Essentials: Understanding & Treating Addiction | Dr. Anna Lembke

0:00Welcome to Huberman Lab Essentials, where we revisit past episodes for the most potent and actionable science -based tools for mental health, physical health, and performance. And now for my discussion with Dr. Anna Lemke. I and many listeners of this podcast are obsessed with dopamine. What is dopamine? And what are maybe some things about dopamine that most people don't know? And probably that I don't know either. So dopamine is a neurotransmitter, and neurotransmitters are those molecules that bridge the gap between two neurons. So they essentially allow one neuron, the presynaptic neuron, to communicate with the postsynaptic neuron.

0:45Dopamine is intimately associated with the experience of reward, but also with movement, which I think is really interesting because movement and reward or linked, right? If you think about, you know, early humans, you had to move in order to go seek out the water or the meat or whatever it was. So dopamine is this really powerful, important molecule in the brain that helps us experience pleasure. It's not the only neurotransmitter involved in pleasure, but it's a really, really important one. And if you want to think about something that most people don't know about dopamine, which I think is really interesting is that we are always releasing dopamine at a kind of tonic baseline rate.

1:35And it's really the deviation from that baseline, rather than like hits of dopamine in a vacuum that make a difference. So when we experience pleasure, our dopamine release goes above baseline. And likewise, dopamine can go below that tonic baseline. And then we experience a kind of pain. Interesting. So is it fair to say that one's baseline levels of dopamine, how frequently we are releasing dopamine in the absence of some, I don't know, drug or food or experience just sitting being. Is that associated with how happy somebody is the kind of baseline of happiness or level of depression? There is evidence that shows that people who are depressed, mandied have lower tonic levels of dopamine.

2:25So that's a really reasonable thought. And there is some evidence to suggest that that may be true. The other thing that we know is that if we expose ourselves chronically to substances or behaviors that repeatedly released large amounts of dopamine in our brain toward pathway that we can change our tonic baseline and actually lower it over time as our brain tries to compensate for all of that dopamine, which is more really than we were designed to experience. Interesting. And is it the case that our baseline levels of dopamine are set by our genetics, by our heredity? Well, I think, you know, if you think about sort of, you know, the early stages of development and infancy, certainly that is true.

3:15You're kind of, you know, born with probably whatever is your baseline level. But obviously your experiences can have a huge impact on where your dopamine level ultimately settles out. Do you think that's a set in terms of our parents and obviously nature and nurture interact, but is that is dopamine at the core of our temperament? I don't really think we know the answer to that, but I will say that people are definitely born with different temperaments. And those temperaments do affect their ability to experience joy. And, you know, we've known that for a long time and we describe that in many different ways.

4:01One of the ways that we describe that in the modern era is to use psychiatric nomenclature like this person has a dysphemic temperament or, you know, this person has chronic major depressive disorder. In terms of looking specifically at whose vulnerable to addiction, that's an interesting sort of mixed bag because when you look at the research on risk factors for addiction, so what kind of temperament of a person makes them more vulnerable to addiction. And you see some interesting findings. First, you see that people who are more impulsive, who have a thought to do something and just do it impulsively.

4:38Are people who are more vulnerable to addiction? What we now conceptualize in our current ecosystem as mental illness are actually traits that in another ecosystem might be very advantageous. They're just not advantageous right now because of the world that we live in. And I think, you know, impulsivity is potentially one of those, right? Because we live in this world that such a sensory rich environment, right, that we're being bombarded with all these opportunities, these sensory opportunities. And we have to constantly check ourselves. And so so so impulsivity is something that right now can be a difficult trait, but isn't in and of itself a bad thing.

5:24In a previous conversation we had, you said something that really rung in my mind, which is that many people who become addicted to things have this feeling that normal life isn't interesting enough. Maybe you could just tell us a little bit about your experience with this association if it really exists between people's sense of the normalcy or maybe even how boring life can be and their tendency to become addicts of some sort. I think that life for humans has always been hard, but I think that now it's harder in unprecedented ways. And I think that the way that life is really hard now is that it actually is really boring.

6:08All of our survival needs are met. We don't even have to leave our homes to meet every single physical need, you know, as long as you're of a certain level of financial well -being, which was frankly, you know, we talk so much about, you know, the income gap. And certainly there is this enormous gap between Rich and Poor, but that gap is smaller than it's ever been in like the history of humans. We don't really have anything that we have to do. So we're all forced to make stuff up, you know, whether it's being a scientist or being a doctor or being an Olympic athlete or, you know, climbing Mount Everest.

6:49And people really vary in their need for friction. And some people need a lot more than others. And if they don't have it, they're really, really unhappy. And I do think that a lot of the people that I see with addiction and other forms of mental illness are people who need more friction, like they're unhappy, not necessarily because there's something wrong with their brain, but because their brain is not suited to this world. I'd like to take a quick break and acknowledge our sponsor, AG1. AG1 is a vitamin mineral probiotic drink that also includes prebiotics and adaptogens. As somebody who's been involved in research science for almost three decades and in health and fitness for equally as long, I'm constantly looking for the best tools to improve my mental health, physical health, and performance.

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8:55Let's talk about the pleasure pain balance and addiction. I've heard you use this CSAUR balance scale analogy before, and I think it's a wonderful one. To me, one of the most significant findings in neuroscience in the last 75 years is that pleasure and pain are co -located, which means the same parts of the brain that process, pleasure, also process pain. They work like a balance. When we feel pleasure, our balance tips one way, when we feel pain, it tips in the opposite direction. One of the overriding rules governing this balance is that it wants to stay level, so it doesn't want to remain tipped very long to pleasure or to pain.

9:35With any deviation from neutrality, the brain will work very hard to restore a level balance or what scientists call homeostasis. The way the brain does that is with any stimulus to one side, there will be a tip in equal and opposite amount to the other side. It's like you have principal laws of physics. Yes, right. I like to watch YouTube videos, when I watch YouTube videos of American Idol, it tips to the side of pleasure, and then when I stop watching it, I have a come down, which is a tip to the equal and opposite amount on the other side. That's that moment of wanting to watch one more YouTube video.

10:15It's not something that consciously happens or that we're aware of, unless we really begin to pay attention. One way to combat that is to do it more, and more and more and more. I think that is really what I want people to tune into and get an awareness around, because once you tune into it, you can see it a lot. If you keep the model of the balance in mind, I think it gives people a way to imagine what they're experiencing on a neurobiological level and understand it, and in that understanding, get some mastery over it, which is really what this is all about. Because ultimately, we do need to disengage.

10:56We can't live in that space all the time. We have other things we need to do, and there are also serious consequences that come with trying to repeat and continue that experience or that feeling. If I understand this correctly, when we find something that we enjoy that feels pleasurable, social media, food, sex, gambling, whatever happens to be there's some dopamine release when we engage in that behavior. And then what you're telling me is that very quickly, and beneath my conscious awareness, there's a tilting back of this scale where pleasure is reduced by way of increasing pain. And I've heard you say before that the pain mechanism has some competitive advantages over the pleasure mechanism such that it doesn't just bring the scale back to level.

11:53It actually brings pain higher than pleasure. What happens right after I do something that is really pleasurable and releases a lot of dopamine is again, my brain is going to immediately compensate by down regulating my own dopamine receptor is my own dopamine transmission to compensate for that. And that's that come down or the hangover or that after effect that moment of wanting to do it more. Now, if I just wait for that feeling to pass, then my dopamine will re -regulate itself and I'll go back to whatever my chronic baseline is. But if I don't wait, and here's really the key, if I keep indulging again and again and again, ultimately I have I have so much on the pain side, right, that I've essentially reset my brain to what we call like an anhydonic or lacking enjoy type of state, which is a dopamine deficit state.

12:44So that's really the way in which pain can become the main driver is because I've indulged so much in these high reward behaviors or substances that my brain has had to compensate by way down regulating my own dopamine such that even when I'm not doing that drug, I'm in a dopamine deficit state, which is akin to a clinical depression, I have anxiety or an ability and Sami dysphoria. And a lot of mental preoccupation with using again or getting the drug. So in general, what we want is some kind of flexibility in that balance and the ability to easily reassert homeostasis. We don't want to break our balance, which is possible if we over indulge for enough period of time and end up with a balanced tip to the side of pain, the stopamine deficit state we've been talking about.

13:32We want to we want a flexible resilient balance, right, which can be sensitive to things going on in the environment, which can experience pleasure and approach, which can experience pain and recoil, right, this is all adaptive and healthy and necessary and good. We would never want a balance that doesn't tilt, right, that would be a disaster, we wouldn't be human. And we wouldn't want that. We'd really, really boring. On the other hand, what people in recovery from addiction talk about is to some extent having to learn to live with things being a little boring a lot of the time, right. So trying to avoid some of this intensity and thrill seeking and escapism that really is at the core of addictive tendencies.

14:16So along those lines, I've heard you say that in order to reset the dopamine system, essentially in order to break an addictive pattern, 30 days of zero interaction with that substance, that person, et cetera. Right. Is that correct? Yeah. And 30 days is in my clinical experience, the average amount of time it takes for the brain to reset reward pathways for dopamine transition to regenerate itself by depriving ourselves of this high dopamine high reward substance or behavior. We allow our brains to regenerate its own dopamine to for the balance to really quite right. And then we're in a place where we can sort of enjoy other things.

14:58So I'd like to dissect out that 30 days a little more finally. So days one through 10, I would imagine will be very uncomfortable. Yes. Anxiety, trouble sleeping, physical agitation into the point where, you know, maybe impulsive, angry should one expect all of that should the. Yeah. So what I say to patients and it's a really important piece of this intervention is that you will feel worse before you feel better. For how long? Yeah. This is probably the first question they ask, right? And I say usually in my clinical experience, you'll feel worse for two weeks. But if you can make it through those first two weeks, the sun will start to come out in week three.

15:40And by week four, most people are feeling a whole lot better than they were before they stopped using their substance. So it's a hard thing like you have to sign up for it. Then days 21 through 30 dopamine is starting to be released in response to the taste of a really good cup of coffee. Exactly. Whereas before it was only to insert, you know, addictive behavior. Right. One thing I've seen over and over again, sadly, often in the same individuals is they get sober from whatever they're doing great. And then all of a sudden you get this call so and so's back in jail so and so's wife is going to leave him because he drank two bottles of wine and took a Xanax at 7 a .m.

16:28Crash is trucking to a pole. It's got two beautiful kids like how did this happen again to the point where by the fourth and fifth time people are just done. And so what I'd like to talk about in this context is what sorts of things help other people that we know that are addicted what really helps. And are there certain people for whom it's hopeless. Yeah. So there are people who will die of their disease of addiction. You know, and I think conceptualizing it as a disease is a helpful frame. There are other frames that we could use, but I do think given the brain physiologic changes that occur with sustained heavy drug use and what we know happens to the brain, it is really reasonable to think of it as a brain disease.

17:20And for me, the real window of let's say being able to access my compassion around people who are repeat relapses even when their life is so much better when they're in the air. Yeah, it's like it's like a no brainer right is is to conceptualize this balance and the dopamine deficit state and a balance tilted to the side of pain. And to imagine that for some people after a month or six months or maybe even six years, their balance is still tips to the side of pain that on some level that balance has lost its resilience and its ability to restore homeostasis. It's almost like the hinge on that balance is messed up exactly.

18:03Imagine that you had an itch somewhere on your body. Okay, I mean, we've all had that like, you know, whatever the source. You know, if you really focus, you could go for a pretty good amount of time not scratching it. But the moment you stopped focusing on not scratching it, you would scratch it. And maybe you do it while you were asleep, right? That is and that is what happens to people with severe addiction that balance is essentially broken homeostasis does not get restored despite sustained abstinence. They're living with that constant spectre of that poll. It never goes away. So let me see there are lots of people with addiction for whom that does go away and it goes away at four weeks for many of them.

18:48But in severe cases, that's always there and it's lingering and it's the moment when they're not focusing on not using, it's like a reflex. They fall back into it. It's not purposeful. It's not because they want to get high. It's not because they value using drugs more than they do their family. None of that. It's that really they they they cannot not do it when given the opportunity and that moment when they're not thinking about it. Does that make sense? That's a great description. And actually in that description, I can feel a bit of empathy because the way you describe scratching an itch in your sleep.

19:27Yeah, you know, I've done that with mosquito bites and scratching like I wake up scratching that mosquito bite. And I also have to admit that I've experienced not feeling like I want to pick up my phone because it's so rewarding, but just finding myself doing it. Yes, of course, I'm not going to use this thing. I'm not going to use this thing and then just finding myself. Like what am I doing here? Right. Sort of the how did I get back here again? And I know enough about brain function to understand that we have circuits that generate deliberate behavior. And we have circuits that generate reflexive behavior.

20:04And one of the goals of the nervous system is to make the deliberate stuff reflexive so you don't have to make the decision because decision making is a very costly thing to do. Exactly. Why is it that people will relapse not just after getting fired from a job or their spouse leaving them, but when things are going really well? Is it this unconscious mechanism? Because I've seen this before is they have a great win. I have a friend who's a really impressive creative. I don't want to reveal any more than that, but and relapsed upon getting another really terrific opportunity to create for the entire world.

20:44And I was like, how can that happen? But now I'm beginning to wonder, was it the dopamine associated with that win? That opened the spigot on this dopamine system? Because it happened in a phase of a really great stretch of life. Yeah, triggers are things that make us want to go back to using our drug. And the key thing about triggers, whatever they are, is they also release a little bit of dopamine. Right. So just thinking about whatever the trigger is that we associate with drug use or just thinking about drug use can already release this anticipatory dopamine, this little mini spike. But here's the part that I think is really fascinating.

21:25That mini spike is followed by a mini deficit state. So it goes up and then it doesn't go back down the baseline. It goes below baseline tonic levels. And that's craving. Right. So that anticipation is immediately followed by wanting the drug. And it's that dopamine deficit state that drives the motivation to go and get the drugs. So many people talk about dopamine is not really about pleasure, but about wanting and about motivation. And so it is that deficit state that then drives the local motion to get it. And earlier, your description of dopamine being involved in the desire for more giving the sense of reward, but also movement.

22:04Right. I have to assume that those things are graded together in our nervous system for the specific intention of when you feel something good, then you feel the pain. Yeah, maybe you don't notice it. And then the next thing you know, you're pursuing more of the thing that you use the word braided together. That's beautiful. There are people for whom bad life experiences, loss, you know, in any form, stress in many different forms. That's a trigger, but there are absolutely people for whom the trigger is things going well. And the things going well can be like the reward of the things going well, but very often what it is is the removal of the hyper vigilant state that's required to keep their use and check.

22:45So it's this sense of I want to celebrate, you know, or I want to this reward happened. I want to put more reward on there. And it's really, really fascinating because when people come to that realization that about themselves that they're most vulnerable when things are going well. That's really a valuable insight because then they can put some, you know, things in place or barriers in place or go to more meetings or whatever it is that they do, you know, to protect themselves. I would like to take a quick break and acknowledge one of our sponsors, wealthfront. I've been using wealthfront for my savings and for my investing for nearly a decade.

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24:33That's wealthfront .com slash Huberman to get started now. This has been a pay testimonial of wealthfront. Wealthfront brokerage isn't a bank. The APY is subject to change. For more information, see the episode description. Today's episode is also brought to us by BetterHelp. BetterHelp offers professional therapy with a licensed therapist carried out entirely online. I've been doing weekly therapy for well over 30 years. Initially, I didn't have a choice. It was a condition of being allowed to stay in school. But pretty soon I realized that therapy is an extremely important component to overall health.

25:05In fact, I consider doing regular therapy just as important as getting regular exercise, including cardiovascular exercise and resistance training, which of course I also do every week. There are essentially three things that great therapy provides. First of all, it provides a good rapport with somebody that you can trust and talk to about all issues that you're concerned about. Second of all, it can provide support in the form of emotional support or directed guidance. And third, expert therapy can provide useful insights. With BetterHelp, they make it very easy to find an expert therapist with whom you resonate with and can provide those benefits that come through effective therapy.

25:41Also, because BetterHelp allows therapy to be done entirely online, it's very time efficient. It's easy to fit into a busy schedule. There's no commuting to a therapist's office or sitting in a waiting room or anything like that. You simply go online and hold your appointment. If you would like to try BetterHelp, go to BetterHelp .com slash Huberman to get 10 % off your first month. Again, that's BetterHelp .com slash Huberman. I wanted to just touch on something that you mentioned, which is the shame. I heard you say in an interview with somebody else recently that truth telling and secrets are sort of at the core of recovery.

26:20And tell us more about that. Yeah, so one of the things that I found really fascinating about working with people in recovery was how telling the truth even about the nearest detail of their lives was central to their recovery. It's not even just not lying about using drugs. I have to not lie about anything. I can't lie about why I was late to work this morning, which we all do. I hit traffic. No, I didn't hit traffic. I wanted to spend two more minutes reading the paper and drinking my coffee, right? So people with addiction will get into the lying habit where they're lying about random stuff because they're sort of in the habit of lying and how recovery is really about telling the truth.

27:00And there's really interesting neuroscience behind it that suggests that when we tell the truth, we actually potentially strengthen our prefrontal cortical circuits and their connections to our limbic brain and our reward brain. And of course, these are the circuits that get disconnected when we're in our addiction, right? Our balance in our reward pathway or limbic brain, our emotion brain is doing one thing. And our cortical circuits are completely disengaged from that, ignoring what's happening, which is easy to do because it's reflexive. We don't need to think about that balance for the balance to be happening.

27:33But we have to reengage those circuits and anticipate future consequences, think through the drink, you know, not just how am I going to feel now if I use, but how am I going to feel tomorrow or six months from now. And that telling the truth is in fact a way to do that, to make these connections stronger in there. I talk about some studies in my book that that kind of indirectly show that. So I find that really fascinating. Plus they're just like being open and honest with people really does create very intimate connections and those intimate connections create dopamine. You think people are going to run away from you if you tell them about all like your weird neuroses, but really they don't.