? Is that something that you have started using yourself to masturbate or get as an 0.99

01:31:39.580 escape or release? How is that working for you? How do you feel afterward? I think really zeroing in 0.98

01:31:47.320 on how do you feel afterward can be very instructive because usually there's a pretty hard come down

01:31:54.160 as well as a feeling of like, wow, that didn't actually do for me what I was hoping that it did.

01:32:00.040 And I kind of am feeling bad about that experience. So again, this gets into the whole quagmire of

01:32:06.800 sexual liberation and this argument, nothing's wrong with pornography, nothing's wrong with 0.98

01:32:11.780 masturbation. You know, so people are going to come to this with different value systems and I

01:32:15.880 respect that. But all I can tell you is that-

01:32:19.820 What do the data say? I think we can put our feelings aside for a moment. I think the real

01:32:23.860 question here is, are there data to tell us that one approach is healthier than the other? And then

01:32:29.540 obviously, what are the clinical anecdotes that probably are more valuable than just our built-in

01:32:34.920 beliefs? The data that we have is that men and boys, and actually women now too, are spending

01:32:41.680 a lot more time consuming pornography. And young people in particular are much less likely to go out

01:32:49.380 and actually have sex with other people and be in relationship. Now, whether or not those things are

01:32:55.060 causative or correlative, we don't know. But we could certainly make an argument that all the time

01:33:01.760 that men and boys are spending engaging in pornography is actually becoming a substitution for real life

01:33:09.120 engagement, either with their spouses or partners or other people that they might meet.

01:33:13.820 And in clinical care, what we see with behavioral addictions, including sex addiction, is that the

01:33:20.360 phenomenology is identical to drug and alcohol addiction. People start out for fun or to solve

01:33:25.240 a problem. If it works for them, they repeat that behavior. They go back again and again. Over time,

01:33:30.940 it tends to work less well. They need more potent forms or larger quantities to get the same effect.

01:33:35.500 And then at some point in severe cases, they're marshalling all of their available resources in

01:33:41.660 order to do that activity or consume that drug. So this is a very new problem. We don't have a lot

01:33:48.840 of good data. People are not rushing forward saying, I have a sex addiction. Let me tell you all about it.

01:33:55.620 In fact, it's very common in clinical care that we'll have a man come in and say in the first

01:34:01.740 one to two to three visits that he's here for some reason, that's not really the reason that he brought

01:34:07.700 him in. He's really here for a sex addiction, but it's so difficult for him to talk about that.

01:34:13.040 So, you know, this is like highly stigmatized because at the same time that we have this incredible

01:34:19.400 access to pornography, we also have a culture and a climate in which men and boys are really seen

01:34:27.660 as sexual predators. So it's a very potentially uncertain and dangerous environment for them

01:34:34.720 to be trying to cultivate in real life relationships, right? It's a risky environment.

01:34:40.820 And so all of that, I think, is contributing to this kind of retreat from engagement and instead

01:34:46.960 a kind of a self-soothing through this medium.

01:34:50.440 Let's talk about sort of a very near cousin of that, which you've already alluded to,

01:34:53.860 which is social media. Now, this is the forefront of everybody's attention right now. There's a

01:34:58.680 book out about this by Jonathan Haidt that talks a lot about this. I had dinner with Jonathan several

01:35:04.900 months ago before the book came out and it was wonderful to sit down with him and have this

01:35:09.320 discussion about everything. And I posed a question to him that I don't want to speak for him, but I

01:35:14.900 think it's safe to say he didn't really have a great answer for, but I think it is the jugular

01:35:18.960 question. And it's interesting that since the book has come out, there have been folks in the

01:35:24.680 medical establishment that have come out and argued the opposite side of his. And so the question I

01:35:30.520 posed to Jonathan was, Jonathan, it's very clear here that the correlation between social media

01:35:36.300 and declining mental health amongst young people in particular is overwhelming. But I said,

01:35:43.000 how compelling are the data and what would need to be done to demonstrate causality? Because

01:35:48.320 if you have causality, it becomes much easier to have a discussion about policy and action. So

01:35:56.120 once causality could be unambiguously established for tobacco use and cancer, which really occurred in

01:36:03.920 the late 60s, by the way, it didn't occur through RCTs, right? It occurred through a very careful

01:36:09.800 application of the Bradford Hill criteria, coupled with some mechanistic and animal research. Obviously,

01:36:16.720 no one could do the RCT to demonstrate the harm of tobacco with respect to cancer. But nevertheless,

01:36:23.640 once causality was established, the dye was cast for the monotonic decrease in tobacco consumption

01:36:32.280 that has occurred over the last 50 years. And when causality is missing, it becomes very difficult

01:36:38.880 to make the case for it. So I've read all these arguments. And again, these are the minority arguments,

01:36:44.520 to be clear. I think the majority of people believe that if they're even thinking of it that way,

01:36:49.700 they believe there is causality. But the minority argument is, look, there are a lot of reasons that

01:36:54.100 young people are too anxious today. Social media might be one of them, but it's far from the only 0.61

01:36:59.100 one. These people would argue that we've catastrophized everything in the world. We've

01:37:04.700 got every young person thinks that by 2030, the climate is going to have eroded to the point where

01:37:10.340 the world will be uninhabitable. Even though, of course, that's not true. But nevertheless,

01:37:14.960 there are enough people who have catastrophized so many things in terms of the future of this planet

01:37:20.660 that maybe that's part of the reason. And anyway, they just go on and on and on. So I guess my question

01:37:24.820 for you as a person who I know thinks about this deeply is, do you think we have causal evidence

01:37:32.320 that will pin what seems intuitive to many of us, which is social media probably is a net negative.

01:37:40.180 It has some benefits, but it's got a lot of negatives, at least for a vulnerable population.

01:37:46.040 Or do we think that we just haven't got that causal bullet and that really we're looking at two

01:37:50.580 things that have gone up over the same period of time that are correlated, but getting rid of social

01:37:55.500 media is not going to fix the mental health of young people. So sorry for the long question,

01:38:00.700 how do you think about that? Well, I'll start at the end. I don't think anybody who thinks there's

01:38:06.980 a causal harm from social media thinks that we should get rid of social media. That anyway is

01:38:12.560 an impossibility. I think what we're talking about is guardrails. I should just be clear there. And

01:38:18.660 Jonathan doesn't think that either. I think Jonathan's argument is maybe people should not be using social

01:38:23.780 media while they're young. But anyway, yes, I just wanted to make sure I wasn't putting words in

01:38:28.000 anybody's mouth on that front. Great. Yeah. So, I mean, let's look at the different types of

01:38:32.540 evidence. One of the most important types of evidence in medicine is empirical evidence. This

01:38:39.380 is observation and subjective experience. And we have plenty of empirical evidence to show that

01:38:48.980 young people, and I'm going to focus on young people because when you think about a policy

01:38:53.540 intervention, I really think we're thinking about how to direct that to young people, that young

01:38:58.340 people endorse that they feel addicted to social media, not all, but many, and that they use it more

01:39:07.580 than they would like and that it's adversely affecting their mental health. That is a powerful

01:39:12.920 piece of evidence. Now, you could say there's cultural stimulation or stimulated reporting. Sure.

01:39:17.840 But we have loads of young people now who are endorsing that. We also have a lot of observational

01:39:24.320 evidence that is showing many of the Bradford Hill criteria, starting with a dose-dependent response.

01:39:33.220 We know that the more time that people spend on social media, the more likely they are to experience

01:39:39.700 anxiety, depression, insomnia, inattention, etc. Now, you could argue, well, chicken and the egg. Maybe

01:39:46.560 those were individuals who were vulnerable or already had depression anxiety, which made them

01:39:50.940 want to self-medicate by using more social media. But I think the strongest evidence against that is

01:39:57.180 the evidence that we have on another Bradford Hill criteria, which is experimentation. When we

01:40:02.860 intervene in these cases of depressed and anxious individuals and take social media away for a period

01:40:09.080 of time or even limit use, people are feeling less depressed and anxious. And that is a very

01:40:16.060 powerful piece of evidence to me, but not even the only one. Other Bradford Hill criteria, you have

01:40:21.480 biological plausibility. Does it even make biological sense that engaging with social media can change the

01:40:28.660 brain in ways that are potentially harmful and beneficial? Sure. That's the organ that we're using to consume

01:40:35.460 social media. So it's completely biologically plausible. We also know that when people are doing

01:40:41.900 activities that engage in, for example, social validation, that releases dopamine in the brain's

01:40:47.200 reward pathway. And what is social media if not a slot machine for validation? You have strength of

01:40:52.840 association. So yes, these are correlative phenomenon, but study after study after study is showing similar

01:40:59.880 findings. Yes, there are exceptions, but in general, powerful studies that we have are showing the

01:41:04.700 strength of association. And then you have temporality. Now, temporality is hard to get, meaning that which one

01:41:11.240 comes first are people using social media a lot and then get depressed and anxious, depressed and anxious,

01:41:15.920 and then using social media. And of course, our natural retrospectoscope will want to rationalize

01:41:21.260 and explain certain irrational behaviors. But I mean, we can often get pretty good reports of temporality

01:41:28.180 subjectively in an individual clinical case, but also epidemiologically. And this is Jonathan

01:41:33.260 Height's work. He's saying, look, if you look at when, for example, social media became widely available

01:41:41.240 on college campuses, it didn't happen uniformly. Some college campuses got social media up and running

01:41:47.700 much earlier than others. And you see on those campuses where it was widely available and used

01:41:52.420 worse mental health outcomes. To me, the weight of the evidence makes it more likely than not

01:41:58.700 that social media is causing mental health harms, especially in youth. And so earlier, you asked me,

01:42:04.900 what can parents do? Because to me, pornography, that begins to fit into social media as well.

01:42:10.500 What can parents do? I don't think it should be solely up to parents. Parents need help.

01:42:15.620 Schools need to get smartphones out of the schools so that adolescents can actually have the liberty and freedom

01:42:22.560 to concentrate on learning. Because these devices, the way that they hijack the reward system, make it

01:42:29.100 almost impossible for children to learn and almost impossible for teachers to teach. You analogize to

01:42:35.240 alcohol. We have lots of laws that limit a child's access to alcohol. We have federal funding for highways

01:42:43.720 that are tied to drinking age limits in those states. The age of 21 is universal in every state now.

01:42:51.160 Why? Because people wanted those dollars to build their highways. We should be doing that. We should be

01:42:56.940 offering federal and state funding to schools that actually make sure that from the top down, kids are not

01:43:05.140 looking at their smartphones and that they have some tech-free spaces and some opportunities for both socializing

01:43:10.680 and learning that don't rely on the internet and rely on technology. What are we hearing from schools, mostly

01:43:16.260 private schools that are eliminating smartphones, that the schools are noisy again because kids are

01:43:22.080 actually interacting with each other? So lots and lots of empirical evidence that that's also, yes,

01:43:28.040 consistent with our intuition that, gee whiz, there's a problem here. We need to do something about it.

01:43:33.100 Which isn't the same thing as saying social media is bad and nobody should be on social media and it's

01:43:38.460 all evil and it's the devil and that's what people said about TV and that's what they said about radio.

01:43:42.840 This is on a very different scale. The way that the algorithms learn what we've done before,

01:43:49.480 making these media so potently addictive. We only have to walk through an airport to see

01:43:55.980 the ways in which we've all stopped engaging with our surroundings.

01:44:01.900 I want to talk about something we haven't talked about yet, but that gets often lumped in the category

01:44:05.660 of addiction, which is exercise. So maybe let's start with the brain chemistry of exercise. I think

01:44:11.260 people have heard the term endorphins, but what exactly is an endorphin? Is that an irrelevant

01:44:16.900 topic here and is this really boiled down to dopamine again? I would say yes and yes. So

01:44:22.840 endorphin is an endogenous opioid. We make our own opioids. Thank God we do. Otherwise, we wouldn't be

01:44:28.880 able to cope with physical pain. Exercise is actually immediately toxic to cells. Strange. Why would

01:44:36.740 something that is toxic to cells be ultimately healthy for us? And the evidence is overwhelming

01:44:41.820 that exercise in moderation, depending upon that person's fitness level is healthy. Essentially,

01:44:48.640 what's happening is that as the body senses injury, we upregulate production of our own feel-good

01:44:54.660 neurotransmitters like dopamine, but also serotonin, norepinephrine, endogenous opioids. That's the

01:45:01.160 runner's high. If you look back at this metaphor of the pleasure-pain balance, we saw that when we press on the

01:45:06.460 pleasure side, the gremlins of neuroadaptation hop on the pain side as a way to bring us in balance

01:45:13.180 ultimately again. The same thing happens with painful stimuli. When we do things intentionally

01:45:17.820 that are physically or mentally challenging for us, our body senses injury, upregulates feel-good

01:45:23.580 neurotransmitters, and those gremlins actually go over and hop on the pleasure side. So we get our 1.00

01:45:27.740 dopamine indirectly by paying for it up front. And you see this, for example, with studies that have

01:45:32.580 looked at ice-cold water immersion, noting that dopamine levels rise gradually over the latter half

01:45:39.060 of the immersive ice-cold water bath. And then interestingly, those dopamine levels and serotonin

01:45:45.220 and norepinephrine stay elevated for hours afterwards before going back down to the baseline levels of

01:45:51.400 dopamine firing, which is amazing because what that says is we never go into that dopamine deficit

01:45:55.940 state. We get our dopamine indirectly by paying for it up front. And that process is relatively

01:46:03.140 more immune to the problem of addiction because we had to work first to get it. Whereas intoxicants

01:46:10.860 cause that sudden upward spike of dopamine, followed by dopamine freefall, that dopamine deficit state,

01:46:16.760 that state of craving before going back to the level position. Now, are there certain personalities

01:46:22.740 that can get addicted to exercise? Absolutely. We do see this in clinical care, and I think we also see

01:46:29.700 it, again, just in our culture. We've also drugified exercise, made it more potent, made it possible to

01:46:36.580 do it in more extreme conditions. We've social media-fied it so that now people are comparing themselves not

01:46:42.800 just to their immediate neighbor, but to people all over the world. We've quantified it down to the nth

01:46:48.580 degree. We're constantly measuring ourselves, our heartbeats, our breathing, our sleep. Many people

01:46:55.540 actually get kind of addicted to those numbers or quantifications. Now they're pursuing a certain

01:47:00.640 numerical outcome. Dopamine is probably ultimately quite sensitive to numerification.

01:47:07.320 When we intervene for an exercise addiction, we intervene similar to the way that we intervene for

01:47:11.980 other addictions. We ask people to abstain from that particular exercise for a period of time,

01:47:17.020 try to reset reward pathways, and then when they go back to using, using in a way that's not harmful

01:47:22.720 or self or other destructive. This idea, by the way, that both exercise and cold are, for the most

01:47:30.000 part, healthy ways to experience pleasure because the pain comes first and you have to do the work

01:47:37.820 to get the pain to experience the pleasure. I think it's safe to say that that's probably how the

01:47:42.920 majority of people would experience that. You do write about a fellow in your book who maybe took the cold

01:47:48.880 plunge thing a little too extreme, but I would argue in his context, it might have been the lesser of two

01:47:55.480 evils because ultimately this became, I think, a more well-adapted coping mechanism to an otherwise

01:48:02.000 maladaptive addiction. Would you say that's fair?

01:48:05.400 I do. I agree with you. So this was an individual addicted to alcohol and cocaine who got into recovery,

01:48:10.540 experienced a lot of dysphoria, and discovered that taking an ice-cold shower in the morning that

01:48:16.640 was recommended to him by a trainer or a coach actually made him high. It gave him the kind of

01:48:23.660 response that he often got from drugs. So he began doing daily ice-cold showers and then over time

01:48:30.920 got himself a cooler and would submerse himself in ever colder temperatures and then got a motor to

01:48:36.840 circulate the water. So he was breaking the ice off in the morning. At some point, kind of realized,

01:48:41.760 oh, wait a minute, I think my tendency to take things too extreme may be operating here. But yes,

01:48:46.540 absolutely, I agree with you. Ultimately, this was a healthy coping strategy, which really speaks to

01:48:52.100 what is a healthy coping strategy. It's something that we also do with other people. So he started

01:48:57.720 doing it with his family, with social groups. People would come over for ice-cold water bath parties,

01:49:03.200 much better than having people over to snort some lines or whatever the case may be.

01:49:08.660 So yes, and we have lots of patients who, when they get into recovery from drugs and alcohol,

01:49:14.120 will often discover sports and endurance athletes in order so that they can still have that striving

01:49:19.820 and that goal and the endorphins. We just have to make sure they don't continue to do it to the

01:49:25.220 point of personal injury.

01:49:26.840 I discovered something several years ago, which was if I took an ice-cold shower when I was very

01:49:34.440 upset, angry, the mood would reverse quite quickly. And I kind of attributed that to

01:49:40.240 stimulation of the vagus nerve. My head had to be immersed in cold water. It could have even

01:49:46.100 presumably been dipping my head in a cold water, sort of stimulating the dive reflex. But like others

01:49:52.580 who enjoy cold plunging, which I do very, very much, I would completely share that experience.

01:49:58.300 It is a absolutely mood lifting experience. And when people ask me, which I get asked,

01:50:03.280 as you can imagine, all the time, is cold plunging kind of an elixir of longevity? Having looked at the

01:50:09.280 data very carefully, I can say that the answer appears unlikely. I see no evidence that cold

01:50:16.240 immersion alters any of the hallmarks of aging, with the one possible exception being a reduction

01:50:23.700 in inflammation. But that's never translated to a clinical benefit vis-a-vis disease in the way

01:50:29.820 that I do think that there is benefit to sauna. So I do think if you look at the sauna literature

01:50:34.320 and run that same Bradford Hill criteria, along with the experimental data which are included,

01:50:39.500 there really is probably causality between the benefits of sauna and disease prevention.

01:50:44.360 So again, I don't see that with cold, but my use of it personally just stems from the mood

01:50:50.660 elevation. Believing that it has no benefit on my ability to reduce the risk of cancer,

01:50:55.780 heart disease, or dementia, just the mood elevation alone, for me, seems to be reason enough. So

01:51:01.340 I enjoyed the story of that gentleman. Yeah, that's interesting. I didn't know that about the

01:51:07.220 data with sauna or even longevity relationship with ice-cold water plunges. But in terms of a mood

01:51:13.940 modulator and a replacement behavior, I do think that ultimately we are strivers, we want to experience

01:51:23.620 intense emotions. And it's not that we can just sort of not have goals and not have emotions. We want

01:51:32.360 that kind of intensity. And certainly many of my patients have reported similar types of positive

01:51:38.960 responses to ice-cold water plunges. Which by the way, I don't notice with sauna. So with extreme heat,

01:51:44.720 which I also enjoy greatly, it's a different sensation. I'm curious, do you think that there's

01:51:50.100 something about cold that produces more pain? I mean, I guess it does feel much more painful.

01:51:55.020 Is it simply come down to the pain? I don't think we know. I do think that the immediate response is

01:52:00.760 going to be some kind of hormetic response. Hormesis being this Greek term that means to set

01:52:06.400 in motion, setting into motion our own regulatory healing response in response to injury. And the

01:52:13.880 branch of science called hormesis is looking at the ways in which toxic or noxious stimuli actually

01:52:19.780 makes us more resilient over the long run. So yes, I think that it's an immediate hormetic response.

01:52:25.360 And let me just say, we see this being beneficial, not just in people struggling with addiction or

01:52:32.520 looking for alternative sources of dopamine, but also when people get immediately dysregulated. So

01:52:37.060 you noted that when you get angry, it's helpful. So when we have patients who are very dysregulated,

01:52:42.300 overwhelmed by their emotions, can't re-regulate, we say, stick your face in an ice-cold water bath,

01:52:47.180 plunge your hands in an ice-cold water bath. And it really, really works for some people.

01:52:51.020 There's also interesting work looking at cold more broadly and what it does to neurons. And it turns

01:52:58.800 out that cold is one of the most potent stimuli for neurogenesis. So very interesting looking at

01:53:08.160 like mice brains after exposing the mouse to extreme cold or the effect of hibernation in extreme cold

01:53:14.860 and finding that cold initially causes a sort of, not neuronal death, but if you look at the brain

01:53:21.560 slices, it looks almost like these dendritic tree-like neuronal structures sort of die out,

01:53:27.440 you know, in response to cold. But then very quickly afterwards, you get a spring-like regrowth,

01:53:33.380 an amazing neurogenesis. So who knows, maybe the repetitive use of cold on some level is causing

01:53:39.900 or facilitating human neurogenesis as well. I don't know. I would love though to see more broadly in

01:53:47.440 the field of neuroscience, people look at this concept of drug of choice because it's so interesting.

01:53:52.320 Cold, for example, does absolutely nothing for me. I don't enjoy the experience, but I also don't get

01:53:58.340 benefit afterward. I sure wish I did because it's a nice, easily accessible kind of a tool. But for many

01:54:05.560 people, including you, it's very potent and that's great. You write about a very famous experiment that

01:54:12.540 I'm sure everyone listening to this has heard, which is the marshmallow experiment. And most of

01:54:16.860 us who are parents did the marshmallow experiment on our kids with the real hope that they would be

01:54:22.780 able to refrain from eating the marshmallow because of how we believe it might predict better success

01:54:28.860 later in life. But you also write about a revised version of that experiment, which I think is

01:54:34.400 actually a little more interesting. Do you mind just explaining both the original for those who

01:54:39.200 might not be familiar with it and also, of course, the revised version and above all else, what it is

01:54:43.160 that that tells us about being parents? The original marshmallow experiment was conducted at Stanford

01:54:49.480 and it looked at kids between about the age of two and five. The child was placed in a room with nothing

01:54:57.400 in the room except for a table, a chair, a little plate, and on that plate, a single marshmallow.

01:55:02.840 And the researcher said to the child, I'm going to leave the room and I'll be back in 15 minutes. If you

01:55:10.840 can go the whole 15 minutes without eating this marshmallow, when I come back, I will give you a

01:55:15.780 second marshmallow so you'll get two. And the whole point of it was to really measure delayed gratification

01:55:21.860 and a child's ability to delay gratification. The most significant finding was very simply that

01:55:29.060 older children were better able to delay gratification than younger children so that this is a skill or a

01:55:35.220 capacity that children will develop with age. But even within a single age cohort, there were

01:55:41.860 differences. Some children were better able than others to wait the full 15 minutes or just wait longer

01:55:48.600 before eating that first marshmallow. And what they then did, and this part of the study is a little

01:55:54.220 bit controversial, but what they then did was followed those kids prospectively, some cases all

01:55:59.040 the way through college and later, and sort of looked at their life outcomes. And the claim was that

01:56:04.200 the kids who within their age cohort were able to wait longer for the marshmallow, i.e. delayed

01:56:09.580 gratification, were also more likely to graduate high school, graduate college, and go on to have

01:56:14.420 successful lives, so to speak. So the variance on the marshmallow experiment that I learned about

01:56:22.080 in my researching for this book was that they decided to do another version in which they divided

01:56:28.680 the groups of kids into two groups. And in addition to the plate and the marshmallow, there was also

01:56:33.760 a bell that they could ring. And they told one group, if at any point in these 15 minutes you'd like

01:56:41.120 me to return for any reason, just ring this bell and I'll come back. So they told that to both of those

01:56:46.880 groups. But in one group, when the child rang the bell, the researcher came back. And in the other

01:56:52.000 group, when the child rang the bell, the researcher didn't come back until the full 15 minutes were

01:56:56.960 over. So in other words, one group of children was told the truth and another group of children was

01:57:02.000 lied to. What they discovered was that the children who were lied to were much more likely to

01:57:07.360 eat that marshmallow before the full 15 minutes were up. To me, it's such a powerful paradigm for the

01:57:15.260 importance of truth telling, not only to teach our kids the importance of telling the truth,

01:57:20.060 but to model that for our kids and actually be truthful and show up when we said we were going

01:57:24.980 to show up. Because it looks like what happens when we're living in an environment where people cannot

01:57:31.260 rely on other people around them, especially adult caregivers, to do what they said they were going to

01:57:37.740 do, that we essentially go into a kind of survival mode where we just feel like nobody's going to

01:57:43.980 take care of me. I got to take care of myself. I better eat this marshmallow now. Because if they're

01:57:48.120 not going to come back in the room, maybe they're also not going to bring me a second marshmallow if

01:57:51.780 I wait the full 15 minutes. And that can really breed within a family dynamic, a very toxic

01:57:59.860 interpersonal family system that I think does increase the risk of addictive behaviors later on.

01:58:08.120 Because what we'll often see in patients with severe addiction is not only that they have a parent or

01:58:13.680 caregiver who was addicted, but that they lived in a house where lying was rampant, where people

01:58:18.560 almost never showed up. When they said they were going to show up, never did what they said they were

01:58:23.000 going to do. So it's very interesting to me how something like telling the truth can be such a powerful

01:58:30.040 shaper of appetitive control.

01:58:34.000 Speaking of appetitive control, you note how individuals who have had gastric bypass, while quite

01:58:39.680 successful in curbing appetite and ultimately food consumption and therefore being a great tool for

01:58:46.800 managing obesity and type 2 diabetes, are prone to higher rates of alcoholism. Can you say a little

01:58:54.220 bit more about that? And ultimately what I want to really talk about is this new class of drugs that

01:58:59.380 have been introduced, GLP-1 agonists, but let's just set the stage on the gastric bypasses.

01:59:04.440 So about a quarter of individuals undergoing gastric bypass for obesity, which you might conceptualize

01:59:11.000 as food addiction in certain vulnerable individuals, will go on to develop an alcohol use disorder after

01:59:17.460 their gastric bypass. And that's probably operating on multiple levels. One level on which it's operating

01:59:23.320 is that alcohol becomes immediately a much more potent drug for them because through the gastric bypass,

01:59:31.280 they essentially have a kind of a dumping syndrome where they get the equivalent of many more drinks

01:59:37.360 because it immediately goes into the duodenum and is absorbed. So they get where they can have one

01:59:42.720 drink and immediately feel their effects. And part of potency is not just how much dopamine it's

01:59:48.900 released, but how quickly it's released, which is why, for example, injecting is so potentially

01:59:54.040 addictive because it's basically right to the brain. So alcohol becomes a very potent drug for them,

02:00:00.460 but also because of the problem of cross addiction where when people give up one addictive substance

02:00:06.600 or behavior, they are vulnerable to switch that addictive tendency over to another substance or behavior.

02:00:12.460 And so unless we're directly addressing the problem of the behavioral addiction itself at the same time

02:00:18.360 that we're addressing the obesity and doing the bypass surgery, folks are going to be vulnerable to that.

02:00:24.580 What has been your experience clinically with the significant increase we've seen in the use of GLP-1 agonists

02:00:33.500 and the expansion in use from type 2 diabetes to obesity to overweight to basically anybody?

02:00:43.720 On the one hand, there have been a lot of reports that GLP-1 agonists not only curb appetite,

02:00:49.820 which is the desired outcome, but may in fact also curb desire and maybe even pleasure.

02:00:56.360 And that would actually suggest that unlike a gastric bypass,

02:00:59.560 an individual who uses a GLP-1 agonist to achieve their weight loss goals

02:01:04.120 might also have another benefit in that it might curb other maladaptive behaviors such as alcohol consumption.

02:01:12.580 So curious as to what you've seen is the field is still quite nascent in our understanding,

02:01:17.920 but obviously you're probably the canary in the coal mine for some of these things.

02:01:22.580 Yeah. So, I mean, these are really fascinating drugs.

02:01:26.320 And what we are seeing clinically is individuals with food addiction and individuals with alcohol addiction,

02:01:33.120 alcohol use disorder, which by the way is closely linked to food addiction because alcohol is caloric.

02:01:39.280 So we've got both mediated through the carbohydrate system.

02:01:42.160 Individuals, at least in the cases where we have experimented off-label with semaglutide, the GLP-1 drugs,

02:01:52.280 these individuals have tried almost everything to get their addiction under control.

02:01:59.160 And I would say we have more experience with treatment refractory alcohol use disorder,

02:02:03.120 including trying medications, medications like Baclofen, medications like Naltrexone.

02:02:09.540 I didn't know about Baclofen. So tell me, Baclofen, the muscle relaxant, is used to treat alcohol disorder?

02:02:15.660 Yeah. So there are more placebo-controlled trials in Europe than here in the U.S.

02:02:20.180 It's not FDA approved for that indication. It's not first line for us, but we will sometimes use Baclofen.

02:02:26.140 Sometimes we'll use Gabapentin.

02:02:28.320 What doses of Baclofen and Gabapentin are necessary to produce that effect?

02:02:33.460 Well, Gabapentin, we usually, I will say I'm using less Gabapentin than I used to

02:02:39.700 because we've been seeing people actually get physically dependent and in some cases addicted to Gabapentin.

02:02:45.460 But typically we'll use the 600 milligrams three times a day to help people withdraw from alcohol

02:02:50.660 and in some cases maintenance, although less of that.

02:02:54.500 I don't use Baclofen often enough to tell you what the doses I have to look it up.

02:02:58.340 I would say more often we're using naltrexone, the opioid receptor blocker,

02:03:03.720 which can be very nice because many people's goal is moderation, not just abstinence.

02:03:08.540 And naltrexone's been shown to help not just with abstinence, but also reducing drinks on drinking days.

02:03:14.260 So that's very nice. We use that almost as first line.

02:03:17.460 We use Antibuse, Disulfiram, which is the one that's a deterrent.

02:03:21.500 If you drink on it, you'll get sick.

02:03:23.020 People don't usually like to go to that first line, but it works when people take it.

02:03:26.140 It should be pointed out that if patients do use that and drink through it,

02:03:30.520 they are actually increasing the toxicity of alcohol gram for gram

02:03:34.840 because they're experiencing more acetylaldehyde, which is obviously the toxic mediator.

02:03:39.740 Yes, exactly. So you really have to be careful who you prescribe it to.

02:03:43.260 And it has to be somebody who can really be committed to not drinking once they've taken that medication.

02:03:49.300 We also use Topiramate, which is a seizure medication,

02:03:52.460 which was first discovered off-label to be helpful for binge eating disorder

02:03:57.140 and later was shown to be helpful for alcohol use disorder.

02:04:01.300 But the bottom line is when we have a case of a patient who has tried these various medications,

02:04:07.320 who's been involved in Alcoholics Anonymous, who's tried psychotherapy,

02:04:11.040 who's gone to rehab, who's done it all,

02:04:13.140 In that rare instance, because it is off-label and because it's so new,

02:04:17.020 and so we're conservative with medications,

02:04:19.380 we have occasionally recommended semaglutide or the GLP-1 drugs.

02:04:25.020 And in one case in particular,

02:04:27.800 it was very striking the extent to which this individual with treatment refractory alcohol use disorder

02:04:34.060 endorsed the complete cessation of alcohol craving with semaglutide.

02:04:40.980 And it's very moving to see that in an individual who has struggled so long and so hard

02:04:47.440 to battle their addiction.

02:04:49.580 And then there's this drug that seems to just suddenly turn off all the noise for them.

02:04:57.120 Was that patient at all overweight?

02:04:59.820 Yes.

02:05:00.360 And so that's how we could justify it.

02:05:02.220 We were giving it to him for being overweight,

02:05:05.640 for not having type 2 diabetes, but being at risk for type 2 diabetes.

02:05:10.980 But our real agenda was the alcohol, and it worked very well for that.

02:05:17.360 Do you think that we'll ever be able to explore in a rigorous scientific way

02:05:22.760 the question of whether or not independent of weight,

02:05:26.100 GLP-1 agonists might be tools to help people with addictions more broadly,

02:05:31.220 beginning with alcohol even, before we talk about other substances?

02:05:35.380 Oh, yeah.

02:05:36.920 So those small trials are already underway and showing some effect.

02:05:41.740 I would not be at all surprised if in 5 to 10 years,

02:05:45.460 semaglutide is FDA approved for alcohol use disorder.

02:05:49.800 It might not happen because the company doesn't need it,

02:05:52.780 and it's expensive to get those FDA approvals,

02:05:55.500 and there's no shortage of demand for semaglutide.

02:05:59.500 So they may never pursue that FDA indication,

02:06:03.140 but I think that it will be used more and more often

02:06:06.340 for alcohol use disorder in particular and binge eating disorder.

02:06:11.200 And I think you do the best job I've ever encountered

02:06:15.760 of describing 12-step programs,

02:06:17.900 which I think people tend to have very polarizing views of.

02:06:23.320 So you've got people who view these things as the best things in the world.

02:06:28.500 Everybody should be in a 12-step program,

02:06:30.520 even if they've got just the mildest inclination towards addiction.

02:06:33.820 And then you've got another group of people who say it's a cult.

02:06:37.620 It should never be a part of addiction recovery.

02:06:40.100 You very eloquently, I think, describe both sides of this

02:06:44.600 and I think land in a very reasonable position,

02:06:46.900 which is actually quite favorable for a given individual

02:06:49.840 and maybe not for all individuals.

02:06:51.340 Do you mind just saying a little bit about that?

02:06:53.260 Because I know that there are many 12-step programs out there.

02:06:56.560 I've been to many meetings myself

02:06:58.680 and have actually always found them to be remarkable,

02:07:01.220 even when the topic at hand is not something

02:07:04.600 that I particularly share the addiction for,

02:07:06.760 but where I've always found it amazing is in the sharing

02:07:09.480 and in something that you described as the pro-social shame.

02:07:13.480 Maybe say a little bit about your view on 12-step programs

02:07:16.700 and the help of those who are struggling with addiction

02:07:19.580 and what pro-social shame means

02:07:21.520 and why it's an important part of recovery.

02:07:24.200 I always like to say there are many ways to the top of the mountain

02:07:27.700 and everybody is going to take their own path,

02:07:31.700 but we have clear evidence for things that work.

02:07:35.740 And at the same time, there's, again,

02:07:38.140 enormous inter-individual variability.

02:07:40.260 So what works for one person may not work for another,

02:07:43.160 but it would be good if all persons had access

02:07:45.280 to all the different options so that they could explore what works for them.

02:07:49.640 12-step groups are not a treatment per se.

02:07:53.260 They're not professionally led.

02:07:54.640 These are peer recovery groups where people are helping other people

02:07:58.320 struggling with the same problem,

02:07:59.760 and they intentionally eschew affiliation with any kind of political agenda.

02:08:06.940 There's no fee structure.

02:08:08.580 They don't involve themselves in money.

02:08:10.160 All of that incredibly wise, recognizing that we humans are so vulnerable

02:08:15.780 to mismanaging and asserting our own agendas in these kinds of endeavors

02:08:21.400 and sort of keep it free and accessible and everywhere

02:08:25.020 makes the bar for admission much, much lower, which increases access.

02:08:31.400 So even if you're talking about an effect size that may not be as large

02:08:36.100 as some kind of professional-mediated treatment,

02:08:37.820 the simple fact that it's free and it's in every church or synagogue basement

02:08:42.000 in the world or community center equivalent

02:08:45.360 makes it already a very potent intervention.

02:08:49.100 I think it's also important to acknowledge that for people

02:08:52.400 with more extreme forms of addiction,

02:08:54.920 that the 12-step groups may work even better

02:08:57.340 than individual or group psychotherapy that's professionally led.

02:09:00.860 And I refer folks to the Cochran Review

02:09:03.060 by John Kelly and Keith Humphries and co-authors

02:09:06.380 that really reviews the evidence and clearly shows that 12-step

02:09:10.000 are an evidence-based treatment or effective intervention

02:09:14.980 for people who actively participate.

02:09:17.920 For reasons that I don't entirely understand,

02:09:20.920 the press and the media and sort of the culture

02:09:22.940 has been very 12-step bashing of late.

02:09:25.880 I don't know quite where that comes from.

02:09:28.140 I do think that it's important not to force people

02:09:32.220 to go to 12-step or to say that's the only way to do it,

02:09:35.840 but you don't want to also then malign

02:09:38.480 or get rid of something that's clearly very effective.

02:09:42.020 Why does 12-step work when it does work?

02:09:44.940 I think one of the main sources of efficacy is,

02:09:48.040 again, easy access, low bar for participation,

02:09:50.980 and it may be one of the few places left in modern society

02:09:55.360 where people can show up and be their fully flawed

02:09:58.560 and broken selves and be entirely accepted for that.

02:10:02.640 Not just accepted, but where our brokenness

02:10:05.880 becomes a positive social good.

02:10:08.340 This may not even be true anymore

02:10:10.580 in faith-based organizations

02:10:12.080 where people sometimes get so caught up

02:10:15.260 in proving the bounties of believing

02:10:17.960 that they are then loathe or reluctant

02:10:20.360 or even discouraged from disclosing

02:10:22.620 the ways in which their life is not working out.

02:10:25.480 I have a very good friend who's a theologian

02:10:28.480 and a devout Christian

02:10:29.960 who of late has stopped going to his church

02:10:32.940 and instead is going to 12-step meetings.

02:10:35.300 He does not, in fact, have an addiction,

02:10:37.220 but he gets so much nourishment

02:10:39.380 from this coming together of people

02:10:42.240 who can talk freely about their mess-ups

02:10:45.300 and their greed and their mistakes that they've made

02:10:49.480 and their shameful, guilt-ridden types of behaviors

02:10:54.120 and come out on the other side

02:10:56.540 feeling better for it, less ashamed,

02:10:59.940 more motivated to change those behaviors.

02:11:03.560 And plus, the whole sponsorship program is so powerful

02:11:06.760 where you get a sponsor, you work the steps.

02:11:09.800 I mean, people can call their sponsors

02:11:11.380 any time of the day, any day of the week.

02:11:14.340 You can't do that with me.

02:11:15.780 Like, if you call me at midnight on a Saturday,

02:11:18.080 I'm not going to get that message till Monday.

02:11:20.540 And depending upon the clinical acuity,

02:11:23.160 I might not return that call till Tuesday.

02:11:25.040 That's not true for a sponsor.

02:11:26.340 You can call a sponsor in the middle of the night

02:11:27.720 and that sponsorship bond,

02:11:29.900 that person might even come over to your house.

02:11:32.820 So to me, it's just a very remarkable social movement,

02:11:35.800 definitely not for everybody,

02:11:37.400 but incredibly potent and powerful,

02:11:39.180 especially in a world that is in general

02:11:42.900 conspiring against our mental health.

02:11:45.700 You write about something so eloquently

02:11:47.400 and it really reminds me of a close friend, Paul Conte.

02:11:50.480 And I don't know if you and Paul ever overlapped

02:11:52.280 when he was doing his residency at Stanford,

02:11:54.440 but Paul always talks about the patient's story,

02:11:57.860 the patient's story.

02:11:59.760 And so I was really touched by,

02:12:02.060 you really wrote about the same thing, right?

02:12:03.600 Which is we've pathologized mental health so much

02:12:07.420 down to history of present illness, review of systems.

02:12:11.960 And you've talked about your own journey as a psychiatrist

02:12:15.460 and your own evolution away from the traditional training

02:12:20.740 where at the end of the day,

02:12:22.720 you've got to come up with a DSM-4 or DSM-5 code.

02:12:26.080 You have to be able to come up with a label.

02:12:27.940 And so you're interacting with a person

02:12:29.620 and you're in the mode of what's the label?

02:12:33.020 What axis is this person?

02:12:34.760 What's the diagnosis?

02:12:36.400 And you talk about now how you teach residents

02:12:39.060 to just put that aside

02:12:40.420 and listen to the story of the person.

02:12:43.540 What is it in your journey that led you there?

02:12:46.780 And how difficult or how easy is it to be training

02:12:49.500 other psychiatrists in that school of thinking?

02:12:53.420 Yeah, I mean, what comes to the mind immediately

02:12:56.620 about what in my journey led me to do that

02:12:59.540 is gonna sound super selfish,

02:13:01.540 but it was the realization that I was not engaged

02:13:05.300 or interested in this person.

02:13:08.080 I could not capture my own empathy for them

02:13:10.900 unless I knew the story.

02:13:13.420 Sort of, as I say, the mini autobiography of their lives,

02:13:16.820 what had transpired in their early life?

02:13:19.540 What were the major milestones?

02:13:21.480 How did they end up where they are today?

02:13:24.000 Who was in their life?

02:13:25.180 What were the major influences?

02:13:27.440 Narrative is so powerful.

02:13:29.000 As you know, our brains are wired for story.

02:13:31.540 Our prefrontal cortex is activated

02:13:33.360 when we listen to narrative.

02:13:36.500 We learn through narrative.

02:13:37.920 I mean, narrative is such a powerful mechanism

02:13:41.460 for so much of what we do.

02:13:43.520 I think Foucault said something like,

02:13:46.240 narrative is the only way we can measure lived time,

02:13:51.540 which I think is really powerful.

02:13:53.900 And it's also one of the primary ways to get at causality.

02:13:57.420 Of course, we can tell ourselves stories that aren't true

02:13:59.740 and come up with causal relationships

02:14:01.940 that aren't based in fact.

02:14:03.940 But when we're telling true stories,

02:14:05.420 it is the way that we understand

02:14:07.980 what led to what led to what.

02:14:11.480 And it's also just much more interesting and more fun.

02:14:14.220 I see that as a psychiatrist's job.

02:14:15.900 That's the data.

02:14:17.100 That's our bread and butter.

02:14:18.660 The cardiologist gets the EKG,

02:14:20.540 the surgeons cutting and sewing,

02:14:22.920 and we deal in story,

02:14:24.560 and we must deal in story.

02:14:25.900 And when we have new fellows,

02:14:28.740 we have addiction medicine fellows,

02:14:30.020 they come from many different specialties.

02:14:32.120 We have family medicine doctors,

02:14:34.280 emergency medicine doctors,

02:14:36.200 pediatricians, psychiatrists.

02:14:38.260 And it's so hard for them to let go

02:14:40.480 of that kind of structured categorization,

02:14:43.300 chief complaint, history of present illness,

02:14:45.660 past medical history.

02:14:46.820 But I just say, trust me on this.

02:14:48.820 Trust me.

02:14:49.900 Start with their story.

02:14:51.800 Say, tell me the story of your life,

02:14:53.820 where you were born, who raised you,

02:14:56.380 what you were like as a kid,

02:14:57.980 major milestones, memories that you remember

02:15:00.680 that were impactful or important.

02:15:02.880 All the way up into the present day,

02:15:04.300 who do you live with?

02:15:05.180 Who are the important people in your life?

02:15:06.700 What do you care about?

02:15:08.140 What are your goals and dreams?

02:15:09.880 If we don't do that,

02:15:11.160 we end up with a kind of a laundry list of symptoms

02:15:13.660 that is not actually a person.

02:15:15.220 Anna, when you think back over your career,

02:15:18.320 you've written about what are undoubtedly

02:15:20.700 a lot of the amazing success stories.

02:15:23.280 People who seemed on the brink of death in some cases,

02:15:27.000 and if not death,

02:15:27.880 outright destruction of their lives and relationships.

02:15:30.780 But I have to imagine that there's a graveyard too

02:15:32.840 of people that you haven't been able to help.

02:15:35.040 How have you coped with that?

02:15:36.760 It's a great question.

02:15:38.040 And it's very timely

02:15:39.000 because I just had clinic yesterday

02:15:40.900 and I had an interaction with a patient

02:15:42.660 that was really not good

02:15:44.560 and the patient was very angry at me.

02:15:47.000 The key, I think, for me is to just stay curious,

02:15:51.180 to just continue to wonder about this person,

02:15:55.300 what shaped them,

02:15:56.860 what their motives might be,

02:15:58.800 and how all of that might inform

02:16:01.000 how we can help them.

02:16:03.400 So to stay in this empathic professional stance,

02:16:06.960 to look at myself,

02:16:08.240 if a patient criticizes me or the treatment,

02:16:10.640 what is potentially correct about that?

02:16:14.420 How have I messed up?

02:16:16.380 How can I make amends?

02:16:18.380 So really trying to walk a path of humility.

02:16:21.300 The longer I've practiced psychiatry,

02:16:23.900 believe it or not, in some ways,

02:16:24.900 the less I think I actually understand

02:16:26.800 about the brain and how people change.

02:16:30.440 I mean, at some really core level,

02:16:32.140 it is a great mystery.

02:16:33.780 So just trying to stay humble and curious

02:16:36.480 and empathic and then also go home

02:16:40.140 and forget about it for a while

02:16:41.600 and make sure I take care of myself and my family.

02:16:45.560 Yeah, the further you get from shore,

02:16:46.880 the deeper the water gets, for sure.

02:16:50.540 When you lose a patient,

02:16:52.800 which I'm sure you do, right?

02:16:54.140 I'm sure there are many patients

02:16:55.480 where it's not just that they're angry at you in clinic,

02:16:58.260 it's that they succumb to their addictions,

02:17:00.760 physically succumb, literally die.

02:17:02.560 Okay. Is that something where you've accepted the fact

02:17:05.860 that that's going to happen,

02:17:06.980 but being attached to that patient

02:17:09.300 and suffering the pain of their loss,

02:17:11.980 is the price you pay to be a better doctor

02:17:14.240 or is there a way to create a boundary

02:17:17.000 and never let yourself hurt in that situation?

02:17:20.440 One of my early mentors and supervisors

02:17:23.400 said something to me that I'll never forget.

02:17:25.380 He said,

02:17:26.400 Anna, the reason that the work that we do works

02:17:30.420 when it does work is because

02:17:32.520 we actually love our patients

02:17:35.740 and the emotions are real.

02:17:38.140 We have to come to the therapeutic encounter

02:17:40.240 with our own physical, mental, sexual needs met

02:17:44.520 so that we are there 100% for the patient's needs,

02:17:48.060 but the emotions are real.

02:17:49.540 The relationship is real.

02:17:51.140 We have to care about these folks.

02:17:53.260 So I think that is a deep truism.

02:17:56.180 And when a patient dies, it is devastating.

02:18:00.720 It's absolutely devastating.

02:18:01.860 And the guilt is enormous.

02:18:03.980 The kind of what ifs, if only I had done that,

02:18:06.860 if only we had been more present or more proactive

02:18:10.220 or whatever it is, you can't get away from that.

02:18:14.800 This has been a fantastic discussion.

02:18:16.860 I really appreciate the work you're doing.

02:18:19.260 Your writing is exceptional

02:18:20.660 and I certainly appreciate it.

02:18:22.560 And obviously just appreciate your time today.

02:18:24.540 Thank you very much.

02:18:25.220 Thank you.

02:18:26.240 It was a lovely interview.

02:18:27.760 I enjoyed meeting with you.

02:18:28.860 Thank you for your important work.

02:18:30.700 Yeah, it was a pleasure to talk with you.

02:18:33.200 Thank you for listening to this week's episode of The Drive.

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The Peter Attia Drive - October 14, 2024

#321 – Dopamine and addiction： navigating pleasure, pain, and the path to recovery ｜ Anna Lembke, M.D.

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