Best of: The future of addiction

0:00Hey everyone, it's your host Russ Alban from the Future of Everything. Today we're re-releasing my conversation with psychiatrist Anna Lembke. She's an expert on addiction, whether it's substances, screens, or work itself. Addiction in some form touches many of us either directly or indirectly. Anna's going to break down the dopamine mechanisms behind addiction, how it all works, everything from opioids to social media. There's lots of addictions. And in her case, It was romance novels. No matter what kind of addiction you might be thinking about or seeing in yourself or others, I think this one is worth another listen.

0:34Before we get started, please remember to follow the show so you'll get alerted to all of our episodes.

0:46You know, addiction seems to be increasing everywhere in our life. We've all heard about the opioid epidemic. We know about alcohol. We know about other drugs. But we also are now worried about addiction to social media, addiction to YouTube, addiction to behaviors that cause us pleasure. Well, it turns out that all of these addictions share a common mechanism to some extent. It's dopamine. We are addicted to dopamine and we will do things to increase the dopamine level in our brains. The problem is, as we do those activities, it gets harder to get the dopamine levels that we crave. And so we need to do those activities more and more.

1:24What's worse is if we stop those activities, the dopamine levels can go very low and it can get us very cranky. Well, Anna Lemke is a professor of psychiatry and behavioral sciences at Stanford University, and she's an expert at addiction of all kinds. She knows how to diagnose it and she knows how to treat it. She'll be telling us about her own addiction and ways in which it illustrates many of the principles of how to diagnose and treat addiction. Ana, I'm sure we're going to talk about very serious, life-threatening addictions. I know you work on opioid, alcohol, many other things. But I want to start out a little bit lighter.

2:01In our common parlance, people are all the time saying, I'm addicted to YouTube. I'm addicted to social media doom scrolling. I'm addicted to my exercise. And of course, that's just a turn of phrase. But from your perspective as an addiction expert, are those really addictions? Or are there elements to what they're saying that is true? Or is that just what they're saying and it's not really something that you would take seriously as an addiction expert? Yes, yes, and yes. So basically, I mean, we do overuse and trivialize that term. And I used to joke, I'm addicted to romance novels. But it turns out I really was addicted to romance novels and I didn't see it, right?

2:41Okay, now we're talking. Okay, great. Now we're getting into it. Now we're getting into it. So tell me about that. The romance novels? And the whole story. Yes, this sounds good. Okay, so first of all, we overuse that term. We trivialize it. When we talk about addiction, we are talking about a form of psychopathology. We consider it to be a brain disease. It's a spectrum disorder defined as the continued compulsive use of a substance or behavior despite harm to self and or others. But there's no brain scan. There's no blood test. We're basing this on patterns of behavior. People could disagree.

3:20And importantly, as we ourselves become addicted, we often don't see it happening, right? Other people can observe it. We're in this state of denial. As one of my patients said, denial is don't even know I'm lying. So I will use myself as an example. You know, in my early 40s, I was turned on to romance novels. For whatever reason, I hadn't discovered them earlier in life, but I'd always been a reader. Escape fiction, that was my big escape. Then I read the Twilight Saga, vampire romance novels. totally got hooked on vampire romance novels, got a Kindle, became a chain reader, was reading every night, you know, late into the morning, going to work tired, hungover, started not enjoying - So there's the harm, because in your definition of addiction, you said there needs to be harm.

4:05And I was wondering if it was like, if it was an idle and an innocent, you know, reading habit, but you said this began to have actual measurable or harms. Right. And the harms can be subtle, right? Like not getting enough sleep and then not being able to be your best self in the other things that you care about. The other harms in my case were not really being present for my children and for my husband in a way that I value and that's important to me. The other harm was kind of a gradual degradation in my mood, in my interest in other things, like my interest narrowed. All I wanted to do was read romance novels to the point where we were literally invited to a neighborhood barbecue.

4:46And I took a romance novel with me, hid in a room at these people's house to read romance novels. Now, that is really weird. That's genuinely weird. Were you already an addiction expert? Oh, I was already an addiction expert. I was teaching it. I was treating it. And like the low point for me, there were a couple lows, but basically I started to take romance novels to work. And in the 10 minutes between patients, because you know, the psychotherapy hours, 50 minutes, then you can have 10 minutes to reflect and keep it. I was reading my romance novels. So, and I didn't really see it, but I would joke about it.

5:20Oh, I'm addicted to romance novels. But really I had become a little bit addicted to romance novels and it was an insidious and gradual progression. Okay. So that's, a great example. And then all of us are now taking an inventory of our activities. So let's use that as an example. Tell me what was going on in your brain. And then, of course, I think people are very interested in if it's an ongoing struggle for you. Did you do cold turkey? I think if you're willing to share, I think a lot of people would be interested. But tell us about what was happening in your brain. Okay. So now, first of all, nobody stuck a probe into my nucleus succumbents and measured dopamine levels.

5:56So we are inferring based on animal and human studies, what was happening in my brain. But essentially we're always releasing dopamine at a kind of baseline tonic level. Dopamine is essential for the experience of pleasure, reward, and motivation. It's kind of like the little heartbeat of the reward center of the brain. When we do something that's pleasurable and reinforcing, we temporarily increase dopamine firing above baseline. Hey, that feels good. That gets me to want to do it again and again and again. Does that happen in the matter of seconds or minutes? Like how long does that take? Great question, and it's controversial.

6:27Some people think that it happens immediately as in a matter of seconds. Other people think, especially that neuroadaptation. Well, first of all, the dopamine hit happens instantly. I mean, in a matter of certainly seconds. But what happens next is that our brains adapt to that increased firing by down-regulating dopamine transmission, not just to that baseline tonic level, but actually below baseline to a dopamine deficit state, which if we don't consume again and again, eventually levels out back to baseline tonic levels. That's what neuroscientists call homeostasis. And as you know, we're always trying to get back to homeostasis and our brains work very hard to achieve that.

7:05So what happens in addiction is that with repeated exposure to the same or similar reinforcing stimulus. And by the way, what's reinforcing for one person may not be for another. For me, it was romance novels and the broad category of human attachment, sex, you know, romance novels are in many ways, socially sanctioned pornography for women. So, and over time, by the way - That's a whole nother discussion, which I'm going to put aside. Maybe we want to eliminate that. But for people who didn't understand the addiction, that last sentence is very helpful to see why it might be addictive. Yes, right.

7:40And so what happens over time with repeated exposure is essentially our dopamine levels settle down in this lower subthreshold dopamine deficit state. And that's the addicted brain. Now I need more of my drug in more potent forms, not to get high and feel good, but just to bring it back up to baseline and feel normal. And when I'm not using, I'm walking around in that dopamine deficit state, experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and craving. And that's essentially the place that I got to with romance novels, right?

8:17I was more anxious. I was more depressed. Things that I used to enjoy were no longer enjoyable. Really important aspect of this huge opportunity costs. other things that I wasn't doing that I valued more than reading romance novels were going by the wayside because I was reading romance novels. So that's essentially what we can surmise was happening in our brain. Now, if you want to know the course of my trajectory, very interesting. I did not really realize I had a problem till I was interacting with a young psychiatry resident in an exercise where we're teaching them motivational interviewing, which is how to screen and intervene.

8:54So we were one student short. So I played his patient. He said, is there a habit you want to change? I said, I'd like to change my late night reading habit. He said, oh, tell me more about that. I did not tell him in detail what I was reading. I just said, I'm staying up later than I want to, spending more time, finding it's kind of compulsive. And he said, well, what's one thing you could do to change that? I said, well, I could get rid of my Kindle or my e-reader. The point is the next day I could not unsee that behavior. That conversation, and this is really important because in our therapeutic role as addiction medicine doctors, we are encouraging patients to narrate that experience.

9:33And in doing so, we get the information, but even more importantly, they get the information, right? They see that behavior when they put words to it in a way we're really not able to see when it's hidden in the dark recesses. So the very next day, even though I was still reading romance novels, I was watching myself reading romance novels. And I thought to myself, you know what? I really do want to stop this behavior. And then I basically did with myself the same intervention we do with patients. Did that, and I want to hear about that, but did that trainee know that this was a real thing and not something you were making up just for the purposes of, uh, of the training?

10:09So he did not know, oh, he knew that it was a real habit for me. I think he could sense, I mean, kind of a benign, you know, I didn't get up there and said like, I, you know, I've got a problem with heroin. Oh, I've got to – it sounds sort of anodyne. But actually, he had no idea the extent to which that conversation actually helped me in the long – I did tell him later because I wrote about it in my book. I told him later and I said, you know, you're in the book. And he's like, oh, yeah, I remember that. That is fantastic. And then – so let's go right to the treatment, either your treatment or the approach to treatment.

10:41And I also wanted, because I know that at our last discussion, by the way, you're a second timer on the Future of Everything, which puts you in an elite high-level group. You said that you were disappointed with the ability of healthcare professionals to detect addiction when they're interacting with patients. And it sounds like you were training this. And so maybe let's talk about that right now. Have we made progress in our ability to detect? Are you getting it out, I guess, first to other psychiatrists, but also to primary care physicians and family docs who are on the front line? How good are they these days and have they gotten better?

11:16And what's the prospects look like? Huge paradigm shift in medicine. Huge improvements in terms of educating our medical workforce to screen and intervene for addiction. But I can't take any credit for it. And I'm not sure any of my colleagues can either. What changed was the opioid epidemic. With the opioid epidemic, doctors had to recognize their complicity in a problem that they had previously been able to say, well, that's those people over there. All of a sudden, it was like, well, no, actually, those are our patients and we're giving them the drugs. So, we've seen a huge sea change in the last 15 to 20 years in terms of not just, you know, the level of information, education for health professionals, but also the interest.

12:01It's so wonderful. I mean, 10 years ago, I couldn't have scraped a medical student up off the sidewalk to come and rotate in my addiction clinic. It would be like, what's that? It's a penalty. Right. And now they're like beating down the door. It's so awesome. Also in 2016, addiction medicine was recognized as an actual medical specialty. So there's been a lot of movement. We have a long way to go. Don't get me wrong. But it's a lot of progress. I'm also struck by the parallel of how you articulating the romance novel issue got you to introspect. And it sounds like the medical community as a whole has articulated its problem, so to speak, with prescribing opioids.

12:42And it had a similar effect of kind of sunshine on the problem is like the first step towards. right okay so let's go back to the issue of treatment and the the novel treatments especially i mean especially we're going to talk about i'm sure we're going to talk about opioids and the physical uh and and then and the medications i don't know if there are medications for romance novel or or for whatever my favorite you know i'm i really am going through my head and there are certain youtube channels that i know i need to stay away from because it's just a rabbit hole Dr. Pimple Popper? Yes, exactly.

13:16What's your poison? My poison is there's a guy who takes apart and reassembles mechanical watches. I love it. And at first I called it like ASMR because it was very zen. And he doesn't talk or he hardly talks. But now I realize that I'm seeking this out when I have to prepare for my interview with Dr. Lemke instead. And so that is on the border. Love it. Yeah. And you know, right after, you know, right after this, like people are going to go and look for that guy. Right. So there's that social contagion phenomenon, too. Like, well, what you're doing that I want to do, it's really fascinating. Yeah.

13:53Yeah. Thanks for sharing that. So yeah, no, and we could go on because, well, the other one I'll like say is that many years ago, I had some health scares and I started doing exercise. And I was very aware of a low level addiction in the sense that I get extremely crabby and kind of a little bit cantankerous, quite cantankerous. If there's anything blocking me from doing my regular kind of workout schedule. Right. And, and, and, and, you know, there's, there's the, I don't know if it's a dopamine high or whatever kind of, wherever that high comes from, it's real. And I get very, I needed to protect that.

14:30And I need to be very aware of how, if I don't feed that dopamine itch, I can really be kind of antisocial. antisocial. Yeah. So that's a great little, you know, sort of segue into how we treat it because dopamine is not only important for pleasure, reward, and motivation, it's also essential to movement. Like even the most primitive nematode will release dopamine in response to its food and its environment, allowing it to locomo. We know that in Parkinson's, we have a depletion of dopamine. So part of what happens in addiction, well, really how we're wired is to have to move and do a lot of physical work to get our rewards.

15:04But today we don't have to move, right? We can just sit there and have them come to us. So that means part of the treatment of addiction is actually getting people to reconnect to their dopamine firing to their physical movement and body. So we actually prescribe what we call hormesis. Hormesis is Greek for descent in motion. It's actually the science of how pain is good for us. And we ask people to intentionally do things that are physically difficult, challenging, painful, or mentally so that they can get their dopamine indirectly. So the idea is that intoxicants spike our dopamine followed by a dopamine deficit state, which is the state of craving.

15:37But exercise, we see a gradual rise in dopamine over the latter half of the exercise. It remains elevated for hours afterwards. And then it goes back down to baseline. And it really typically doesn't go into that dopamine deficit state. But it's also possible to get addicted to exercise, right, if we overdo it. So I love what you said about during the second part of exercise, because for me as like a runner and a cyclist, it's obvious why, because when you get to the halfway point, you know, it's going to end soon. And so I can tell my mood getting better and better as I, as I approach the end of a run, because I know that I'm going to be in such a great mood at the end.

16:16And so it's kind of, of course you're happy. Yeah. You're a man after my own heart because sometimes I'll talk to people like, but, but I look forward to exercise. I'm like, really? You're in a lucky category. When I'm sitting like standing by the edge of the pool in the morning, I would rather stab myself in the stomach than jump into the pool. You know what I I mean, it's like within half a lap, I'm already like, OK, it's better. This is great. Well, this is this is the future of everything. I'm Russ Altman and we'll have more with Anna Lemke next.

16:55Welcome back to the future of everything. I'm Russ Altman, your host, and I'm speaking with Professor Anna Lemke from Stanford University. In the last segment, we discussed the general principles of addiction. We heard an interesting story about Anna's experience with romance novels, but we didn't get the end. So in this section, we're going to hear what happened to Anna's addiction. And we're also going to turn our attention to the opioid epidemic and get an update from Anna about how it's going and whether the future looks promising. And I want to deliver Anna on the promise to get the end of the story.

17:25So when we last left you, you were having introspection about this and maybe not being happy with your level of romance novel reading. And tell me how it ended. Or did it end? Yeah, good question. So, you know, addiction is a chronic relapsing remitting disorder. And when I finally saw my double life of addiction to romance novels, I decided to do a self intervention like we do with our patients as a first pass, which is a dopamine fast, abstaining from our drug of choice for 30 days. Why 30 days? Because we find experientially, that's the average amount of time it kind of takes to get out of the craving state and reset reward pathways.

18:05Knowing that those first 10 to 14 days are super painful because we are in withdrawal, but then things start to get better. And so I abstained from romance novels for 30 days. I was shocked at how difficult it was for me. I had lost the art of putting myself to sleep without this particular behavior. And I had incredible insomnia, restlessness, and also just incredible anxiety. The anxiety that we get when we cannot engage in these habitual kind of protective behaviors, and especially escape behaviors. And it was intense. And boy, did it give me a whole new level of empathy for people with severe life-threatening addictions, the people that I treat.

18:44But I was able to do it. And by the end of four weeks, I'm like, like, hey, I'm feeling great, better than I have in a long time, not craving romance novels. I think I'll give a romance novel a read this weekend. And I had something we call the abstinence violation. I binged all weekend long, went to work that Monday bleary-eyed, and I was like, oh dear, that was a disaster. I guess I have to abstain from longer. So then I committed to a year. And you know what? It was a good year. And since then, which is some decades ago, So, you know, I've tried occasionally to read romance novels and for the most part, zero pleasure, zero pleasure.

19:21It's like I've burned out that neurotransmitter system. I still have euphoric recall for how it felt and I still want to read them, but they just, they're completely non-pleasurable for me, which is kind of the cost, right? So that's kind of, it's like, I've sort of now deprived myself for the rest of my life of really enjoying that. Now, I have switched to other genres. I'm like a big mystery thriller. But even then, I have to really watch out because once I start, it's difficult for me to stop and I don't want to get it. Did you do any of these other dopamine increasing activities either during that month or during that first year?

19:58I mean, you talked about exercise or did you flirt with a different addiction that got you a little bit of dopamine on the side? Yeah, yeah, yeah. You can imagine all of these strategies. Yes, I mean, my real, so yes, so cross addiction is real. So we're giving up one addiction and going to another. I've always tried to start my day with pain, you know, get up, exercise, because that sets me up for better. My mood just is a lot better. But I don't think, especially as I've aged, I haven't really been able to do more exercise. In fact, I've had to pull back. So that's sort of been a natural protector for me.

20:32You know, workaholism is real, right? This kind of flow state that you get into when you're working. I think it's hard for me to stop working, right? Which is like really weird. And it's usually detrimental. We're not present again for our families. We're not cultivating other activities and hobbies. We become sort of reliant on that to-do list and that sense of like accomplishment and validation we get. But like, at the end of my life, do I want to look back? Oh, wow, I did all that. No, that's not where, I know that's not where meaning and connection is. To some extent it is to the extent that I can be altruistic at work and support other people's careers and help patients.

21:11But a lot of it's just about my own anxiety and managing my own anxiety by chunking through this to-do list. I think our colleagues at a medical school, we're filled with people like that. Okay. I want to move to the opioid epidemic because it's the addiction that people are thinking about the most. And I think you would probably agree it deserves a lot of thought. But before that, just one quick question. Is the idea of an addictive personality a thing? It's a thing. We don't use that terminology anymore in the field of addiction medicine, but basically what it's talking about is somebody with a big genetic load for addiction, and that is real.

21:44People come into this world with differing degrees of vulnerability to addiction, some a lot more than others, just like some people are predisposed to bipolar disorder, depression, or schizophrenia, anxiety, what have you. We know this from family studies. If you have a biological parent or grandparent with addiction, you're at increased risk for addiction, even if raised outside of that substance using home. So that's real. The terminology we use though, instead of the addictive personality is more like vulnerable to the disease of addiction or heavy genetic load for addiction or strong family history for addiction.

22:16A little gentler and a little bit perhaps less judgmental. So good. Well, what I would also add, which is important is that, you know, when we think about vulnerability or innate vulnerability, it's very tied to drug of choice, which is to say like, I'm pretty much invulnerable to alcohol. it does nothing for me. I wish it did. Caffeine, same thing. But once I discovered my drug of choice, romance novels, attachment, you know, all those social, you know, sex related stuff, boy, I was off and running. So we may be exploding this idea of vulnerability as we get new, more drugs online that more people are susceptible to.

22:53Yes. Yes. Okay. So in the last five minutes or so, I wanted to talk about the opioid epidemic. Uh, it, um, it had, I think you and I last spoke probably during the pandemic, maybe before the pandemic, but I think everybody has heard that the pandemic had a huge impact on the epidemic, that it is an ongoing epidemic. And as the pandemic has receded, opioids are still here. We've heard about big legal settlements and you've made some actually very optimistic statements about doctors being more aware of their role in this. So from your perspective, as somebody who has an addiction clinic, where are we?

23:27And what is the situation with the opioid clinic? And what should people know about it? So I think the best way to conceptualize it through time is that there were essentially three waves. The first wave was oversupply of prescription opioids due to overprescribing, due to the hoodwinking of the medical establishment by the pharmaceutical industry. Then as prescribing started to go down, many people who were already addicted turned to illicit sources. That was heroin, approximately 2013-ish. And then fentanyl, a highly potent and lethal opioid, got introduced into the drug supply. And that's really where we still are now, where even though prescription opioid-related deaths have decreased, fentanyl-related deaths are still on the rise.