A (3:56)

Ah, good question. Good, good place to start. I mean, dopamine matters because it's fundamental to our survival, right? So it's the chemical that we make in our brain that tells us this is something we should approach, explore, investigate. So it's, it's really almost the survival chemical.

B (4:16)

So what is dopamine? If you had to explain it to a 10 year old, how would you go about explaining it?

A (4:21)

So dopamine is a chemical that we make in our brain. It has many different functions, but one of its most important functions is that it helps us experience pleasure, reward, and motivation. It may be even more important for the motivation to do things than it is for the pleasure itself. So, for example, there's a very famous experiment in which rats were engineered to have no dopamine in the brain's reward pathway. And the scientists discovered that if they put food in the rat's mouth, the rat would eat the food, would seem to get some pleasure from the food. If you can determine that from watching a rat eat, which I think they felt like they could, but if you put the food even a body length away, the rat will starve to death. The idea being that without dopamine, we. We're not motivated to seek out the things that we need for our basic survival.

B (5:20)

That's crazy. So you get a rat, you put the food an inch from its mouth, and it will starve to death because it doesn't have dopamine. The dopamine required to just reach out and eat.

A (5:31)

Yeah, essentially. Maybe it's not an inch, maybe it's a little more than an inch. But the idea being that dopamine is necessary to be motivated to do the work, to get the thing that we need.

B (5:43)

And having an understanding of dopamine, how might that improve my life?

A (5:49)

Having a basic understanding of how dopamine works, how we process pleasure and pain, and also what happens with dopamine as we go from adaptive recreational use to maladaptive addictive use is something that is really useful, especially for those of us living in the modern world, where now we're exposed to so many reinforcing substances and behaviors that we've all become vulnerable to the problem of addiction.

B (6:17)

And what are the biggest misconceptions on the subject of dopamine? Because it's kind of thrown around in society. I see it in my group chats, people saying, I need more dopamine or whatever, or, you know, that person just craves dopamine. What are the biggest misconceptions you've come across?

A (6:31)

The main misconception is that somehow we can get addicted to dopamine. We're not getting addicted to dopamine itself. Dopamine is neither good nor bad. It's a signal to tell us whether or not something that we're doing is potentially useful for our survival. And also it's related to what we predicted about how rewarding or pleasurable something would be. And so it's really, you know, I sort of. Sometimes I joke. It's like the reward theory of relativity. Dopamine is, in the sense that Pleasure and pain really are truly relative to one another. And so dopamine gives us information about where we are in that relativity scale between pleasure and pain.

B (7:17)

And when you say relative, you mean. I mean, it's quite fitting for anyone that can't see we have a set of scales on the table, and scales are relative to each other because if you pour in one end, the other end goes up, and if you pour in the other end, the other end goes up and this end goes down. And when you say relative, that's what you're describing, right?

A (7:34)

Yes, that's what I'm describing, yes.

B (7:36)

Okay. And what activities that I do every day have an impact on my dopamine?

A (7:42)

Well, probably almost everything. You know, in some ways, I mean, every time we are doing something that's pleasurable, reinforcing, rewarding, that will affect dopamine, it's really the primary signal that lets us know that this thing is potentially important for our survival, as I mentioned. But, you know, even aversive stimuli can trigger dopamine.

B (8:10)

What's aversive?

A (8:11)

Oh, something that's painful or not pleasurable. Dopamine gets involved in that equation. Anything that's novel or new is something that triggers dopamine in our reward pathway. Dopamine is fundamental for movement, so not just pleasure and reward, but also movement. So, for example, Parkinson's disease, which is a disease related to stiffness and tremor, is caused by a depletion of dopamine in a part of the brain called the substantia nigra. And as dopamine gets depleted in that part of the brain, people lose the ability to move their bodies. And it's probably no coincidence that the same neurotransmitter that is so important for pleasure, reward motivation, is also really important for movement, because most organisms have to locomote toward the object of their desire. We want that thing. We have to exert effort, right? We have to put in the work to go get it. But in the world today, we really don't have to do that, right? We can swipe right, we can swipe left, and all of a sudden it magically appears at the touch of a finger. And that's very confusing for our brains because that's not how we evolved. We really evolved for having to do quite a bit of upfront work for a tiny little bit of reward.

B (9:32)

I just want to, before we move on, talk about this point you said, because I think it's quite foundational to everything we're going to talk about about dopamine being relative to Pain. And I have this set of scales in front of me, and here I have some chemicals that are likely to produce dopamine in my brain, I believe.

A (9:49)

Right.

B (9:50)

So alcohol. I have some rum. I have some whiskey. I have some vodka. And can you explain to me, using this rum, whiskey, and vodka, how dopamine is relative to pain and what's going on in my brain?

A (10:03)

Sure.

B (10:03)

Okay. I'll slide this over to you.

A (10:04)

Oh, okay. So one of the most exciting findings in neuroscience in the past 75 years is that pleasure and pain are co located in the brain. So the same parts of the brain that process pleasure also process pain. And in a very simple reductionist kind of way, they work like opposite sides of a balance. So imagine that deep in your brain's reward pathway, which is another exciting discovery, right. That there's this dedicated reward pathway of the brain that consists, broadly speaking, of the prefrontal cortex, which is this large gray matter area right behind our foreheads that's so important for future planning, for delayed gratification, for appreciating future consequences. You might think of it as like the brakes on the car if we're going to analogize to an engine. And then deep in the brain, we've got what we call the limbic areas, or the emotion brain. And there you have the nucleus accumbens and the ventral tegmental area that are rich in dopamine releasing neurons. Right? And they act like the accelerator on the car. So when you've got a healthy, functioning brain, you've got enough accelerator, but not too much. Right. So enough dopamine being released, but not too much. And you've got a healthy prefrontal cortex putting the brakes on that dopamine release. When people become addicted, there's either a problem with the brakes, the prefrontal cortex, or the accelerator, the nucleus accumbens, and ventral tegmental area, or. Or both. Right. What we're finding is that there's actually a disconnect. So there are large neuronal circuits and pathways between those deep limbic structures and the prefrontal cortex that literally get severed or disconnected when people become addicted. As we think about pleasure and pain being co located in the same parts of the brain working like opposite sides of the balance. In order to understand what happens in the addicted brain is to appreciate that there are fundamental rules governing this balance. And one of the most important rules is that the balance wants to remain level. It does not want to be tilted very long to the side of either pleasure or pain. And in fact, what our Brain does is first tilt an equal and opposite amount to whatever the initial stimulus is. So I'm going to try to illustrate that here. So let's say our initial stimulus is alcohol. Now, alcohol works through its own chemical pathway. It works on our endogenous opioid system. The opioids that we make, we have receptors for opioids in our brains. It works on our endogenous GABA system, which is our calming neurotransmitter. And at the end of the day, it releases dopamine in the reward pathway. So any potentially addictive substance will release dopamine in the reward pathway. The more that's released, and the faster that's released in a given individual, the more likely that substance is to be addictive. Now, another important concept here is what we call drug of choice, which is to say, what releases a lot of dopamine in your brain may not release a lot of dopamine in my brain, and vice versa. Right. Which is this idea that people have predilections to different kinds of drugs. And by the way, people can get addicted to behaviors, too. I should emphasize that when you say.

B (13:27)

Drug of choice, you mean the brain has a particular sensitivity to that drug in terms of dopamine?

A (13:35)

Yes.

B (13:35)

Okay.

A (13:36)

The more dopamine that's released, the faster that it's released, the more likely that drug is to be addictive for a given individual.

B (13:42)

So you're holding some whiskey there.

A (13:44)

I'm holding.

B (13:45)

There could be a brain that is very sensitive to whiskey, and there could be a different brain that you could pull all the whiskey in you like. And the dopamine response is sort of limited.

A (13:55)

Exactly.

B (13:56)

Okay.

A (13:56)

And for many of my patients who become addicted to alcohol, they will tell you that from the first moment they had alcohol, they knew they were either in trouble or had met their best friend or some combination. It was a very potent experience for them. All right? So let's go ahead and put this on the pleasure side of the balance. Dopamine's being released, but no sooner has that happened, then my brain will work very hard to restore a level balance. And by the way, a level balance is what neuroscientists call homeostasis. Okay. And one of the overarching physiologic drives for all living organisms is to return to homeostasis. Homeostasis is that parameter of what's often called affordances or states of being that are adaptive and healthy for the organism. For example, like, we have a certain homeostasis of body temperature, and if we go much beyond that either too high or too low, we will disintegrate and die. Right. So homeostasis is that states of being that are compatible with existence and potentially advantageous too.

B (15:04)

Sort of baseline level.

A (15:05)

That's right, yeah. Baseline level. And by the way, we're always releasing dopamine at a kind of tonic baseline level in our brains. I sometimes think of it as the heartbeat of the brain.

B (15:13)

So what's happened here for people that can't see is you poured a little bit of whiskey into one end of the scale, the pleasure side of the scale, and the other side of the scale has risen because now there's whiskey in the pleasure side, which I guess has released dopamine.

A (15:26)

Exactly. So now we've released dopamine in the reward pathway. Okay.

B (15:30)

Because the pain side went up, does that mean there's now less pain in the brain?

A (15:34)

Well, I think. You know, again, this is a metaphor. It's an oversimplification. The idea here is just when we press on the pleasure side, we're relaxing, releasing dopamine in the reward pathway and experiencing pleasure. Okay, okay. But no sooner has that happened than our brain will try to compensate or adapt to increased dopamine firing by down regulating dopamine transmission. For example, by involuting postsynaptic dopamine receptors.

B (16:01)

What does that mean?

A (16:01)

Okay. Okay. So our brain is a bunch of wires that conduct these electrical signals. And these long, spindly cells are called neurons. And the thing about neurons is that they don't actually touch end to end. There's a little gap or space between them. And that gap is called the synapse. And that gap or synapse is bridged by what we call neurotransmitters. And dopamine is one of those neurotransmitters. Okay. And when the presynaptic neuron pulses and releases dopamine, it crosses the synapse and binds to a receptor on the postsynaptic neuron, which either continues or aborts that electrical signal. Does that make sense?

B (16:43)

Yes.

A (16:43)

Okay. So one of the ways that our brain can decrease the effects of dopamine, decreased dopamine transmission is by involuting or taking inside the neuron, the postsynaptic receptor. That way, when dopamine is released, it has nowhere to bind.

B (17:00)

Oh, okay. So it's like removing the docking station.

A (17:03)

Exactly. Okay, very good. It's removing the docking station. So essentially, getting back to our scale, we've, you know, ingested alcohol, we've increased dopamine firing in the reward pathway. But remember, Our pleasure pain balance wants to return to the level position, level with the ground homeostasis. So it's going to decrease dopamine transmission by, for example, involuting those postsynaptic dopamine receptors. But one thing about the brain in its process of trying to get back to homeostasis. And again, I like to think of this neuroadaptation process as these gremlins hopping on the pain side of the balance to bring it level again. Have gremlins here, you have these little rocks. But let's go ahead and put a rock on the pain side of the balance. And these rocks are our friends, right? Their job is to level the balance because remember, we gotta go back to homeostasis. I'm put a rock on and you're gonna see. Oh my gosh, it overshot. Right now I've got it pressed down on the pain side of the balance. But that's exactly what happens in our brains in this process of neuroadaptation. Those gremlins hopping on the pain side of the balance don't get off as soon as the balance is level, they stay on until we're tilted an equal and opposite amount.

B (18:14)

So is that what a hangover is? Or a comedown, as they would say when people take drugs, they say, I have a comedown.

A (18:21)

Exactly. That's exactly what it is. That's the hangover, the comedown, the Blue Monday. Or on a much smaller scale, just that moment of craving, right? That moment of wanting to have one more shot.

B (18:34)

Why does it overshoot? Why can't it just perfectly hit homeostasis?

A (18:38)

Such a great question.

B (18:39)

Because then we'd feel fine.

A (18:41)

Yeah. Why did mother Nature do that to us? So cruel, right?

B (18:45)

Yeah.

A (18:46)

Okay, I'm gonna tell you an evolutionary just so story. What we mean by that is we don't really know why this mechanism exists, but from an evolutionary perspective, if you're living in a world of scarcity and ever present danger, this is the perfect mechanism to make sure that we're never satisfied with what we have, that we're always wanting more. It's made us the ultimate seekers.

B (19:13)

Okay. Because immediately after getting something, I'm now feeling a lack of pleasure and I'm at a deficit, you know, on the pain side of the scale, which means that I'm gonna go seeking out more dopamine. And in a world where everything is quite scarce, that could mean going on another four hour hunt the next day to go kill a gazelle or something.

A (19:32)

Perfect. Yeah.

B (19:34)

Okay. Interesting.

A (19:35)

Yeah.

B (19:36)

Okay, so that's going to motivate me because this gets so. Jesus. People that have hangovers don't seem very motivated.

A (19:44)

Right. So now that's. So why is that? Right. It's because alcohol is a product of human engineering that releases so much dopamine all at once in the reward pathway that our brains are reeling to compensate. Right. We really weren't evolved for this much pleasure with this much easy access, as you said yourself. We were really evolved to have to do quite a lot of work up front and to be hungry and to be lonely and to be tired and then get a little bit of reward that would then bring us back up to homeostasis. So really, we were evolved to be pressing on the pain side of the balance in our effort to find pleasure. And then when we find it, that little bit of food or clothing or shelter or a mate would bring us back to the level position. Does that make sense?

B (20:39)

Yeah. So you're telling me essentially that we're all wired to be addicted, because if this is how our brain works in a world, it's designed to seek out more dopamine. But the problem we have now is we have all this synthetic dopamine effectively, like this sort of synthetic chemicals and synthetic things, and, you know, an Internet that is wiring us to give us so much dopamine so easily. That means that our brains are effectively, like, mismatched to the world that we live in and therefore wired to be addicted. Yeah, I think you actually said that. I found a quote you said in an interview where you said, we are all wired to be addicted. And if you're not addicted yet, it's right around the corner.

A (21:19)

Right. Coming to a website near you. Yes. I guess I would qualify that a little bit by saying we're wired for survival in a world of scarcity. That's not the world we live in now. We live in a world of overwhelming overabundance. And so there is a mismatch between this ancient wiring that has us relentlessly pursuing pleasure in order to survive and a world that's so infused with pleasure and so many rewarding stimuli that now we're overwhelming our reward system and our brain are reeling in response to try to compensate.

B (21:53)

So what happens to this scale, then, in such a world where I can get a big hit of dopamine all the time using some of these synthetic things or the Internet or pornography or whatever else, what's going on with this scale over and over again?

A (22:05)

Okay, great. So let me get there. Let me first say, though, that, remember, after we do something that's highly pleasurable. Our brain compensates with neuroadaptation, tilting an equal and opposite amount to the side of pain and then restoring our balance back to the level position. Right? Or what we call homeostasis. So this doesn't last forever, right? It's to pleasure, then it's to pain, then it's back to the level position. But if we continue to consume our drug of choice over days to weeks, to months, to years, and we add in a whole bunch of other drugs, and now we're consuming pornography and smoking pot and eating donuts and, you know, you name it all at the same time, then essentially what happens is those gremlins on the pain side of the balance end up camped out there for.

B (23:00)

Anyone that can't see. She put all of the rocks into the pain side to represent all of the addictive behaviors that this individual has now taken on.

A (23:08)

Right. And now we've entered addicted brain, by which I mean that we've changed our hedonic or joy set point to the side of pain. Now we need more and more of our drug in more potent forms. Not to get high and feel good, but just to level the balance and feel normal. And this is not going to be enough to level the balance. I would have to like keep filling this much more than this container can hold. And that would be in pursuit really, of just trying to level that balance so that we can feel normal. And when we're not using, we're walking around with a balance tilted toward the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, depression, and craving.

B (24:01)

So if I manage to get enough vodka, whiskey, rum, and pour it into the pleasure side of the scale, now that all the rocks are in the pain side of the scale, I managed to outweigh it, what would then happen?

A (24:14)

More rocks.

B (24:15)

More rocks would be added.

A (24:17)

Yes, more rocks.

B (24:18)

So momentarily I would maybe be in a little bit of pleasure.

A (24:22)

Yes.

B (24:22)

But then my brain would remove those docking stations again, remove more of them, and more rocks would go in and I'd slam down on the pain side again, which means I need more alcohol to try and get up to pleasure. Slap. Okay, so really, you wanna like dopamine fast or you need to just balance this? And this is so difficult because of the world we live in. It's almost. It's funnily enough. Cause this little scales experiment analogy here has given me a huge amount of empathy for people that are addicts.

A (24:51)

Oh gosh, I'm so glad you said that. Because I think that is the key to empathy for the disease of addiction as well as for people with the disease. Having empathy for themselves is recognizing that on some level it's out of their control. Right. Because when we are tilted to the side of pain, the overwhelming drive to restore a level balance or restore homeostasis as quickly as possible overwhelms any other rational thought about the consequences of my drug use. Right. It's just like get back to the level position. Because if I do that, I'll at least feel temporarily better.

B (25:31)

One of the things this analogy also highlights for me is that people who are addicted aren't trying to self harm.

A (25:40)

Right.

B (25:40)

And this is kind of the prevailing narrative that if you're like, why would you do that to yourself? Whereas when I look at this analogy, I go, actually what they're trying to do is to deal with pain and we're all trying to find ways to deal with our pain. But in this analogy, what ultimately happens, and I guess is what's happening with addicts is the way they're choosing to deal with their pain is becoming self destructive and that's creating more pain.

A (26:05)

Right.

B (26:05)

And it's this vicious downward cycle.

A (26:07)

Yes.

B (26:07)

And I think that sort of reframing of what's going on there is really critical because again, it begets more empathy.

A (26:12)

Absolutely, I agree with you. And I think, you know, we, this, this metaphor, it makes an assumption that we all start with a pleasure pain balance that's level with the ground. But actually that's probably not true. Right. Some people at baseline may actually be more depressed or more anxious or may have had life experiences that sets them up for a kind of chronic stress reaction. And we know that people with co occurring psychiatric disorders, for example, are at increased risk of developing addiction, probably because they're reaching for that substance to self medicate their psychiatric problem. The issue with that is that it's not medicinal. Right. It's not healing. Although in the short term, substances can help with those kinds of feelings of psychological and physical pain over time because of the way the brain adapts. As we've discussed, substances and other addictive behaviors just make psychiatric problems worse. Right. As we drive ourselves further into the kind of, you know, the pain side of the balance.

B (27:20)

So is this why trauma often leads to addictive behaviors? Because the trauma has caused a pain, a stress, and we're searching for ways to medicate that pain or stress?

A (27:33)

Yeah. To numb ourselves, to not be present in our reality and have to deal with what's going on there.

B (27:39)

What role's dopamine playing in survival?

A (27:41)

It's all the same. Dopamine originally was to help us find those things that we need to survive. Food, clothing, shelter, a mate. We call those natural rewards. But today, that same reward pathway that relies on dopamine has been hijacked by all of these artificial rewards that our brain confuses as necessary for survival. Which is why people with severe addiction will be willing to lose, not consciously, but unconsciously, their loved ones, their homes, their jobs, everything they have in pursuit of their drug of choice. It's because their brain has been hijacked and they now confuse the drug as necessary for survival. The other thing about drugs is that they're incredibly potent. They release a lot of dopamine all at once, which, again, is confusing for our brain. Natural rewards require upfront effort, where we do a lot of work, and then we get a little bit of dopamine. And that's what our brains evolved for.

B (28:46)

I mean, I can. That makes sense. In my own life, when I'm most stressed or most challenged by something professionally, is when I immediately notice that my diet goes out the window. I start eating things that are bad. I actually stopped going to the gym as much. And it's. It can form a bit of a downward spiral, can't it? I guess, as we've kind of seen from the dopamine scale.

A (29:09)

Can I get back to your question, though, about trauma and stress? So there's a very serious. There's a very interesting series of experiments in rodents, mice and rats, where they, first of all, rodents very easily get addicted to cocaine. They will press a lever for cocaine until exhaustion or death. But if that cocaine is then taken away, that behavior will extinguish. Which means that the mice will eventually just stop pressing the lever. Right. Cause they're not getting any cocaine. Totally makes sense. And then they'll go off and do something else in the cage. But if they're then exposed to a very painful foot shock, right? So a very extreme physical pain, which you could equate to a serious life stressor, the first thing the rat will do is run over to the lever and start pressing for cocaine. Which tells us that once our brain has discovered a drug that releases a lot of dopamine in our reward pathway, even after we stop using that drug, if we are exposed to an extreme stressor, our brain will tell us immediately, go and do that thing that gives us a lot of dopamine, because you are under stress and I need to be relieved of stress. Does that make sense?

B (30:34)

Makes perfect sense.

A (30:35)

Yeah.

B (30:35)

Yeah. So if you. Especially so if you discover your drug of choice when you're younger and it's food or it's pornography, or if it's. I don't know, anything that really made you feel good for a moment, a moment of pleasure, that will always become, in the case of these rodent experiments, the thing you run back to when life gets hard.

A (30:55)

Right. And we see that again and again in people in sustained recovery from addiction, that when they are under stress, that is a trigger potentially for them to relapse. So they have to be really thoughtful in their lives for, number one, trying to avoid stressful situations. And by the way, stress can come in many different forms. There's a great acronym in Alcoholics Anonymous called halt, Hungry, Angry, Lonely, Tired. Those kinds of stressors, everyday stressors which we all experience, Hungry, angry, lonely, tired, can trigger us to want to use. So people in recovery have to be really thoughtful about not getting too hungry, not getting too angry, not getting too lonely, and not getting too tired.

B (31:42)

At the end of this conversation, I want to go through all of the sort of practical solutions that someone struggling with an addiction to social media, pornography, food, whatever it might be, can implement to try and shift that cycle that they might be going through, especially when they're halting, hungry, angry, lonely, or tired. How often have you worked with addicts? Have you spent much time working with addicts directly?

A (32:03)

Oh, my gosh. Yeah. So that's. The bulk of my career is working with people with all different kinds of addictions.

B (32:10)

An example of the most obscure, the most.

A (32:13)

I had a patient who was addicted to water. I know. Hard to imagine. You have to, though, understand her narrative. So she had a very severe alcohol addiction. She got into recovery, recovery from that addiction, and gave up alcohol. But she discovered that by drinking copious amounts of water, she could become hyponatremic, meaning that she could lower the sodium levels in her bloodstream, which would then lead her to become delirious. And so in her desire to just be checked out, she would do that. She would drink large amounts of water.

B (32:50)

She's doing okay.

A (32:52)

No, sadly, she's not. She ended up taking her own life. So that was very sad.

B (33:00)

Gosh, in that situation, was there a root cause of that behavior pattern further upstream, some kind of trauma or experience that had set this sort of cascading set of issues off?

A (33:14)

Yeah. You know, I'm just speaking broadly. For some patients with severe addiction, trauma is a huge factor, especially severe early childhood trauma. But there are also many Folks we see who have kind of great parents and have had happy childhoods and have great social networks and work that they enjoy, and yet they still become addicted. And that's because we, again, we are wired to consume as much as possible of whatever releases dopamine in our brains, to have survived evolution to this date. And yet we're living in this world where we have access to so many drugified substances and behaviors that we've all become vulnerable to this problem. And the reason I highlight this is because one of the things that I think has happened in the field of addiction medicine that maybe isn't the best is that oftentimes patients themselves, as well as their providers, are digging really deep to find the trauma or the reason that someone has become addicted. And I think that that's important to do in some cases, but in other cases, it can lead to kind of manufacturing trauma where there really isn't any. Furthermore, I would say that when a person is in the throes of their addiction, they're not going to be able to really do the complex emotional of their trauma While they're still using their drug of choice. That they really need to get out of that vortex of addiction and get into some degree of recovery before you would even want to go tackle some of those early traumatic experiences.

B (34:59)

How many people do you think are struggling with some form of addiction?

A (35:03)

Well, if you think of addiction as a spectrum disorder, right, there's mild, moderate, and severe. And there's I would even say, a kind of a pre addiction state where we're all sort of dabbling in compulsive overconsumption. I would say the vast majority of us, like 90, probably 95%, have some degree of compulsive overconsumption. And if and when it tips over into what we would call addiction, there's not a brain scan or a blood test to assess that. It's not like switching a light switch. And it's like, oh, yeah, now you have addiction. It's not like that. It's a gradual, often a gradual and insidious thing. And we don't, in fact, have a biological measurement of addiction. We base it on what we call phenomenology, which is patterns of behavior that repeat themselves across time. And broadly speaking, the definition of addiction is the continued compulsive use of a substance or a behavior despite harm to self and or others. And so, you know, that harm can be very subtle or not. Right. And it can be a judgment call.

B (36:11)

Interesting. Cause we do throw the word addiction around a lot in society. But really the most important part of that is to understand if it's harming yourself or someone else. The behaviour pattern.

A (36:22)

Yes, that's right. And to also recognize that we're not very good judges of that when we're chasing dopamine.

B (36:28)

Okay. So we sometimes justify behaviors we have as being not harmful and it's fine and it's not impacting me at all. And what do you mean exactly?

A (36:35)

And we don't, we're not very good at seeing true cause and effect honestly when it comes to these behaviors. Which is why oftentimes people won't really see the harm until they've stopped using for a period of time.

B (36:47)

In your book Dopamine Nation, you talk about an addiction that you had.

A (36:50)

Yes.

B (36:51)

And it was really surprising to me because I would never have thought that being obsessed with erotic novels could be classified as an addiction. What happened? What was the behavior? Take me into that phase of your life.

A (37:06)

So I was in my early 40s, my kids were no longer little. I got a lot of my self worth and identity from being a mom. And my kids were sort of entering adolescence. They were doing fine, but they didn't need me as much. So I had kind of a grief reaction, you know, in response to that was trying to figure out, you know, how to navigate this next phase of my life. I'd always been a reader, and in particular a reader of novels in my own way. That was how as a child I self soothed was to escape into the fantasy life of novels. But I never had what I would call a problem with it. And then one day I heard another mother at school said that she was reading this great book, it was called Twilight, it was about these vampires. And she was going on and on about it and I read it and I can't tell you what it was, but it was just like the key in my particular lock, it was completely transporting. It just released a lot of dopamine as all I can imagine in my brain's reward pathway. And so I read the whole series and then I read the series again and I read it again and of course the third or fourth time it wasn't as, you know, reinforcing. And I thought to myself, I wonder if there are any more vampire romance novels. And then for me the real tipping point was I got an E reader, I got a Kindle. Because what happened was even before I got the kindle, I started reading novels that I would say I would be slightly embarrassed to admit that I was reading like kind of bodice Ripper novels. As time went on, I needed more and more, like, graphic kinds of descriptions in order to find it pleasurable. And by the way, that's classic for the addiction narrative, right? Where you start out with a little bit and it goes a long way, and then over time, you build up tolerance. That's neuroadaptation. The gremlin's pressing down on the pain side of balance. Now I need more of my drug in more potent forms to get the same effect. Gradually, over time, I started reading, you know, more and more sort of graphic, erotic, sexualized versions of this novel. And I would. I was embarrassed, so I would hide that I was reading them. And that gets into the whole double life of addiction, where now we're lying about our use, we're using our drug over here, but pretending like we're not. So my kids or my husband would walk in the room, and I would be, you know, hiding behind another book, one book behind another book, so it looked like I was reading. Is something, you know, I don't know, more sophisticated. And then the tipping point for me came really when I got a Kindle or an E reader. And then my reading was totally anonymous. I could read these books anywhere, anytime. No one knew what I was reading. And as soon as I finished one, I could read another one. And I, almost overnight, became a chain reader. Like, literally, when I wasn't doing something else that I had to do, I was reading romance novels one after another after another, which meant I was less present for my kids, less present for my husband. I would often stay up till 2, 3, 4 in the morning on a weeknight reading romance novels, have to get up two hours later, go to work, exhausted, not able to be present for my patients, not enjoying my work, gradually getting more depressed, more irritable, more anxious, more insomnia. We went on a family vacation with family, friends of ours, everybody together at this beach house, all the kids playing. I was, like, hiding in a room reading romance novels. So. And this is exactly what happens with addiction is that our focus narrows and the things that we used to enjoy are no longer pleasurable. Only this one thing has salience for us. We plan our whole day around getting it, using it, hiding our use. And that's what happened to me.

B (41:00)

It's so interesting because as you were talking about that, I was thinking about all the behaviors that I have that are maybe isolating me or, you know, just even things like spending a lot of time on the Internet, just watching video after video after video on YouTube or those kinds of Things or just, like, spending tons of time in my WhatsApp group chat roasting my friends about nothing.

A (41:26)

Right.

B (41:26)

How do you know if, like, this is. It's. Cause on one end of the spectrum, I could say, okay, well, that's harming my relationship with people in the real world. But it's helping. Making me feel good. And it's, you know, maybe helping me in another department. Cause I'm learning more about vampires or, you know, like. So, like, you know. Cause there might be net harm somewhere else, but then an upside over here. And then I start rationalizing this behavior. Like, how do you distinguish between these behaviors and know what's bad and what's good?

A (42:02)

You know what? It's really hard. These digital devices are powerful tools, but also very potent drugs. There's no doubt that digital media lights up the same reward pathway as drugs and alcohol. These devices and platforms were designed to be addictive, that is, to keep us scrolling and tapping long beyond what we plan for or what we want or even what's pleasurable. I think we can all relate to using this medium to a point where we don't even like it anymore and yet have difficulty getting ourselves off of it. That really speaks to the inherently reinforcing and cognitively adherent nature of this medium. It is a drug. And so, you know, if and when and how we're crossing into addictive use, I think we need to be very vigilant about whether that's happened in our lives. And one of the ways to do that is actually to try cutting out that particular digital medium, that website, or that behavior for a period of time long enough to experience withdrawal, potentially reset reward pathways, and then reevaluate. Because when we're in the behavior, as you yourself noted, it's very easy to rationalize, oh, I need to do this for work. Oh, I need to do this to stay in touch with my friends. Oh, I'm learning so much from this. Right? And all of that may have been true initially, but may not be that true anymore. And what I often point to is the subtler signs of addiction, which are things like depression, anxiety, inattention, insomnia, restlessness. These can be early signals for our consumption, entering into that addiction range, but us not realizing it, because, again, we don't see cause and effect. Which is why doing an experiment like I did with my romance novels, you know, following in the footsteps of my patients and taking the advice I give them, and I gave my romance novels up for 30 days, right, just to see, like, okay, I think this Is a problematic behavior. Can I give it up? How will I feel? And the very first day that I. The very first 24 hours that I did not read any romance novel, any novel at all, I was astounded at my level of anxiety, restlessness, and utter insomnia. I had completely unlearned the art of putting myself to sleep without this digital narrative. And that lasted a good 10 to 14 days, completely mapping on with the amount of time it takes, typically, to get out of acute withdrawal, that is to say, for those neuroadaptation gremlins to hop off the pain side of the balance and for homeostasis to begin to be restored. But by the time I got to weeks three and four, I felt not just better than I had in the first two weeks, but actually better than I had felt in a really long time. I enjoyed my kids more. I was more present for them. I enjoyed my husband more. My work seemed salient again. I had started to think, oh, maybe I should do something else. You know, maybe. Maybe I. You know, this work, I've been doing it a long time. I don't. It's not that interesting anymore. All of a sudden, it was interesting again, right? So you see the relativity of that hedonic pathway and how when we're doing that behavior or substance that's so reinforcing that everything else loses its salience, we can really misidentify what is causing our irritability, anxiety, insomnia, until we stop that substance for long enough to see its impact on our lives.

B (45:57)

How is it making you feel? Because I think a lot of people can't understand how you could get addicted to a book. I'm sure some people understand that, but for me, it's not something I've ever become addicted to. So how did it feel? Was it, like, exciting? Is it arousing? Is it somewhere in between?

A (46:17)

I mean, I think that romance novels are essentially socially sanctioned pornography for women. And the medium is narrative. And if you're a person for whom narrative is a powerful drug, as it is for me, a story and narrative, a fiction, very potent since I was a child. Then, you know, it was a natural that that would be the thing that I would get addicted to. And basically, just like we've hacked and bioengineered everything to make it more potent. I mean, people. There's a formula for writing romance novels. Like, if you take a physical copy, if you go to a store and you pick up a romance novel, and you literally think you physically open it to 2/3 of the way through you will get to the climactic scene, pun intended. Right. It's like it's engineered. I mean, I got to a point where I wouldn't even read it. Read after I wouldn't finish the book, I would go on to the next.

B (47:11)

Book just to get to the climax part. And then you'd move on.

A (47:14)

Yeah. And I wouldn't even read the denouement or, like, what happens to the characters. I didn't care.

B (47:18)

You didn't care about?

A (47:19)

No. And also I got to a point where I didn't care about the quality of the writing or the depth of the care. It didn't matter. It was the drug. It was that moment I was looking for. And there are a lot of free books on Amazon, some of which are high quality and some of which are not. But like, any good drug dealer knows free samples. That's the way you hook people. I would search for these free samples. And that's part of it, too, like the searching for the drug. So the upfront work you do for the drug is part of the drug. Right. It's all that, the machinations and the hiding and the this and the that, that gets to be part of all of the rituals surrounding it.

B (47:57)

As you were talking as well, I thought about work and work addiction.

A (48:00)

Yes.

B (48:01)

Because earlier you used the term excessive consumption. And when I think about work, even my work, I think, jesus, I excessively consume work. I start so many bloody businesses and invest in so many things. And if you looked at that behavior objectively, if you're like an alien looking down at me, you'd go, this guy's got a fucking problem. Do you know what I mean? Do you think that's funny?

A (48:22)

No, I'm joking. I feel for you. Do you know?

B (48:29)

And it's funny. Cause in society, we then those people are reinforced. We clap.

A (48:33)

That's right.

B (48:34)

We clap. We go, this guy's not sleeping. He's working 18 hours a day. Clap, clap, clap. Give him a trophy, an award. Name a thing after him or her. Or, you know. And it's just really interesting that that addiction of work. And you tell me if it is. It can be an addiction, certainly on the scale of one end being sort of consumption, excessive consumption, and the other end being addiction is on.

A (48:57)

People can get addicted to work. And part of the reason is that we've drugified work, Right? When I say drugified, what do I mean? We've made it more potent. And this is true for all these drugs. We've made them more potent, more novel, more bountiful. Meaning there's more of it and more accessible. So if we break that down with work, how is work more potent? Well, certain types of work are more reinforcing, not all types of work. So for example, works, white collar work is often now associated with stock options and bonuses, right? There's often like a social media aspect to it or maybe even a fame aspect. Or as you pointed out, those are our cultural heroes, right? So you get all this, you know, adulation for being a workaholic. And that also because we're such social creatures, right? And human connections stimulates dopamine, that, that also makes work more of a potent.

B (49:53)

Drug, a personal brand, right? So your LinkedIn. Oh my God, this person got a promotion. We'll all clap, we'll all drop the likes, the comments. You're amazing.

A (50:00)

Congratulations. As you said, the awards, the trophies, and then you've got the fact of novelty. So once we've exposed our brains enough times to a certain drug, as I said, we develop tolerance, right? And then we need more potent forms or novel forms. One of the ways we overcome tolerance is by taking our drug and then changing it slightly, like adding a little new molecule on this chemical, right? Or on the Internet, you know, when we're searching videos, we want something similar to what we liked before, but just a little bit different. And that's what the algorithm does automatically, right? It offers, oh, you should check this out. Oh, how about this? Oh, check that out, right? And that engages our treasure seeking function. We're looking for that novel thing, but that's not too novel, right? It has to be in our category of things we like. And I think for work we have that too. Like, there are so many ways now that people can engage in their work. And it's not all bad that it's novel, but you know, certain types of work, it makes it very enticing. Then you have quantity, right? I mean, work never ends. There's like no natural stopping point for work. You know, you do a line of cocaine, you run out of money, you run out of cocaine, you're done. Done, right? But that's not true for work everywhere, anytime. And then that gets to accessibility. One of the biggest risk factors for addiction to any drug or behavior is simple access. We know that if you grow up in a neighborhood where drugs are sold on a street corner, you're more likely to try them, more likely to get addicted. If you live in a world where you have access to work 24, 7, you're more likely to expose your brain to more work and more likely to get addicted to work again, especially if it's got all those other reinforcing qualities.

B (51:41)

This is probably in part why people quit their jobs.

A (51:46)

You mean if they just get overwhelmed or it's partially why people can never quit. But I think it's important to make a distinction between work that's reinforcing in those ways and then work that's completely not reinforcing. Alienating, mind numbing work in which the actual task is separated from the meaning of a task.

B (52:07)

I mean, they quit their jobs either in search of more dopamine. So if I'm working in a job where, I don't know, maybe it once gave me dopamine and now it's become monotonous in the same, I need to.

A (52:17)

Quit to go find there's novelty for you. That's right. Yeah. And that's true. Many people change jobs every two to three years. I recently read that the average life of a business now is like 15 years, whereas 50 years ago it was 50 years. And there's all this turnover, all this churn chasing novelty. Also, I do want to emphasize that people who are in work, that's not intrinsically rewarding, but is the opposite kind of soul sucking, that's also a risk factor for addiction because people just wait till the end of the day till they can go home and then use a drug to numb themselves from the stress of work.

B (52:56)

So it's plausible that people who are in lower pleasure jobs are more likely to be overweight or addicted or dependent on alcohol.

A (53:04)

Yeah. Or simply opt out of the workforce, as many young men are doing now in the United States. And what we know from data that's been collected is many of them are playing video games. Right. They've just completely opted out of the workforce.

B (53:16)

I guess this in part explains why there's a drinking culture that's associated with people who are potentially lower classes because they're doing potentially less pleasurable work and therefore they, if we think about the scale, that they would then end up in the pub after work, you know.

A (53:40)

Maybe that's partially true, but even people doing, like doctors and lawyers, there are.

B (53:45)

Oh, okay, yeah.

A (53:46)

Equal rates of alcoholism among those groups. I think what's happening there, though, is that the nature of the work is just so stressful, whether it's white collar or blue collar, that there's this kind of work hard, play hard. Right. Where I'm gonna work all day, and at the end of the day I'm gonna reward myself. So now you've got a pleasure Pain, balance. That's going. Pleasure, pain, pleasure, pain. And remember, the biological definition of stress is any deviation from neutrality. So that every time our brain has to work to restore a level balance, we're actually triggering our stress response, triggering our own adrenaline. It's stressful to have to restore the balance from those extremes of pleasure and pain.

B (54:26)

I read in your book you were talking about how different behaviors and sort of chemicals and substances have different impacts. And I was on page 50 of Dopamine Nation. In a study of mice, sex, increases the release of dopamine by 100%. And amphetamines, which is like drugs are right, hardcore drugs, increases it by 1,000%. By this accounting, one hit of a meth pipe is equal to 10 orgasms.

A (54:50)

Yes.

B (54:51)

It's interesting to think about the different behaviors we have and how they'll have a bigger impact on our dopamine. Is there like any, in a typical order of things that are extremely dopamine inducing and things that aren't? What's at the top and bottom of the list? But in your view?

A (55:08)

You know, I really think that it depends on the person. And we've got to look at drug of choice, right? I mean, potent drugs like methamphetamine, like opioids, like alcohol, like nicotine, like cannabis, are going to be very reinforcing for many people, but not for all people. And most people do have their one drug that they sort of prefer above all others. So although generally speaking, intoxicants release a lot of dopamine in the reward pathway, I think every person is gonna be different. And also, we don't really have good ways of measuring absolute values of dopamine in human beings. Right. We can do that in rats, but we can't really do that in humans. It's relative values.

B (55:56)

I've got this picture here which shows what looks like brain scans in a normal person, but then in someone who's addicted to different substances. I'll put this on the screen and I'll link it below in the description for anyone that needs it and wants to see it. But it effectively shows the impact that, like cocaine has on the brain. Meth, alcohol, and heroin. What is going on here?

A (56:18)

So the red in this image represents dopamine transmission. So how much dopamine is being released from the presynaptic neuron, crossing that synaptic binding to receptors on the postsynaptic neuron, how much dopamine is kind of swirling around in the reward pathway part of the brain? And what this image shows is that on the left hand side. In healthy control subjects who do not have addiction, there's plenty of red. Right. So there's plenty of dopamine transmission in the reward pathway, specifically here in the nucleus accumbens. But if you look at the right hand column, you'll see that in these individuals who have been using cocaine, methamphetamine, alcohol and heroin in addictive ways, there's almost no red, which means there's decreased or below normal levels of dopamine transmission. They are in a chronic dopamine deficit state. This is evidence of the brain trying to compensate for too much dopamine being triggered by down regulating its own dopamine production and transmission, not just to baseline, but below baseline. And importantly, these individuals who are addicted to these substances, these brain scans were done two weeks after they stopped using.

B (57:44)

Oh, wow.

A (57:45)

Yeah. Which tells us that this dopamine deficit state persists. Persists for some period of time.

B (57:53)

For how long?

A (57:54)

Well, it depends on the person. But we know, at least from this experiment that the first two weeks are this persistent dopamine deficit state, which is consistent with acute withdrawal. Right. People feel, when they first stop their drug of choice, they feel terrible. Right. They experience all of the symptoms of physical withdrawal that correspond with that particular drug they were using, usually the opposite of what the drug did, plus the universal symptoms of withdrawal from any addictive substance or behavior. Anxiety, irritability, insomnia, depression and craving. Now, if they can get through the first 10 to 14 days, what we see clinically is those acute withdrawal symptoms slowly start to get better. And we think that that is mapping onto regenerating dopamine transmission in the reward pathway. And if they can make it to a month, that's usually the point for, on average, based on clinical experience, when people really can start to get out of that constant state of craving for their drug of choice and begin to see some light at the end of the tunnel for what their lives might look like if they can maintain abstinence from their drug.

B (59:07)

And we can't just inject or drink dopamine. I mean, I guess that would be like drinking alcohol. We can't just artificially mess with the balances to try and restore the dopamine levels in an addict. Can we can't just add a little bit of dopamine?

A (59:19)

Yeah, it's a great question because we have some natural experiments that suggest what might happen if we do that. So as I mentioned before, people with Parkinson's have depletion of dopamine in the substantia nigra. That's what causes that motor disease. The treatment for it is to give L dopa, which is a dopamine precursor. If I were to give you a spoonful of dopamine, it would do absolutely nothing because it doesn't cross into the brain, it doesn't cross the blood brain barrier. But I could give you L dopa, which is a precursor chemical that would cross your blood brain barrier and get turned into dopamine, and then diffusely bind dopamine receptors in your brain in the reward pathway, but also in the movement pathways. When we give patients with Parkinson's dopamine in this form, that can temporarily improve their movements. But in about one in four Parkinson's patients, they will develop a de novo addictive disorder. Shopping addiction, sex addiction, other types of addiction, because we have the same problem. We are stimulating the reward pathway with dopamine that is ingested exogenously from the outside. And our brain reads that as, oh boy, gotta compensate by downregulating dopamine transmission to below baseline, which then puts us in that addiction vortex. Does that make sense?

B (60:47)

It does. So we have to, I mean, it tells me that we have to live lives in a certain sense of. We have to live our lives in a certain sort of homeostasis. And it's so easy not to in the world we live in. It's like impossible to live in a perfect homostasis balance in the world we live in, right?

A (61:08)

Even more than having to try to live within this sort of narrow range of homeostasis in the world we live in today, we probably have to intentionally do things that are painful, do things that are hard. Pleasure, pain, balance. Like we learned that when we press on the pleasure side of the balance, like with alcohol or pornography or romance novels or cannabis or whatever it is, right? No sooner does that happen than our brain adapts by those neuroadaptation gremlins hopping on the pain side of the balance to bring it level again. But they like it on the balance, so they don't get off right when it's level. They stay on until we're tilted an equal and opposite amount to the side of pain. That's the come down, the hangover, et cetera. But it turns out the opposite is also true. If we intentionally press on the pain side of the balance, for example, with exercise or an ice cold water bath or intermittent fasting, those gremlins will hop on the pleasure side of the balance and we will get our dopamine indirectly by paying for it up front. And there are studies in humans Showing that when humans expose themselves to exercise, for example, dopamine levels gradually rise over the latter half of the exercise. And then when the exercise stops, dopamine levels will remain elevated for hours afterwards before going back down to the baseline level position without ever going into that dopamine deficit state. So it's a great way to get our dopamine in directly because it's much less vulnerable to that compulsive craving phenomenon of overuse.

B (62:45)

So you're not going to get an exercise come down.

A (62:48)

You can. And people can get addicted to exercise. Right. But typically it's very unusual because the upfront cost to do the work and endure the pain of exercise in the first place mitigates our vulnerability to an exercise addiction and in general.

B (63:08)

Ah, okay. Because it's so hard to do that. It's gonna be hard. It's not like pulling a lever on a slot machine or clicking on a porn website is difficult.

A (63:16)

Yes.

B (63:16)

Okay. So fighting for the dopamine insulates us against the chance of an addiction having to really fight hard for it. Okay.

A (63:25)

Yeah.

B (63:26)

And this kind of explains, I guess, in part, why I pulled out some stats ahead of our conversation today, that from 1996 to 2008, participation in ultramarathons has increased by 1,676%. The ice bath market is expected to rise from 350 million in 2024 to nearly half a billion by 2030. The number of people taking part in obstacle course races like Tough Mudder or Hyrox etc, etc has increased by almost 7x from 2010 to 2017. It seems like in society there's this counter movement towards people seeking out hard dopamine. Chasing pain.

A (64:08)

Yeah, those are amazing. I didn't know that. Those are amazing numbers. You know, in general, there's a part of me that wants to say, well, that's a good thing. But there's another part of me that's wary also, because we're so good at drugifying everything that we do, that there's a way in which these types of behaviors can also be druggified. Right. Made more potent with all of the technology, the way that we count ourselves, the leaderboards, the social comparisons, all of that takes this thing which. Which is really in its natural state, kind of impervious to addiction. Like, you just typically wouldn't get addicted to these types of painful physical activities. You would do what you needed to do for survival. But we've managed to make them addictive in all these different ways. I still think it's a better way to get your dopamine. Like, I really encourage exercise. We always talk about movement as medicine. And in general, our life is so convenient, so easy, so passive, so sedentary that I'm telling patients all the time, you know, get up off the couch, move your body, walk around the block. I think that's the bigger obstacle right now is just getting people to move. But I do think we need to be wary of not going too far in the direction of like the ultra, ultra, ultra, whatever it is.

B (65:25)

So what is a better way to live? If we're trying to optimize for happiness and to keep our dopamine in balance and not have the crashes, et cetera, and come downs and hangover, what is a optimal way to live our lives? Do we have to look back at our caveman ancestors and live like them?

A (65:40)

I think that part of the problem is that we've organized our lives now around rewards. Almost everything that we do is predicated on the feel good moment we'll have at the end of it. And because of that, we are missing out on the process. We're projecting our psyche forward into the future toward the reward and not able to really be here in the moment. Okay, this is gonna sound weird. I'm gonna give you a weird example. So driving over here today, I found I was nervous for this interview and in a way, looking forward to it, but in a way wanting it to be over, right? And in seeing that in myself, I thought, that's so sad like that. That's so sad that we live our lives that way. Myself included. Always this weird blend of wanting whatever we're doing to be over so that in a way we can just go hide and do whatever that self stim thing is that we do where we're safe and we're like, you know, stimulating ourselves in some way. And then I thought, well, what if I knew that I was gonna die right after this is. I'm gonna go off really weird now, but what if I knew that I was actually gonna die right after our conversation today? That totally changes my perspective, doesn't it? Because this time, you and I have. That's all I got. It's over for me when this. So this conversation is it. I really better be right here right now and really taking joy in whatever you and I can find together. And I think the more we can do that, the better.

B (67:19)

What's happening there? You're removing the thought of the outcome, the reward, the potential, you know, failure or whatever. And you're focusing on just being present and in Doing. So what is happening?

A (67:30)

It's a great question. And I've actually given this quite a lot of thought because I remember when I was in college and I, you know, met some, like, Zen people, and they were like, be here now. Be here now. And I thought, well, whenever I'm here now, I'm miserable. Like, I, I, I don't like me, and I don't like being in the world. I don't want to be here now. I want to be somewhere else. So I didn't really understand what they were getting at. It really took me, you know, till I had lived quite a lot of life and had some, you know, some significant experiences and given it some thought that I realized, oh, be here now means be here now and be uncomfortable and be okay with being uncomfortable and being okay with not being able to control my pleasure or my pain or my comfort level, but just being open to whatever comes. And I think that's a really a key shift that I'm not trying to control my experience in the moment and that it's okay to be unhappy or restless or uncomfortable and not trying to run away from that, but just really turn and face it and embrace the discomfort, which I also think is quite universal. I don't think I'm alone in that. And then the key piece about not anticipating the reward helps me be in the moment, right. Because I'm not just waiting for the good thing to come after. I'm saying to myself, imagine there's nothing good coming after, nothing at all. Right? There's just, there aren't rewards. This is it. And then also being able to say, and it's okay if in the moment, like, it's not great, like, I can embrace that, you know, I can be unhappy or restless or anxious or whatever it is. And then when I do that, you know, I feel like there's a funny, funny thing that happens, and all of a sudden I'm not as anxious, right. And I am present, and there is some joy there.

B (69:35)

Interesting. So when you allow yourself to deal with being uncomfortable in the moment, and it turns out it removes the thing that was making you uncomfortable in the moment, which is like the avoidance or the worry or overthinking whatever else.

A (69:49)

Yeah. I think we have this, and it's fed by modern culture, this kind of expectancy that really we should be happy all the time, and that if, you know, if we've arranged things appropriately for our lives and if we've done our work and aimed true, then we should just be like, life is great and I don't believe that anymore. I think that, you know, I mean, like Buddha said, life is suffering, but I really think that fundamentally, like, it's uncomfortable to be alive and that it's a kind of a constant state of restlessness and discomfort. If we're being really honest and tuning in. When I really let myself see that and feel that, all of a sudden I'm freed from some of that.

B (70:41)

What has caused you anxiety throughout your life in the moment you referenced earlier, that some things have happened that have led you to understand this better and understand yourself better. What am I missing from this jigsaw puzzle?

A (70:53)

Yeah, well, you're good. You could have been a psychiatrist.

B (70:57)

It's always time.

A (70:58)

This doesn't work out. There's still time, right? It's not too late. He's got a new profession. Yay. I think, you know, for me, the big turning point was that we lost our. We lost a child. And in the immediate aftermath of our child's death, I was just determined to, like, sort of undo the experience and, you know, get enough psychotherapy and enough whatever it took to sort of not feel that pain. And it wasn't until I really just said, oh, like, I'm gonna feel this pain for the rest of my life. It's never going away, that suddenly I felt some relief from that pain. And that was a real window for me.

B (71:45)

So interesting that it's acceptance.

A (71:52)

Yeah. And I think one of the reasons I love treating patients with addiction is because I really relate to that hitting bottom moment. You know, that moment when it's like you just have the feeling that, like, everything I try to do to manage this behavior or to make my life better only makes it worse. I felt like I had a very similar experience and that it was only when I kind of realized, oh, I. Yeah, I can't run from this. I cannot run this pain. That I begin to have some. The beginnings of relief from that experience.

B (72:33)

I can't outrun this pain. It's our natural sort of disposition to try and outrun pain, isn't it?

A (72:40)

That's the irony, Right? We're really wired to outrun the pain. We are like, we reflexively seek out pleasure and avoid pain. And yet that's the very thing. Thing that doesn't get us to where we want to go, but we do.

B (72:52)

Now live in a world where it's very easy to outrun the pain.

A (72:56)

Yes.

B (72:57)

This is not a lion that's chasing me. This could be a bad email. And then I open up a tab and start doom scrolling or open up a tab and start watching video, playing video games or pornography or whatever.

A (73:08)

Yeah, that's exactly right. There are so many ways that we can now distract ourselves from our own suffering or our own awareness.

B (73:17)

And where do you find yourself now with dealing with that grief and the pain as we sit here?

A (73:22)

Yeah, I mean, I feel like in many ways it's been a real gift in my life. You know, it's really informed my life in ways that, I mean, I've learned things from that experience that I think it would have been almost impossible for me to learn otherwise.

B (73:40)

You deal with a lot of people that are, are in a state of suffering. I imagine that's a weight because I even hearing the story of the lady that passed away after that water addiction, it was like a weight on my shoulders just to hear it. So if your profession puts you right at the heart of this type of suffering, how do you manage that to hold that weight?

A (74:09)

A couple things. First of all, a lot of people get better. And when people with addiction get better, it's so much better that it's incredibly rewarding to see. And they're amazing people, like some of the most tenacious, talented people you'll ever meet. And when they get better, it impacts so many other people, right? Their friends, their family, the people they work with, with. So it's very rewarding work and not at all burdensome. Of course, you know, for patients who don't. Don't get better or patients who die, it's a terrible feeling. And there is a sense of responsibility and guilt. Even when I feel like there was nothing that I could have done otherwise, you know, I carry those losses with me. So it's hard.

B (74:58)

Is there any particular cases that. That have stayed with you the most?

A (75:02)

I mean, every patient I've had who's died while under my care, those are incredibly painful. And I will never, you know, those are sort of a. Those people will be with me as a part of me for all of my life.

B (75:19)

Young and old.

A (75:19)

Yeah. Young and old. Yeah. It's especially tragic to lose young people. And it always feels like they're second guessing, like, oh, if only I had done that, or if only we had intervened here. But I just think that's the nature of death. We can't get away from the feelings of guilt around it, no matter who we are and no matter the circumstances.

B (75:40)

How young can addiction and the consequences of addiction ruin someone's life? Like, how young can someone be when their life is ruined from the work you've done and the Patients you've worked with. And what are those addictions typically that seem to be most susceptible to those that are young?

A (75:59)

Well, I mean, you know, some. Some kids start with drugs and alcohol, you know, 5, 6, 7, 8.

B (76:07)

Only 5, 6.

A (76:08)

Oh, yeah. I mean, it's. You know, some kids use with their parents or their caregivers. They're exposed very early. If we seriously conceptualize digital media as a drug, I mean, then we've got. Got even younger cohorts starting with that. And we do know that kids can get addicted to digital media and as a result, die from that. I mean, there was just this tragic case of a young man who essentially got addicted to a chat box. I think he was 14, not my patient. It was written up in the New York times and the Wall street journal. And he fell in love with this chat box, started to isolate, wasn't spending time with his family or friends, and then eventually took his own life pur. So he could join this imaginary person.

B (76:58)

What's the youngest patient you've ever seen?

A (77:00)

The youngest I've seen is probably around 15, 14, 15.

B (77:04)

And they had an addiction?

A (77:06)

Yeah, usually cannabis, alcohol, nicotine.

B (77:09)

Can you get addicted to cannabis?

A (77:11)

Oh, yeah. Oh, my gosh. Cannabis is very addictive.

B (77:15)

Really?

A (77:16)

Oh, yeah, yeah.

B (77:19)

Harmful.

A (77:20)

Very harmful. The target organ that it damages the most is the brain. It's harmful in many ways. I mean, number one, it demotivates people often. And so they can have the feeling that they're getting stuff done or that they're creative when in fact, they're not doing anything. Most people smoke it, and so it can be damaging to the lungs and other organs. A lot of people say that, well, cannabis isn't addictive because I don't have this standard withdrawal phenomenon when I stop. Like, I don't have the shakes or anything like that. But keep in mind, the universal symptoms of addiction are psychological symptoms. Anxiety, irritability, depression, insomnia, craving. And people have that in spades when they try to stop using cannabis. Plus, we often see something called the hyperemesis syndrome. So. So cannabis can help with nausea and vomiting. It can help decrease the feeling of wanting to vomit. But again, as the brain continues to be exposed to it, there's this process of neuroadaptation. It stops working, and it can even turn on them and do the opposite. So eventually, people can actually have a cyclical vomiting syndrome as a result of cannabis. So they'll show up in the emergency room and say, I can't. I can't stop vomiting. And the reason is because of the cannabis that they maybe initially started to stop feelings of nausea.

B (78:48)

On page 40 of Dopamine Nation, you say we've lost the ability to tolerate even minor forms of discomfort. And as I was reading through this section of your book, I was thinking, it sounds like we've gone a little bit soft in society. We've reset our pleasure pain thresholds to the side of pain, that even the slightest thing feels like trauma to us. Even things that, objectively speaking, a generation or two ago would not have been considered traumatic are now trauma. We live in a bit of a trauma society, one that doesn't appear to be very resilient. And the only measure of that that I have is if I think about the work that my grandfather had to do versus the work that, you know, people maybe in my generation do and complain about and seem to be, like, objectively suffering over and stressed about. It seems like there's been a shift in. In our threshold, our tolerance levels. Can this be explained through dopamine? What's going on here? And do you believe that's true? Have we gone a bit soft?

A (79:41)

I would say succinctly, yes, I do believe we have gone a bit soft. But I don't think it's a moral problem or a character problem. I actually think it's a physiological problem based on the fact that we're insulated from pain and we're exposed to all kinds of pleasures. So I really think that we have individually and collectively reset our reward pathways to the side of pain, meaning that the gremlins have now accumulated on the pain side. We've tipped ourselves to the side of.

B (80:07)

Pain because we've had so much pleasure.

A (80:09)

Because we've had so much pleasure. Yes, thanks for having me clarify. So that now we need more and more pleasure to feel any pleasure at all. And the slightest little pain, and we're experiencing excruciating pain. You add to that the fact that we have a culture that tells us we should never be in pain, and that if we are, something's wrong with our life or something's wrong with our wife or something's wrong with our job. And so now you've got, you know, a whole generation of folks who feels like they're experiencing more pain because they're literally don't. Do not have the mental calluses to tolerate pain. And now they're being told, and if you have any pain at all, you must have, you know, something wrong with your brain. Go see a doctor, go take a pill. And I think this is really. This is not A direction we want to keep going in.

B (80:57)

We have a mental health culture where we assume most things are a mental health illness. In page 186 of your book, you say, I've become convinced that the way we tell our personal stories is a marker and predictor of mental health. Now, if you live in a society where everything has a label and it's a. It's a disease or an illness or, you know, I. I don't feel good today, so I've got this disorder, and therefore I need this medication. I guess there's two questions. Is my assessment of the situation correct? And B, is this a bad place to be in a society where we think everything, every feeling we have, every, you know, we think everything that makes us different is a deficiency?

A (81:37)

Let me. Let me start. Let me. Let me answer this by talking a little bit about the role of language and narrative, because I think this is very fascinating. And, you know, as a psychiatrist and a therapist, that is my bread and butter, right? Is narrative how people tell their stories? By giving language to our experience, we gain awareness of our conceptual models of the world. And what I have learned over time is that the way people tell their stories is a window into their model of the world, and that there are healthy narratives and not so healthy narratives. And in general, in my clinical experience, when people come into the room and they tell their life story in such a way that they're always the victim of other people and circumstance in the world, those are people who are, number one, not doing well and number two, not going to do well going forward unless they change that narrative to acknowledge what they've contributed to the problem. And the reason for that is because the way that we narrate our lives is not just a way to understand our past. It actually is our roadmap for the future. So if I see myself as a victim, and that's my narrative, I will literally create victimhood for myself going forward. I will literally change my sensed experience so that whatever happens, I'll make sure I end up as a victim. When people with severe addiction get into recovery, one of the most palpable changes that I see is the way that they narrate their lives. They go from in addiction talking about their lives as if it's always everybody else's fault to in recovery, talking about their lives in a way that says, oh, you know what? I could have done better here, or, you know what? That's something that I keep doing that really messes with my life that I want to change. And I'm Going to figure out how to change that.

B (83:48)

Why is it so hard to take responsibility in such a way?

A (83:50)

Great question. We just hate to do it because when we do it, we feel shame. And shame is an incredibly painful emotion. It's like a gut punch of an emotion that is associated with fear of abandonment, fear of being shunned by our tribe. We'd much rather paper that shame over with anger and resentment toward others.

B (84:11)

It's interesting cause there'll be different groups of people listening to this now. There'll be the high responsibility group that just love and revel in taking responsibility. Cause they think taking responsibility means that they are strong. It means that I'm so strong I can take the blame and withstand it. And it's funny, cause the more I've learned to take responsibility for things in certain areas of my life, the more I've become proud of myself and the more I think I'm strong and I'm like, oh, look at me, I can take responsibility for anything. And then if you go down this spectrum, you'll eventually get to the end of the spectrum where you've got people who even as they heard you say that, will feel cognitive dissonance. They'll feel a sense like a little. It'll irritate them, it'll piss them off. And they will be the whataboutery gang. They'll be saying, yes, but what about Dave? He did this to me. And you know, like the immediate reaction would be they're pissed off. They've probably gone now. They've gone. So we're not even talking to them anymore. But if you say but it's fine, we can talk about them. They're no longer here.

A (85:08)

Right.

B (85:08)

But that group of people. My question really is, how do you speak to that group of people and convince them that actually taking personal responsibility is a good thing for them. And if they're focused on what their core values or their North Star is in their life, then personal responsibility is the path there. Not blame, not victimhood. You know, like, how do you turn those people around?

A (85:27)

Great question. And I have to say, say what I know about this I learned from Alcoholics Anonymous and what they do because they do something that's really incredible. First of all, it's necessary to validate somebody's victimhood. So this is to say you have been wrong. If they really have been wronged to validate that, or you experienced this trauma or you were born into this crappy situation and you were just a kid and you had known choice about that. And to really acknowledge that. But then the fourth step of the 12 steps of alcoholics Anonymous talks about looking at each of those situations and after writing down like this person wronged me and exactly what they did. So, you know, taking time to focus on the resentment, right? Then only after that to say, okay, but is there anything that I did that contributed to that problem? Is there anything at all that I could have done differently? And for a little kid, you know, born into a horrific situation, there's not much. Right. That a kid could have. You know, we don't expect a child to take responsibility, but the adult who was that child who continues to perpetuate some of the harms they experience on other people. Now we're talking. Now you can begin to take responsibility for your actions in the world. So I think starting with validating the trauma or the victimhood or the way in which we were wronged, processing it, so giving it airtime, right. But not stopping there, which is by the way, which is by the way, often in, in therapy, certain types of therapy, that's often where we stop, we don't then take it that very important next step and say, but you know, let's go and look at that again and like, is there anything at all that you're contributing to this problem? Maybe it's just that you continue to ruminate about it, right? That like you're ruminating on your resentments is in a way your happy place. And maybe that's what you need to stop.

B (87:46)

So that form of sort of psychotherapy that stops there can help keep us sick and make us sick. It's interesting because someone that's in that therapy room who has ruminated themselves all the way down to having a low self esteem, being depressed or whatever, it appears to me that people who are at that sort of ground floor state find it hardest to take responsibility for some reason. Just that's an observation in my life that the people that I have met that are the worst still that struggle the most with taking responsibility are those that have a very low self esteem. So it's almost this double edged, like catch 22. And then I've also pondered whether, you know, someone that never takes responsibility is more likely to have bad things happen to them, make mistakes which are then going to further hurt their self esteem, which are going to make it even harder to take responsibility. So I guess the question is, is there a relationship between my current self esteem and my ability or inability to take responsibility for a situation?

A (88:43)

Yeah, great, great question. It brings to mind a patient of mine who Said to me that, you know, that. And he had very, very low self esteem. And he said, essentially, Dr. Lemke, I'm the piece of crap around which the universe revolves. Meaning that he had his own brand of narcissism in which he wasn't the most successful person, he was the most successful at being the least successful person. And that became his identity. Right. That was sort of how he saw himself and also how he saw the world. And it became very entrenched and it was a kind of a narcissism because he created then situations in order to perpetuate, like, I'm the worst of the worst. So I think the ways in which we get these sort of entrenched ideas about ourselves and the world can really hold us back from seeing clearly who we are, who other people are and what the possibilities are.

B (89:52)

Does our personal narrative need to be positive?

A (89:54)

I mean, I guess. Well, what do you mean by positive? Like, rah, rah, I'm great.

B (89:58)

Almost like have a positive ending. Because I was thinking about the personal narrative I've created in my life. And my personal narrative is like, kid born in Africa, came to the uk, little bit of racial abuse here and there felt different. Shame, insecurity, parents weren't around, this made me independent, shame made me motivated. And then I did this, this, this, and it went well. That was like my personal narrative. But if my personal narrative was moved to Plymouth from Botswana in Africa, little bit of shame, little bit of pain, parents weren't around, my parents didn't love me, people don't love me.

A (90:29)

Right, Right.

B (90:30)

If my personal narrative ended there, would it be, you know, would it be detrimental to me ever becoming successful, happy, healthy? I'm just wondering if. Cause we all have a personal narrative. We have like a story. If we're up on stage and someone passes a mic to us and says, tell us your story, we'll narrate this version of events skewed towards victimhood, to heroism, to, you know.

A (90:51)

Yeah. I mean, as I said before, how we narrate our lives is important. Right. It's not trivial. And. And there are healthier narratives and there are not healthy narratives. And I would argue that the victim narrative where. Perpetuates victimhood, you could make the same argument that the hero's journey narrative perpetuates herohood. Having said that, if we get too stuck in any fixed identity or any narrative, I think that can become its own trap. Right. And then we wall ourselves off feeling like we have to show up in a certain way or be a Certain person. And I wonder if you have that experience. Like, I know you have this hero's journey, and now you gotta be this hero. And, I mean, I can imagine that that would be burdensome at times. Yeah.

B (91:38)

I think it causes a lot of, like, dissonance internally. What I mean, like, so when I say dissonance, I mean discomfort internally because people meet a version of you that doesn't reflect the version of you that you know. So, like, the experience you have when you go, like, I go to the gym or something.

A (91:52)

Yes.

B (91:53)

And I say this to my team all the time. Anyone that knows me personally has heard me this 50 times. I will say the phrase, I just don't understand what these people are talking about. Like, I just don't get it. And I said to my team the other day in the office, I went. It's almost like I think they're lying to me. And I said, I was in this meet and greet.

A (92:08)

When you say you don't understand, you mean when they praise you or. Okay, yeah, yeah, yeah.

B (92:13)

It's so unbelievable what they're saying to.

A (92:16)

Me.

B (92:19)

That it feels like you're. I've not even watched the Truman Show. I just know what it means. But it feels like these people are just all lying to you.

A (92:27)

Yeah.

B (92:28)

And I think I was talking to Jack and the team the other day about going to Thailand and being so far away from home and people coming up to you, like, thousands of people. We're doing this meet and greet thing and saying these things to you. And I said to the team, I was like, I think it's part of my brain that's like, these people are lying to me. And also. Yeah, you can see how it can be a slippery slope to slide in to their narrative of you.

A (92:51)

Right.

B (92:51)

And you've got to do quite a lot to just, like, stay at home. What I mean by stay at home, I don't mean, like, physical location. I mean, like, staying grounded in, like, who you actually are.

A (93:00)

Right.

B (93:01)

And this goes for people that obviously, you know, have a public platform or don't. It's very easy for one person on the Internet to say something to you and then to you to start to accept that as your narrative. It's easy for your parents to tell you that you should be a doctor, and then you go to university and you study to be a doctor and you become a doctor, and then you start thinking you're a doctor and how that can sway you away from the full array of things that make you who you are. The music, you know, Whatever hobbies you had. Narratives are comfortable. Sometimes they make us feel heard and understood, they make us fit. But they also are a double edged sword because they can take us away from who we actually are.

A (93:40)

Yes. Yeah. So when I think about your experience of feeling like people must be lying to you, I mean, sometimes we call this something like the imposter syndrome, where you feel like.

B (93:51)

I've never thought of it like that.

A (93:53)

You know, a projected. Yeah, projected personal Persona that is, you know, true in a way, but also doesn't capture the fullness of who you are, or maybe is so extreme in terms of looking good that it's inevitable that you'll feel some dissonance with that kind of heroic figure. And I think the way to think about that and also not become cynically suspicious of people who praise you when they meet you is just to recognize that you have become a kind of cipher or a vehicle for their projections. So they've listened to you, they've had a very positive experience, or maybe they learned something and it meant a lot in their lives and you were the vehicle for that. And so you're a symbol for them. And they're projecting positive feelings onto you because you're now integrated in their mental tapestry as kind of a, you know, a totemic figure or a token, something important and symbolic.

B (94:56)

That's interesting. Cause part of what you. Just as you were talking, I was thinking, do you know what's interesting? I don't even. I'm not even the smart one in this. I'm interviewing these smart people. No, no, the smart people are changing their lives. And then someone comes up to me.

A (95:09)

In Thailand and says, well, you're wrong about that. That. So you're obviously really smart. And you also have, you know, a really high emotion quotient. Right. Which is its own kind of underappreciated smarts where you read people really well and you have intuitive reasoning and I mean, I don't know you, but you also seem very humble and real. And so all of these things that people have a craving for, you know, authenticity, someone they can relate to, someone familiar. I mean, keep in mind too that more and more people live alone and have maybe fewer close contacts. So a person like you, with a regular show that they tune into regularly, you become. You're in their living room. Yeah. You're not just some distant celebrity like you are. Your voice is there, your face is there. They feel they know you because they've seen you in all these different situations. And I think that's really natural and normal and not a bad thing. So you just have to realize when you go out into the world, you know, you become a symbol for people they're projecting onto you. You don't have to necessarily identify with that, but it's okay to let them have, you know, their experience through you, if that makes any sense.

B (96:28)

It makes a lot of sense.

A (96:29)

Okay.

B (96:29)

Yeah, that makes a lot of sense. I felt the same. Imposter syndrome. As you said everything there, I was like, that's very kind of you to say, but it's just very. I think part of the dissonance comes from the fact that I sit here in a room with you and there's only. The person in this whole room, we're in this big studio here in Los Angeles, is Jack.

A (96:44)

Yeah.

B (96:45)

And so there's part of your brain, the like prehistoric brain that thinks the three people that are aware of what happened in this room are me, you and Jack. That's it.

A (96:52)

Yeah.

B (96:53)

And then you walk, you go to Kuwait.

A (96:55)

Right.

B (96:56)

And it comes up.

A (96:57)

It's pretty amazing.

B (96:57)

And a kid comes up in the gym and goes, that conversation that you have about addiction and that's the dissonance. Like you weren't there. But I don't know, the prehistoric brain might not be able to fully comprehend the idea of cameras and numbers. People are listening at the moment.

A (97:11)

Oh, no. They feel that they're there. And again, the guests are totally secondary because they're watching, because they're identifying with you. And the questions that you ask, as you yourself said, are questions that you anticipate they would want to ask. Right. You said said that. So you are also channeling them when.

B (97:32)

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A (98:50)

Yes, well, you know, there's this whole sort of area of the addiction field called codependency. And codependency refers to the ways in which a loved one of the addicted person can actually enable or make their addiction worse without realizing it and without intending to. And the way that essentially happens is that we can. Well, number one, addiction is very often a family systems problem. So the person who gets addicted, their addiction affects everybody in the family. And in order to cope and compensate, the families can end up in these very strange maladaptive places. But they often have difficulty seeing how to get out of those situations or how their behavior is harming their addicted loved one. Because in a sense, they themselves get addicted to the addicted person and then use that addicted person to regulate the way that they feel. So, for example, I treat a lot of families where like, the adult child is deep in their addiction. The parents know that the money they're giving the child is mostly going to drugs and yet cannot bring themselves to stop giving the money. And often they're manipulated by the child. The child saying, well, the adult child saying something like, well, if you don't give me money for drugs, I'm going to go get it off the streets. It's gonna be laced with fentanyl and then I'm gonna die and it's gonna be on your hands. So this kind of like emotional hostage taking. But even when it's not that blatant, what can happen is just this very fascinating, very twisted, enmeshed relationship between the addicted person and the codependent person. Where again, having the person engage in their addiction in a way is a predictable scenario for the codependent person. So even though they may say on the face of it they want this person to stop their addiction, on another level, they really don't. They get to be the martyr, they get to be the savior, or they even just get to predict what that person is doing based on their use.

B (100:59)

I'VE had experiences in my life, and this is why I really wanted to ask this question where I thought I was helping someone, and then the minute I withdrew the help and basically completely gave up, the person got better.

A (101:11)

Yes.

B (101:11)

But for six, seven, eight years, this person struggled. And the minute I stopped helping, they got better. So I said to my partner before, when I was talking about this, I was like, it's possible to prop someone up in their compulsive behavior and not realize you're doing it. In fact, there's three examples which me and my friends are aware of. And one of my friends talks openly about this where. Where I was propping him up, I was letting him stay at my house. I was providing for him while he was in his struggles. The minute I had a difficult conversation with him when he was, I think I was 25 years old and he was 30, and I said, you gotta go, you gotta go. You gotta get out now.

A (101:46)

Get outta here.

B (101:46)

He went back, moved in with his parents in his childhood room. He built up his whole life again. He's out of the compulsive behaviors. He's very successful, very rich, living abroad now. And I was like, God, if I hadn't have pushed him out my basement, he probably would still be there. I thought I was doing him a favor. And there's another really pertinent example to me quite recently where someone who I've known for many, many, many years, minute I said to them, listen, and this sounds really harsh, right? Because I tried paying for their therapy, tried paying for everything for this person. And eventually I got to the point where I said, honestly, I've tried. Don't talk to me about this anymore. Yeah, stop talking to me about it.

A (102:21)

I'm done.

B (102:22)

Just don't message me about it. Don't talk to me about it anymore. They got.

A (102:24)

Yep. Yeah, it's really fascinating. So Kai Erickson wrote this book on deviance where he studied puritan societies and found that no matter what group of humans you looked at, there were always going to be people who were on the margins of the society. He used the word deviance. His point being that groups of humans, we just have these roles and we have these hierarchies, and there's always somebody on top and always somebody below. And when we're occupying a certain niche or when we stop occupying it, we make room for somebody else. So when you stop being the hero and the savior, that person had room to stop being the sick victim.

B (103:10)

Interesting.

A (103:11)

Yeah.

B (103:12)

And my last question on this then is, how do you Approach that conversation with that person because so often it's approached through frustration or shame or blame. What's the best way to approach someone who's struggling with a behavior? To express that you're concerned and to, I don't know, offer your help if that's a good thing?

A (103:28)

I think we can always try to find our empathy for them without necessarily doing things that would perpetuate or enable that behavior. And we need to recognize that for many people with severe addiction, the only thing that will get them into recovery is real life consequences. Consequences, real life negative consequences. And that our trying to protect them from that is not protecting them at all.

B (103:58)

We've got to let them hit the rock bottom.

A (104:00)

I mean, this is a hard one because you have a lot of families now dealing with children who are severely addicted to opioids for whom being out on the streets might really result in their death. So this is not for every situation. But I can tell you in my clinical experience, after 25 plus years, the majority of people with severe addiction who get into recovery get into recovery as the result of a real life negative consequences. Lost their job, lost their partner, ended up in jail, whatever it was. Until there are those significant consequences for some people, they just won't be able to have the motivation to make a change.

B (104:42)

Goes back to a quote I heard a long time ago, some 10 years ago that's said change happens when the pain of staying the same becomes greater than the pain of making a change.

A (104:50)

There you go, That's a good one.

B (104:52)

I want to talk about digital drugs, one of the subjects that's been a recurring theme on this podcast. Inspired initially, I think it was mentioned in an episode we had. But then it was such a huge amount of the feedback we got in the comments section that I thought we need to talk about this more because clearly there's a lot of people suffering. We also then used a tool which looks at what people are googling and searching a lot. And one of the most popular searches around the subject matter of addiction is pornography. Pornography addiction? Yeah, it's actually, it was number number one and four in the, the search tool that we used. And the phrases people are using are how to stop pornography addiction, how to help someone with pornography addiction, how to rewire my brain, which is sort of all sort of correlated themes. So pornography addiction, something you see a lot.

A (105:36)

Oh my gosh.

B (105:37)

I have to create a little bit of a space actually before I ask this question because I did a porn debate on the show and I, I got a very long voice Note from a good friend of mine who said, just watched the porn debate. There was two women there and a guy and me, Steven. But I just wish someone had mentioned that women get addicted to porn too. And then on the episode, one of the top 3 comments on the episode is, I'm a woman. It wasn't mentioned, but I also have a pornography addiction. And you've also kind of echoed that with the erotic novels that you mentioned, the romantic novels. So pornography addiction, do you see that often? And I guess critically, how does one go about overcoming that? And how do you know it's a pornography addiction? I guess it goes back to the point of harm, but yeah.

A (106:20)

Yes. Yeah. So I do think that pornography addiction is one of the biggest addictions and the most silent and the most shameful addictions that we have now in the modern world. We will not infrequently have a patient come in to the clinic who claims to have other problems. And it's not until visit three or four that they finally fess up. I'm really here for a pornography addiction. There's so much shame around it. It's so incredibly shameful for people to admit that they are spending their time looking at these images often associated with compulsive masturbation. Some people, their addiction manifests by actually pursuing partners. So dating apps are highly addictive. And meetups. All of this is related to sex and orgasm, which releases dopamine in the reward pathway. But it's not just the moment of orgasm. It's all of the rituals and the buildup and the searching that's related to it. Women can get addicted to pornography as well as men, although I would say that men outnumber women in my clinical experience, I don't know, 10 to 1. Women, however, are much more vulnerable to love addiction, which is also real, right? The pathological compulsive, falling in love with partners and then getting into these relationships that are really dramatic and not healthy and then falling out of love and then. And then pursuing another love partner. So these addictions are real. They are very harmful for people who get addicted. Ultimately, they're not even about sex. They're about human attachment and the desire for human attachment and also just as a way to self soothe and escape our own everyday suffering. And I'm particularly concerned about girls and boys who now have access to all kinds of sexual images that would not have been possible for them to get access to a generation or two ago. And now, you know, a child of five with an iPad can accidentally end up on a Site that has very graphic sexual images and videos.

B (108:43)

So what's the harm of pornography, watching pornography?

A (108:48)

Well, there's a lot of potential harms. One of the harms, especially if combined with compulsive masturbation, is that it's just simply addictive, which means that the more people do it, the more they want to do it. Then they have the comedown where they don't feel good, and then pretty soon it becomes a compulsive, repetitive loop where they're spending large amounts of their day engaging in this activity. And that in itself, itself is highly debilitating. But other harms I think that are significant are it really does change a person's conceptualization of what sex is and what sex is for. And I don't want to get into the whole thing of, like, you know, sex is exercise or sex is recreational fun compared with sex, you know, as something that's maybe more sacred. Because I'm not here to judge any of that. That. Except to say that if a main pathway for a young person to learn about sex is through watching pornography, that's going to give them a very distorted view of what, you know, real sex is like, not to mention what relationships are like. Right. And how sex becomes a part of an intimate relationship.

B (110:07)

I've heard a few people say that, that pornography lowers our motivation to go out there in the world and to pursue getting a job and getting a career and going to the gym, et cetera, et cetera. And through the lens of what we've talked about today, where dopamine was this motivating force for those rats to just reach out and eat the food, if you remove the dopamine from the rat's brain, it wouldn't even eat food in front of it, and it will starve to death. When we think about men, you said roughly in your practice, about 90% of the people that come in with a pornography addiction are mentioned men. This all kind of overlaps to create this picture that in the modern world, when we think about why more men are lonely, why they're more often in their basements playing video games now or watching pornography than ever before, why they're having less sex and having sex later, why they're struggling to form relationships, why less men are potentially in college at the moment, maybe some of the answers are in the fact of just like how men are wired. Because if they're thinking this through, if men are more likely to have a disposition to these kinds of behaviors, then these kinds of behaviors are more likely to impact and demotivate and destabilize men. Is that all, like, rough, broadly accurate?

A (111:21)

I absolutely agree, which is why I've talked about the smartphone as a masturbation machine. Essentially, these devices have become the way that we meet our physical, emotional, sexual, intellectual needs. And taken to the extreme, that would mean that we're no longer relying on other people to meet those needs. We're meeting the needs ourselves with this technology and with the devices. And I don't think that's a future that anybody wants. Taken to the extreme, right, because we are social creatures, we need to connect with each other. Human connection is vital to a thriving life and survival in general. So, yes, I have a lot of concerns that pornography is now replacing intimacy with people in real life or disrupting our expectations of intimacy with people in real life.

B (112:17)

When you say expectations, do you mean the hard work we have to do to create and find intimacy?

A (112:22)

That too, and also just expectations around sex. So a lot of folks that I work with with sex addiction, as they try to give up pornography, compulsive masturbation, or whatever they define as their sexual addict, sexually addictive behaviors, what they find is that they almost go in the opposite direction and they kind of have zero interest in sexual. Or they just don't have interest in sex with their real life partner or they can't enjoy sex with their real life partner. You know, which all kind of makes sense, right? When you've hijacked the reward pathway with this incredibly potent version of sex, you come back down to earth with your actual partner who's got his or her own needs and, you know, aging bodies or whatever it is. It's hard to experience pleasure in that realm.

B (113:14)

In an attempt to offer people out there now that are struggling with some kind of form of compulsive behavior or addiction a pathway to turn this around. What is step one in your book? I read all these incredible ideas around the wisdom we can learn from addicts. I learned about dopamine, fasting, and I also learned about radical honesty and the role that that plays. What is the process? So someone listening to this right now, they're struggling with one of these addictions. They've got a pornography addiction. They're addicted to gaming. Maybe it's food, maybe it's. Maybe it's erotic novels. Maybe they're on the Twilight. They're reading Twilight at the moment. What do you say to that person at the. Step one is.

A (113:47)

Step one is really just acknowledging the behavior, that it's problematic and that it might require some changing in our lives. The next step is being honest with ourselves and maybe another person about why we do the behavior, what we get out of it, what's positive. Step three would be honestly making a list of all of the problems with the behavior. How is it interfering with my goals and as we talked about my values, what do other people say to me about how it's problematic? Is one of the problems potentially that it's just not working anymore the way that it used to? Right. I'm developing tolerance. I need more to get the same effect. It's doing the opposite of what I want it to do. And after we've done all that, really done a really honest self assessment about the behavior, I recommend a 30 day dopamine fast. Now, we're not really fasting from dopamine, right? Because we're not really ingesting dopamine. What we're doing a fast from is whatever that substance or behavior is that is causing these kinds of problems potentially. Maybe we aren't even really sure, but we think it might be give it up for 30 days. Why 30 days? Well, we know that two weeks is not enough, right. We know that from this imaging study, right. That people are still in that dopamine deficit state two weeks after stopping. But 30 days, based on clinical experience, not just mine, but that of many other people who do this work, that for most people, no matter the drug and no matter sort of the severity and chronicity, once they get to about 30 days, they begin to feel better. They begin to come out of that tunnel of confidence, constant craving. They begin to be able to imagine a life in which they would, you know, not necessarily have to rely on this substance or on this behavior. What I always tell folks when they're preparing for the dopamine fast is just remember you will feel worse before you feel better. But that is withdrawal mediated suffering. Once you get through those first 14 days, you'll begin to feel better. And Potentially eventually by 30 days, you'll feel much better than you have in a really long time. Now this is not to say that 30 days of fasting is going to cure your addiction, not at all. But it's the beginning. It's the beginning of being able to see causality, getting some insight. It's an experiment, right? Our lives are one big experiment. What better way to understand the variables in our lives than to change one thing, one variable, and see what happens?

B (116:19)

Do we then need to you talk about this concept of self binding?

A (116:22)

Yes.

B (116:23)

Self binding, right. What role does that play in all of this?

A (116:26)

Self binding is A way of acknowledging that if we rely on willpower alone, we will not be successful, especially living in this drugified world. And what we need to do is anticipate desire before we're in the throes of desire by creating both literal and metacognitive or thought, you know, gedanken experiment like barriers between ourselves and our drug of choice. So these barriers can be actual physical barriers, like putting our device into a kitchen safe and locking it up over the night, or leaving it outside of our bedroom, or getting the potato chips, the alcohol, the cannabis out of the house. Deleting our contact drug dealers information and telling our drug dealers, don't call me and I won't call you, because these are all cues. These are all cues. That's right.

B (117:16)

And cues can be physical things. So someone I see cues can also be basically an emotion you talked about. Halt. Hungry, angry, lonely, tired. I eat well during the day. Like now as I leave here, there'll be a salad, I reckon, in the green room over there for me. And the only time where I'm susceptible to not eating well is if, if it's late. And so when you said the hungry, angry, lonely, tired thing, that is probably the state that I'm in sometimes when I get home. Certainly hungry, certainly tired, probably a little bit lonely as well, but certainly those two things. And that seems to be when I'm most susceptible to making a regrettable decision as it relates to my dopamine. I've also wondered if dopamine is responsible for what people almost call like the sugar cravings that we have. So. So what I've observed is in previous years of my life, when I was eating lots of sugar, I would then go into about a two week cycle of binging the sugar. And right now I'm in a really great cycle with my food where I have no cravings for the sugar. I'm staying in a hotel here in la. There's a mini bar in the room with Oreos and gummy, all these chocolates and all these things. And I haven't touched them because for some reason in this couple of weeks of my life or whatever, I just don't have the cravings anymore. But I kind of suspect that if I start eating them, then the next four weeks will be a car crash.

A (118:39)

Yes.

B (118:40)

Why does this happen?

A (118:41)

Yeah, it's so fascinating. And I think this is sort of a universal experience. So first of all, sugar is addictive. It lights up the same reward pathway as drugs and alcohol. Clear dopamine release in the nucleus accumbens part of the reward pathway, way in response to sugar. And when we quit sugar, we have a comedown, right? We go into withdrawal. And it's manifested in all the different ways that we've talked about. And it lasts for about two weeks. And one of the most salient symptoms is intense craving for sugar. And it's so amazing how intense it is. But if we can get through that period and get out of that vortex of addictive craving, the craving gradually gets better and then eventually goes away. Which is by the way, very paradoxical because whatever our drug is, when we first stop it, we have intense cravings and we have the feeling that the cravings will only get worse with time. Even though we logically may have experienced otherwise by giving it up before we have the feeling this is going to last forever, it never does, right? With time, the craving goes away. And once we are in that arena where we're not constantly craving, we might have something that triggers the craving, right? But like stress, but generally we're not dealing with a craving. If we were then to re expose our brains to a little bit of sugar immediately back in the vortex of craving. And there's an experiment I love that illustrates this. It's an experiment in rats where rats were injected with cocaine, the same amount of cocaine every day for seven days. And over the course of those seven days, the rats went from kind of hiding in the shadows of the cage to progressively running a little bit more and a little bit more. And by day seven, they were in a running frenzy, right? As measured by these beams of light that they were crossing. Then there was no more cocaine injected after seven days. And no cocaine or any addictive substance administered to the rats for a year, which is a rat lifetime, a really long time that would make you think, oh, you know, that there's no more cocaine in the system, none of that. And then the rats were injected with a single dose of cocaine and immediately they were plunged back into that running frenzy that you saw on day seven. Really important information because it tells us that there's some kind of permanent latent echo in our brains once we've been exposed to, and especially if we become addicted to a particular substance such that even with sustained abstinence on the order of years and decades, if we are re exposed to that drug, we can immediately be plunged into the depths of our addiction. There's no ramp up period that happens. And of course we see this all the time, you know, people with alcohol addiction who are then exposed to alcohol and right back to their Max use or even exposed to something like opioids and alcohol also works on our endogenous opioid system. So there's some homology or similarity between alcohol and opioids. And then immediately being plunged into opioid addiction, which then leads them back to their alcohol addiction.

B (121:56)

It made me think about children. It made me think about children. Because if I am, If I'm a 5 year old and I'm binging on sugar, this sets me up for a life where I'm gonna be. I mean, based on the analogy I just. The experiment I just had, based on the experiment I just heard there, it sets me up for a life where I'm gonna so easily slip right back into that addiction for sugar. And also I know that the brain isn't fully developed when we're children, so maybe the effect is even more lasting in significant. Is any of that true?

A (122:29)

Yeah, it's all true. Which is why a big focus of the addiction medicine field is prevention and trying to make sure that we protect kids brains from the harms of these addictive substances and behaviors.

B (122:42)

Like what?

A (122:43)

From sugar to digital media, video games, pornography, social media, or any other drug. You know, nicotine. So many kids are vaping now, you know, taking 50 plus puffs a day on their nicotine, vape, cannabis, alcohol.

B (122:59)

What's going on in the brain if we, if a kid is exposed to those things.

A (123:03)

So essentially at age 5, we have more neurons and neuronal connections than we have in the rest of our adult lives. About 50% more neuronal connections than we'll have as adults. Which is what makes us such good learners when we're kids. Kids can just absorb anything. Cause they're sort of like these totips, potent sponges with all these neurons and all these neuronal connections. But as we age through adolescence to about age 25, we cut back, or what's called prune, the neural circuits that we don't use and we myelinate or make more efficient the neural circuits that we use most often, such that by age 25, we are left with the neurological scaffolding that will serve us for the rest of our adult lives. That means that if we're engaging in addictive, maladaptive coping at a young age, we're elaborating a neural circuitry based on that maladaptive coping which is going to set us up for addiction in adulthood. I always like to emphasize though, that because the child and adolescent brain is so plastic or totipotent or so changeable, that's also a very hopeful message. It means that even a young person exposed at a young age to an addictive subst. If we can get in there early enough while their brain is still plastic enough, we can rewire them. Whereas when I treat people in their 70s and 80s who have been smoking pot their whole lives or drinking alcohol mainly, it was manageable. Now all of a sudden they retire, they're in their 60s. All this time, the pot's a lot more potent. They can develop these full blown addictive disorders late in life and. And it's very hard to treat them because they've lost a lot of that plasticity that would allow them to regenerate new neural pathways once they abstain.

B (124:52)

What is the most important thing that we didn't talk about that we should have as it relates to dopamine?

A (124:58)

Oh, my God, we talked about so much, I don't even know. It seems like it was a lot of stuff, I guess.

B (125:04)

Based on the questions you're exposed to from the general public. Is there anything that we missed that someone at home right now is gonna be screaming at the screen talk about?

A (125:14)

Yeah, well, I mean, I guess I would emphasize that when I talk about the dopamine fasting. It's an early intervention. It's not an intervention that I would recommend for someone who had repeatedly tried to quit on their own and been unable to, you know, clearly that would be an exercise in futility. That person should go and get professional help. Maybe they need to go to a residential treatment center. I also wouldn't recommend dopamine fasting or just quitting your drug of choice if you're at risk for a life threatening withdrawal. So we could have life threatening withdrawal from alcohol and benzodiazepines like Klonopin, Xanax, Ativin. Again, in those cases, go see a professional, get help with a medical detoxification before you try to, you know, sustain abstinence for a period of time. So, you know, I would blanket the whole thing with like, the caveat. Go see your addiction. Addiction. You know, go see the addiction medicine specialist near you.

B (126:06)

Thank you so much. It's been so unbelievably thought provoking for me in so many ways. I thought I knew what dopamine was. I thought I had covered all the ground there was to cover on these subjects of sort of compulsive behaviors. But I was so unbelievably wrong. And it wasn't until I got into your book and started reading through your work that I was like, oh my God, most people don't have a clue about dopamine and the role it plays on us. And this scale analogy is particularly memorable because that helps me to think through many of the behaviors that I have in my life that I've either struggled with or become quite stubborn in various ways. But also, it's turned a couple of lights onto some of the things I said about, like, my sugar eating sugar and even, like, going to the gym and why, like, my motivation can seem to fluctuate with the gym sometimes. It's so unbelievably important because this little neurotransmitter seems to control so much of our lives. Lives. And we're never taught anything about it. So we become these kind of puppets, and the puppet master is this brain which is firing off all of these neurotransmitters that are determining who we are, who we become, and also who we don't become. Thank you so, so, so much. I know you were nervous coming here today, but I have to tell you, you are very brilliant. You're exceptionally brilliant in so many ways. That's why I said you should start a podcast, because you're really built for this medium.

A (127:21)

Thank you.

B (127:22)

You have a certain warmth and empathy to you while also being incredibly smart and accessible in the way that you communicate. So please carry on, because I don't think, although you overcame that, the difficulty of those nerves, I think there's so many hundreds of thousands and millions of people listening now that are so thankful that you did, like, really thankful that you did. And if you've just nudged their life a little bit in a better direction.

A (127:44)

Thank you.

B (127:44)

That's worthwhile. So thank you. We have a closing tradition on this podcast where the last guest leaves a question for the next guest without knowing who they're going to be leaving it for. What is the most recent piece of information that changed your life?

A (128:03)

I think the most recent piece of information that was very impactful for me was the realization that. That we are probably going to be cybernetically enhanced in the future and interfacing with technology in a way that's completely seamless, and that this is inevitable.

B (128:32)

We're going to become cyborgs, or at.

A (128:35)

Least we're going to be surrounded by the technology in a way that's invisible, and it's going to be just completely integrated into our lives. Whether it'll actually be under the skin, I think it will be. But I can see in that so much potential. Good and promise and so much that's really terrifying, especially when I Think about the way it's going to change us as humans. And my big fear about it is that we will become more and more isolated and that we'll end up sort of in these little cubicles of our own making, scattered alone all across, you know, planet Earth. I hope it doesn't lead to that, but that's my worry.

B (129:26)

It's interesting. When we become connected to the Internet and we truly interface with the Internet, we really don't need to, to use our physical being anymore because we can experience all the joy and adventure and travel digitally and that's, I mean, it just messes with the incentive structures like we've talked about with dopamine.

A (129:43)

Yeah.

B (129:43)

Changes our ability to, to get up and go and to do things. I mean, that's a lovely, hopeful ending. Thank you so much.

A (129:54)

Oh, you're welcome. Yeah, thanks for the opportunity to, you know, teach people about this information. I hope it's helpful for people.

B (130:01)

Super helpful. And I'm going to link both of these books. Below I've got the Dopamine Nation book, which was the original, I believe.

A (130:05)

Yes.

B (130:06)

And then following that, you released Dopamine Nation Workbook, which is a practical guide to find balance in an age of indulgence. I highly recommend everybody reads these. I'm going to go and reread them on my journey home back to London tonight. So I really, really appreciate you reading these books. And honestly, everyone needs to go read these books. I'm sure they will. So thank you so much.

A (130:25)

Thank you so much.

B (130:27)

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