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The Melanie Avalon Biohacking Podcast Episode #140 -
Dr. Anna Lembke

Dr. Anna Lembke received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University. She is currently Professor and Medical Director of Addiction Medicine, Stanford University School of Medicine. She is also Program Director of the Stanford Addiction Medicine Fellowship, and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She is a diplomate of the American Board of Psychiatry and Neurology, and a diplomate of the American Board of Addiction Medicine.

Dr. Lembke was one of the first in the medical community to sound the alarm regarding opioid overprescribing and the opioid epidemic. In 2016, she published her best-selling book on the prescription drug epidemic, "Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop" (Johns Hopkins University Press, 2016). Her book was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic (Zuger, 2018).

"Drug Dealer, MD" combines case studies with public policy, cultural anthropology, and neuroscience, to explore the complex relationship between doctors and patients around prescribing controlled drugs. It has had an impact on policy makers and legislators across the nation. Dr. Lembke has testified before Congress and consulted with governors and senators from Kentucky to Missouri to Nevada. She was a featured guest on Fresh Air with Terry Gross, MSNBC with Chris Hayes, and numerous other media broadcasts.

Using her public platform and her faculty position at Stanford University School of Medicine, Dr. Lembke has developed multiple teaching programs on addiction and safe prescribing, as well as opioid tapering. She has held multiple leadership and mentorship positions and received the Stanford’s Chairman’s Award for Clinical Innovation, and the Stanford Departmental Award for Outstanding Teaching. Dr. Lembke continues to educate policymakers and the public about causes of and solutions for the problem of addiction.

Look for her new book, "Dopamine Nation: Finding Balance in the Age of Indulgence" (Dutton/Penguin Random House, August 2021).



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Dopamine Nation: Finding Balance in the Age of Indulgence

10:35 - Dr. Anna's Credentials

11:35 - Dr. Anna's Beginning

14:40 - what is Addiction?

16:10 - the 4 cs

17:20 - Withdrawal

17:50 - the difference Between Enjoyment And Addiction

19:35 - workaholism

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The Melanie Avalon Biohacking Podcast Episode #38 - Connie Zack
The Science Of Sauna: Heat Shock Proteins, Heart Health, Chronic Pain, Detox, Weight Loss, Immunity, Traditional Vs. Infrared, And More!

22:20 - does the feeling of fulfillment matter?

24:45 - dopamine and motivation

25:50 - pain and pleasure balance

31:10 - dopamine and hunger

32:30 - addiction ritual

36:00 - when did addiction start?

37:10 - modern addiction

38:10 - orgasm

39:50 - who is more likely to become addicted?

41:50 - what role does repetitive exposure play?

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46:00 - could we evolve to no longer be addicted?

49:00 - can everyone recover from addiction?

51:50 - cBD and cannabis

52:50 - can anything become addictive?

55:10 - finding a solution

58:20 - Self binding

1:01:10 - shame and guilt in recovery

1:03:20 - radical honesty, and our addiction to lying


Melanie Avalon: Hi, friends, welcome back to the show. I am so, so excited about the conversation that I'm about to have. A little backstory about today's show. I heard Dr. Anna Lembke, she's made all the podcasts around, she's been on all the shows, and I was listening to her interviews for her new book, Dopamine Nation, and I knew that I had to read the book, ASAP, and if possible, had to get her on this show, because I am very much fascinated by the brain, and by addiction, and in particular, the concept of dopamine. I've always said that I am-- and this is a very casual understanding of it, but I've always thought that I have an addictive personality. I've always said that dopamine is my thing and that I could never really touch drugs or anything like that, because that would just not go well. I always had just an awareness of how I think my brain works with dopamine. But then reading Dopamine Nation was just so eye opening, so enlightening, I really, really learned about the science of what all was going on. Then on top of that, Dr. Lembke is an amazing writer and she shares a lot of personal stories as well from her work. So, it's a really, really engaging read. I just have so many questions. So, Dr. Lembke, thank you so much for being here.

Anna Lembke: Oh, my goodness, my pleasure and thank you for that lovely introduction.

Melanie Avalon: Listeners might be familiar with you from your books, or from podcasts interviews, and things like that, but for those who are not familiar, I will just let them know that you received your undergrad in humanities from Yale, and your medical degree from Stanford, and you are Professor and Medical Director of Addiction Medicine at Stanford, you're also the Program Director of the Stanford Addiction Medicine fellowship, Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, and a Diplomat of both the American Board of Psychiatry and Neurology, and the American Board of Addiction Medicine, and I'm sure a lot more other things, but those are quite the credentials. But to start things off, so, like I said, your book is just so engaging. The first note I had, because I have 30 pages of notes, but the first note I have is, "She is a really good writer, you're really good," so engaging, telling the stories of your patients, and what you've learned from them, and the epiphanies that you've had. I was wondering if to start things off, you could tell listeners a little bit about your personal story and what made you so interested in your work on medications, and addiction, and things like that, and your work with your patients and just why are you doing what you're doing today?

Anna Lembke: Maybe the best place for me to start is just to take a moment for me to express gratitude to my patients, many of whom I interviewed for this book and who were willing to share their stories with a pseudonym in the book, it was their courageous honesty that really made the book possible and I'm very grateful to them, and really hopeful that the stories really bring to life the concepts for readers. I guess, thinking about why I wrote the book or how I got to this place that I wanted to write the book is that a number of different things. I've been practicing psychiatry for more than two decades and I've learned so much from my patients, who I hold up as modern-day Prophets for the rest of us, and how to live in this reward saturated world. I also believe that narrative and story is fundamental to organizing our lives, and shaping our experience, and also teaching us. I wanted to communicate the neuroscience plus these true individual stories of my patients to express certain ideas that I've evolved over two decades of practicing psychiatry about how to achieve the good life in a world that's constantly tempting us to engage in titillating ourselves or the pursuit of pleasure for its own sake. 

I should say too, that I opened the book with the story of a patient of mine with a sex addiction. I did that because I thought his story exemplified very specifically the ways in which technology and the communications revolution wrought by the internet has made it so much harder to manage consumption and essentially turned us all into some form of addict, but also because I wanted to draw parallels between his story and my own addiction to romance novels, which I do talk about in the book, which was a much more minor kind of addiction compared to his addiction or that of many of my patients. But I think still illustrates again the ways in which so much in our world is now drugified and/or our increased access has made us all more vulnerable to this problem of addiction.

Melanie Avalon: Yeah, I really, really appreciated that approach that you took. For listeners, the patient that Dr. Lembke talks about with a sex addiction, it's to the level of he concocted an entire masturbation machine, which I think people looking at that from the outside would clearly, probably say, "Oh, yes, he's addicted to sex or masturbation." But then you tell your story about being addicted to romance novels and you talk about Twilight. I think it's really easy for people to look at that situation, I think and say, "Oh, well, that's not addiction. You just like romance novels." A question from that. How similar are those two situations? What is addiction and what determines when something becomes addiction versus just being something that you really, really like that is socially acceptable?

Anna Lembke: Right. Broadly speaking, addiction is defined as the continued compulsive use of a substance or behavior despite harm to self and/or others. Addiction occurs on a continuum. Everything from compulsive overconsumption, mild addiction to very severe life-threatening addiction. We're all somewhere on that spectrum. Increasingly, more and more of us are struggling with these kinds of minor addictions. Again, as so many things have become drugified and our access has become almost infinite, especially with the advent of the smartphone. When I use the word "addiction," I'm talking about a maladaptive form of coping. I'm not talking about something that's like a passion or something that people are just spending a lot of time doing trying to achieve one thing or another. Now, almost anything can cross over into addiction. The way that it's broadly defined is, again, harm to self and/or others. The way that it's specifically defined in the Diagnostic and Statistical Manual of Mental Disorders is captured by the four Cs, control, compulsion, craving, and consequences, along with the physiologic signs of tolerance and dependence.

Just to briefly summarize, control refers to out of control use, compulsion refers to a level of automaticity outside of conscious awareness, craving refers to both the mental and physiologic onset of an intense urge to use despite the plan not to use, and then, consequence has to do with all of the various consequences from subtle consequences of just not being fully present to significant life-threatening consequences, including jail, loss of serious relationships, loss of jobs, health consequences. Then there are the physiologic signals of adaptation, tolerance, needing more and more over time to get the same effect, and then dependence and withdrawal manifestations, physiologic manifestations of the absence of the drug. A lot of times people are familiar with the very significant physical symptoms of withdrawal that you might get from stopping smoking, or stopping opioids, or stopping alcohol. But every drug and behavior that's addictive has universal psychological symptoms of withdrawal that people really underestimate. Those include anxiety, irritability, insomnia, dysphoria, and intrusive thoughts of wanting to use.

Melanie Avalon: Okay. I'm looking at those different criteria and I'm just wondering, like, for me, for example, I think if I had an addiction, it would be probably workaholism. Just thinking about that, for example, is the difference really the consequences? Because I feel the way I engage with work, for example, could be seen as addictive. I do have compulsion, I do have craving. If I didn't do it, the consequences might be that I have anxiety or feel the need to do it. But because it's so accepted in society and because it seems to benefit my life, I keep doing it. So, does that qualify as an addiction or not, because it doesn't have consequences?

Anna Lembke: Right. Very important point. First of all, let me just say those four Cs plus staunch dependence. That's not a checklist. It's not like you have to meet all of those criteria for addiction. It's basically a kind of a mix and match. The more criteria you meet, the more addicted you are through mild, moderate, and severe, and maybe just one or two of those criteria might put you in the mild range. So, that's important first thing that I want to say, but you're making a very good point, which I think can be captured by this concept of addiction and really all mental health disorders being biopsychosocial diseases. There's a biological component, a psychological component, and there's a social/environmental component. On that social environmental piece of it, that really speaks to the way in which addiction is in many ways defined not just by its biological factors, but by the way that it interacts with whatever the culture is at that time. 

There's no doubt that in our current culture, modern Western capitalist culture, there are certain types of behaviors that really meet almost all of the other criteria for addiction, but which we don't call addiction, because they're so socially validated and reinforced. That certainly would include a workaholism and the ways in which this obsessive, compulsive, 24/7 preoccupation with work, and achievement, and money is something that we actually use to define our heroes and not people, who are ill. Yet, I think through another lens, it's very credible and even useful to say, "Wait a minute, are we individually and collectively addicted to the behaviors surrounding work? Is it ultimately, actually contributing to our unhappiness?"

Melanie Avalon: I'm glad you said that about the unhappiness, because my extension question of that was, "Does it matter?" The awareness or the perception that you have when you "achieve whatever you're achieving." I don't necessarily mean just achievements as well, being addicted to a drug, for example. To clarify further, so, you talk about in the book of how dopamine is, the difference between wanting versus actually getting the thing. Does it matter how fulfilled you feel when you get the thing that you're going for, even if you turn around and go for it again? Like a drug addict, having a drug and wanting it that wanting, then they get the drug and then presumably, they just do it again compared to me with the workaholism, I strive for these things that I want to do with my work, and then I get them. That feels really good and I don't feel unhappy from that. Then I just go for something else. Does your perception of getting what you wanted matter?

Anna Lembke: Uh-huh. Right. Good question, interesting question. Perception is a tricky thing. But I would say in general, the phenomenon of being addicted to something is characterized by the law of diminishing returns, which is to say that thing that we seek out and get is extremely pleasurable, or rewarding, or motivating to us the first time. Then we naturally work very hard to try to recreate that experience because that's how we've been wired over millions of years of evolution, which is to approach pleasure and avoid pain. It's what's kept us alive and procreating. But what happens with addiction generally is that, with repeated exposure to the same or similar reward, it becomes less rewarding over time. A couple hypotheses in your case, it could be that you are just in this lucky category of your drug, I mean, your rewards not yet reaching that point of diminishing returns, which is to say that eventually you will get there [laughs] or it could just be that somehow you've unlocked the secret to a type of reward that is rewarding and meaningful to you in a way that doesn't trigger this vicious cycle of compulsive overconsumption. 

Also, just going back to what you said originally about this wanting versus liking, we know that dopamine is released when we do something that's pleasurable. It is also fundamental to this process of motivation, which is slightly different from pleasure. Motivation is the amount of effort we're willing to extend to get that reward. What we've learned through neuroscience and also our own natural experiments in our lives is that, dopamine is integral not just to the experience of pleasure, but to the motivation to seek it out. One of the ways that scientists have shown this is they engineered a rodent to have no dopamine, essentially no dopamine transmission. What they learned was that if they put food in that animal's mouth, it would chew the food and seem to get pleasure from the food, swallow the food. But if they put the food a mere body length away, the animal would die of starvation not having enough motivation to get up and move that small distance to get the food. This idea that dopamine is important not just to the experience of pleasure and reward, but also to the motivation to get the reward. The way that that plays out is very interesting, because it's essentially the dopamine deficit state that follows on the heels of reward that drives the incentive to seek it out again.

Melanie Avalon: That is so fascinating. I remember you talking about that experiment with the rats and that just blew my mind. What is the baseline state of human being? We keep talking about pain and pleasure, and wanting and liking, and getting things. What is baseline? Is it no pain, or no pleasure, or is it 50-50 pain, 50 pain, 50 pleasure? When an organism is born, what makes them even want something if they haven't had anything to know that they want it?

Anna Lembke: To understand this, I think it's important to understand that we have learned in the past 75 years that pleasure and pain are co-located in the brain, which means that the same parts of the brain that process pleasure also process pain. In my book, I describe the way that pleasure and pain interrelate with each other by using the extended metaphor of a balance, which I think just makes it more understandable. Imagine that in that part of your brain called the 'reward pathway,' which is a very old and conserved part of the brain, similar across species and through millions of years of evolution. There is a balance like a teeter-totter in a kid's playground or a board carefully balanced on a fulcrum. At our resting state, that board on the fulcrum is level with the ground, it's not tipped to one side or the other. That balance represents how we process pleasure and pain, because they work opposite sides of a balance when we experience something pleasurable, the balance tips one way, and when we experience something painful, the balance tips in the opposite direction.

Now, there are three rules governing this balance. The first is that the balance wants to remain level. Then our brains will work very hard to restore level balance with any deviation from neutrality. The way that the brain restores level balance is by tipping the balance an equal and opposite amount to whatever the initial stimulus was. If I do something that's pleasurable, then I get a little release of dopamine, my balance tips to the side of pleasure. But in response, my brain adapts to that pleasure by tipping my balance an equal and opposite amount to the side of pain before going level again. So that means that every pleasure has a cost. The second important rule governing that balance is that, with repeated exposure to the same or similar stimulus, that initial response to get to pleasure gets weaker and shorter, but that aftereffect to the side of pain gets stronger and longer. One of the ways that I imagined this is that there are these neuroadaptation gremlins that hop on the pain side of the balance in response to any pleasurable stimulus. But they like it on the balance, so they stay on until it's tipped an equal and opposite amount to the side of pain. That's the come down the hangover, the aftereffect before hopping off and restoring the level balance. 

But if we continue to bombard our pleasure side with highly reinforcing drugs and behaviors, then we end up with more and more gremlins on the pain side of balance until there we've got like a whole village and they're camped out with their tents and barbecues in tow. That is addiction. That is when we've entered that vortex of compulsive overconsumption, where now, we need to use our drug of choice not to feel good, but just to restore a level balance. When we're not using, we're experiencing the universal symptoms of withdrawal from any addictive substance, which is anxiety, irritability, insomnia, dysphoria, and craving. I think really, all of us today can to some extent relate to this, even with just with our smartphones. That is when we get a text, it's reinforcing and makes us feel good, little blip of dopamine. That we put it away and say to ourselves, "Now, I'm going to focus on this other task," and yet, they remain in our minds, this burning compulsion to want to check it again, and again, and again. That really suggests that now we've got gremlins popping up and down on the pain side of balance that are compelling us to do the work to essentially restore homeostasis. Because remember, the driving biological principle is that the balance wants to be level. 

The final rule governing this balance is that the balance remembers. It has a very keen memory for those initial stimuli that either produce pleasure or produce pain. But we are almost amnestic for the gremlins. That is, we don't remember the come down. Likewise on the pain side, I know that when I exercise those gremlins will help on the pleasure side and give me dopamine through this process called hormesis for upregulation of my own dopamine. And yet, I'm incredibly amnestic about that 24 hours later, when I get up and I think, I don't want to exercise. Even though, I should remember how good I felt afterwards, all I remember is the pain. Likewise, all we remember about the good stuff is the euphoric recall of how we felt, but we don't remember all the bad stuff that came afterwards.

Melanie Avalon: It's so fascinating and I've been really realizing it in myself this past week, because I told you just before recording, I got COVID last week. So, I lost my sense of taste a few days ago. I follow intermittent fasting protocol and I eat pretty much a very similar meal every single night. It's been fascinating to watch myself eat. Because I can't taste the food at all, like at all. But I still want to eat the same amount that I always do. I'm still enjoying the process. I've been watching myself engage with that. I'm not getting any pleasure from the food. Zero pleasure and yet, I still watch myself wanting to keep eating. That has really made me realize, "Wow, if I'm having this response to this, I can't even imagine getting off of hard drugs. We are still getting the pleasure from it."

Anna Lembke: We all have a baseline tonic level of dopamine firing and that's a signal to us that allows us to know what to approach and what to avoid. Again, if it's something reinforcing, then we get more dopamine. It goes above that baseline level, we tip our balance was at a pleasure. When you are eating without being able to taste, what's absent for you is the dopamine release that comes from eating that food. But what is still present for you is the response to your hunger. Hunger is one of the ways that we are balanced tips to the side of pain spontaneously as part of our survival mechanism. I'm hungry, my hunger is now motivating me to do the work to get some food, both because it's pleasurable, but also because it allows me to restore homeostasis. So, I just wanted to put that out there in terms of the parallel things that might have been going on.

Melanie Avalon: I'm really glad you said that and I was actually thinking about that or I have been thinking about it. While eating at night, I've been thinking, "Is this getting rid of my hunger and so, that's why I'm doing it?" Or, is it, "Am I just addicted to this ritual of eating?"

Anna Lembke: Right. That's a very good point, too, that we do develop all these rituals around these reinforcing substances and behaviors, and they become part and parcel of the experience as well, where I remember I had this fascinating case of a young man in China, who was addicted to heroin and his parents paid for him to have the addiction surgery. Now, he had no idea what the addiction surgery was, but essentially, they put in a naltrexone implant, naltrexone is an opioid receptor blocker, which meant that for the next six months, he would not be able to feel anything from injecting heroin. But he just continued to inject on a daily basis, partially, because he thought that somehow magically it would take away, I don't know the whole ritual around it as well as the craving. It didn't actually do that, even though it was effectively giving him no reinforcing effects to take the heroin. But it was just part of his sort of ritualistic routine, which just speaks to the level at which addiction is this innate reflexive response to wanting to restore homeostasis once we're in withdrawal. But it is also all of these other meta narratives and behaviors that surround that deeply ingrained behavior that goes along with the reinforcing effects.

Melanie Avalon: When I've been eating, I was literally thinking about naltrexone and I was thinking, "If I had an addiction that could be treated by that, would I have the same response that I'm having with the food, where it doesn't even matter that it takes away the reward?" Because I'm just so ingrained in the ritual of all of it.

Anna Lembke: Yeah, the other thing too, is that, hypothetically, if you permanently lost your ability to taste from COVID, theoretically, that would eventually extinguish your craving for foods that taste good and you would get to a point, where you would just basically eat for the sake of fuel that would of course, be horrible. That's what we see in in animal studies. For example, if you train a rat to press a lever to get cocaine immediately delivered to its bloodstream, the rat will essentially press that lever until it exhausts itself and can't move or until it dies. But if you then stopped delivering cocaine through or whatever the drug is through that mechanism of the lever press, eventually, that behavior will extinguish and the animal will no longer work to press the lever, because the drug's no longer forthcoming. Although, interestingly, if you then expose that animal to a significant stressor, like a very painful foot shock, it will then reflexively run to the lever and start pressing it again, as a way to create access to that reinforcing drug, which does speak to one of the many risk factors for drug relapse, which is an acute stressor.

Melanie Avalon: Is addiction only really possible in a society, or a situation, or in an environment, where you do have access to these either hyperpalatable or these rewards that we wouldn't be able to get in nature? When did addictions start?

Anna Lembke: Uh-huh. Yeah, great question. I think since the beginning of recorded time, there have been accounts of individuals, who could not use various intoxicants in moderation. You can go very, very far back, thousands of years to find these accounts. As long as there has been the discovery of intoxicants in nature, whether from grain alcohol, or from opium from the poppy plant or coca leaves, there have been individuals vulnerable to the problem of addiction. Yet, the majority of individuals have been able to use these substances in moderation. That's still true today. There's about a 10% to 15% lifetime prevalence for alcohol and drug addiction. In terms of behavioral addictions like pornography, gambling, video games, we don't have as good numbers. But it would probably be something in that range.

What's different today is that we have so much more access to a much broader variety of even more potent drugs that we've all become more vulnerable to the problem of addiction, which means that addiction rates are going up, including in demographic groups that were previously less vulnerable to the problem like older people and women. Likewise, we have many, many more people struggling with minor compulsive overconsumption and mild forms of addiction, unlike the one that I describe happened to me with romance novels. 

Now, other people might not have conceptualized that my experience through the lens of addiction and it's partially the work that I do that led me to look at it through that lens. But I think it's a really useful lens for conceptualizing addiction really as very much a spectrum disorder and this idea that we're all potentially vulnerable given enough access to potent and reinforcing drugs.

Melanie Avalon: Yeah, for listeners, you've got to get Dopamine Nation and read all of Dr. Lembke's story about the romance novels and all of that. I just thought it was really, really eye opening. I have a super random question. You talk about in the book, the level of dopamine that is, well, I guess, it's not released, it's encouraged to be released or released. You talk about the dopamine levels of different substances. So, morphine, or ephedrine, or meth. But you also mentioned orgasms, for example. Is the orgasm feeling, is that literally, dopamine or some other neurotransmitter?

Anna Lembke: Yeah, it's not just dopamine and let me just say that dopamine is not the only neurotransmitter involved in pleasure, reward, motivation, but it is the final common pathway for all addictive substances and behaviors. An orgasm is characterized by a flooding of our brains in that moment by dopamine, serotonin, norepinephrine, all kinds of endogenous feel-good hormones, which makes sex addiction and pornography addiction really difficult, frankly to overcome, because you don't have to go out to the store and get it. All you need is your own body and your imagination. Sex addiction is true and real thing, and potentially life threatening, and certainly, devastating for people with the more severe forms, and on the rise with 24/7 access to these digital images, increasingly graphic digital images, as well as people themselves on the other end. It's an addiction. It's really taken hold and I'm seeing more and more patients coming in with devastating consequences of sex addiction.

Melanie Avalon: Do we know why certain people get addicted to certain things and not others? Why can one person experience an orgasm and not get addicted to sex, but another person does?

Anna Lembke: Yeah, so interesting. This interindividual variability, this concept of drug of choice that what tilts your balances and pleasure may not tilt mine and vice versa. You know what? We don't have very much Information. One of the things I did in writing this book was went looking for that and couldn't find very much talk to the leading neuroscientists. Interestingly, there isn't a lot of knowledge on this. I speculate that from an evolutionary perspective, there's a good argument for making sure that within the tribe, people like different things. A priori are just attracted to different things, which is to say, if everybody, we're looking for the red berry, then we would have too many red berries and not enough let's say, grain, or water, or other people to potentially increase our mating potential. I think that Mother Nature has covered this by making sure that people are different in this regard, and are attracted to different things, and working for different kinds of rewards. So, at the end of the day, the tribe as a whole has what it needs.

Melanie Avalon: I was thinking of it maybe it was something societal, where what you just said, that people needed to do different things in order to keep the society going like how people are different sleep chronotypes, because to function as a society, we needed to have people alert at different times of the day.

Anna Lembke: Oh, that's interesting. I've not heard that before, but that makes sense.

Melanie Avalon: Yeah. I think about it with songs, for example, why do certain people become so obsessed with certain songs and other people don't. Sometimes, you first hear a song and you could care less about it, but then you keep hearing it and then it grows on you. But then you get tired of it like it's the same arc. So, what role does repetitive exposure play in addiction, even if you don't initially like it?

Anna Lembke: Well, if that thing is inherently addictive, then your brain will cycle through the very same phenomenon as if you had originally liked that thing, which is to say, with repeated exposure, that initial pleasurable response or just that initial response, even if not all that pleasurable gets weaker and shorter. But the after response that come down stronger and longer, and now, you really want that thing not really to experience pleasure, but just to restore homeostasis. Obviously, I'm making a big inference and that's hypothetical. But I think another analogy is, if you think about the use of opioids and the treatment of pain, so people, who can get addicted to opioids prescribed by their doctor for pain, and what they will tell you, which I'm sure is true is that, when they first took the opioid, it did not give them any kind of sense of euphoria. It just relieved them from pain temporarily. But it doesn't really matter that euphoria wasn't present. You can still get addicted just because it relieves some kind of pain. That balance, it doesn't really-- Even if it starts out tip to the side of pain, that process of neuroadaptation, and gremlins compensating on the aftereffect, and changing the setpoint that still occurs. So, I could speculate that that's what's going on there with the [unintelligible [00:33:05] that is.

Melanie Avalon: Maybe before we discuss about the way out of this, short of treating, this is sort of esoteric, but do you think our bodies or brains will ever evolve to adapt to a society of plenty, where we don't get addicted? Or, will those who get addicted just get weeded out by their own addictions, so, we wouldn't adapt to it? 

Anna Lembke: Yeah. Well, I think we have to adapt, because we are literally titillating ourselves to death. 70% of global deaths are attributable to diseases caused by modifiable risk factors like smoking, overeating, inactivity. We're also dying of drug and alcohol addiction at higher numbers than ever before. The opioid epidemic is the most visible and tragic example of that. It's very clear that we need to figure this outrates of depression, anxiety, suicide are going up alarmingly and are highest in rich nations compared to poor ones. As you know, I hypothesize that that's because we're getting too much dopamine. I really think we do need to figure this out. It's of some urgency. I think it's going to take hundreds, if not thousands of years, but I am optimistic that we will eventually get there. It's going to take on an individual level doing the things that I talk about in my book, which is intentionally abstaining from certain forms of pleasure and intentionally seeking out psychologically and physically difficult or painful things to try to reset our pleasure setpoint. I also believe that we need a top-down effort. So, collectively, our schools, our governments, our corporations need to help us in this endeavor. It can't be expected that we will just have to use our own individual willpower and know how to try to avoid these temptations. I think collectively we have to have a top-down approach as well that helps us do that.

Melanie Avalon: To clarify, do you think it's possible that our actual brains could evolve to adapt to a higher dopamine rich environment, where we don't get the withdrawal or the negative side effects? Or, is it going to be behavioral changes that we have to make?

Anna Lembke: That reflexive pleasure-pain balance that I've been talking about, that's been conserved across millions of years of evolution, has endured across species. I don't think that is going to change. But what can and likely will change is the gray matter areas that interact and communicate actively with that pleasure-pain balance to optimize our ability to regulate it and interfere with the reflexive nature of it.

Melanie Avalon: Okay, gotcha. Do some people, when they find themselves addicted, can everybody recover or are some people destined to be addicted for the rest of their life, because of changes in the brain?

Anna Lembke: Well, yeah, so, just like other mental illnesses, addiction is a biopsychosocial disease. People can and do recover and I do hold up people in recovery from severe addiction as modern-day profits for the rest of us. It's very possible to recover, but as with any disease, whether it's addiction, or it's cancer, or it's depression, some people with very severe forms will die of their disease and they will not ultimately be able to get well, and of course, that's a terrible tragedy. But I think most people, especially those with mild to moderate forms will be able to achieve recovery. Now, we do think of addiction as a chronic relapsing and remitting disease. It's not like you're cured and you never have the problem again. It's an ongoing, dynamic state, the state of being in recovery. But I would say that, we're all in recovery from life. When I think about this pleasure-pain balance, I really think about it as not on a triangular fulcrum, but really, on a ball, like, a beam on a ball, you might have to imagine in a circus, where in order to stay balanced on that beam, on that ball, we're constantly having to maneuver and shift our footwork, and make adjustments in order to stay in balance. 

People with addiction in recovery have to do that. The rest of us have to do that, too, every day, "It's okay. I have to adjust here, I have to adjust there." That's because the world is constantly changing to continue to try to draw us in. The example that I use in the book is the idea of gluten-free diet. People with celiac disease can't have gluten, which means that they can't have things with flour in them, which means that in general, historically, they haven't been able to have a lot of the kinds of cakes, and sweets, and snack foods that other people can have. In recent decades, a lot of people adopted the gluten diet, not because they have celiac disease, but because it became a good way to restrict certain categories of foods. Well, what did the gluten industry do? It immediately started to make all kinds of gluten-free cakes and cookies. Then all of a sudden, being gluten free, didn't confer that advantage as a restrictive category. The same thing happens with drugs all the time. Nicotine and cannabis are now available in so-called medicinal forms. Just as soon as you figure out how to stop using a certain drug, it represents itself in a new packaging that says, "Hey, I'm good for you, now."

Melanie Avalon: I did want to ask you about that, because people often say, like CBD, cannabis, for example, is "not addictive." Why do they say that and is that true?

Anna Lembke: Uh-huh. There are more than 400 active ingredients in cannabis. The ones that we're most familiar with are THC and CBD. THC binds CB1 receptors and is addictive. CBD binds CB2 receptors and is not addictive. It's really true that CBD is not addictive. The problem is that it's actually very hard to get pure CBD. A lot of these so-called pure CBD products, which are not well regulated, actually have THC in them and/or people are intentionally using a tincture that combines both of those things. THC is highly addictive. So, that's the complexity there. It is true that CBD is not addictive. It's really hard to know if you're just getting CBD.

Melanie Avalon: Even if It's not addictive as a literal compound in your brain, can anything in theory become addictive, if we perceive it as something addictive like a habit?

Anna Lembke: Yeah, so, habit versus addiction. Habit describes a behavior that we do that is outside of conscious awareness, that we can start doing that thing without even really realizing that we're doing it, whether it's biting your nails, picking our nose, sucking the thumb, whatever it is. In many ways, habits are really useful, because it's a very energy efficient way of engaging in motor activities without the cognitive load of having to think about doing it. Tying my shoes is a habit. I no longer have to think about making the bunny ears and having the bunny go down the hole or whatever. Habit in and of itself is not a bad thing, although, we can have bad habits.

Addiction encompasses habit and yet is more than that. There's certainly a level of automaticity in most of our addictions, where we start doing the thing before we even realize that we're doing it. But addiction is beyond habit and it's negative, almost always negative. I think of addiction conceptually as, again, a maladaptive form of coping that encompasses habit. I think CBD is a tough example, because the science to date suggests that it actually doesn't have much impact on the brain, even though, it is FDA approved for this rare form of epilepsy and even though a lot of people swear by it. The controlled studies suggest it's really no different from placebo or a sugar pill. 

On the other hand, placebos are powerful. Even when people know they're taking a placebo, if they were told that it helped other people, they will have benefit from it, even when they know it's a placebo. So, I guess, what you're asking in a way is something like, if you believe that what you're doing, releases dopamine, is that the same thing as releasing dopamine? I don't know the answer to that question.

Melanie Avalon: That was what I was wondering. Going back to the solution here, I feel there's two big camps that are here. One of them you talk about at length in the book, so something complete abstinence. Like AA for Alcoholics Anonymous, for example, compared to a camp of more moderation. How do you feel about those two different approaches? Is it that some people just really do require complete abstinence forever? Can some people moderate? What does the recovery pathway look like, especially in regards to abstinence?

Anna Lembke: Whether your goal is abstinence or your goal is moderation, the place to start is a period of abstinence long enough to allow those neuroadaptation gremlins to hop off the pain side of the balance, so that baseline homeostasis can be restored. When patients come in to me and they say, "Ultimately, I'd like to use this substance or behavior" normal people, I say, "Okay, I can help you with that. I can try to help you with that. But first, you have to abstain for 30 days, because otherwise, you're not going to reset reward pathways." It is much harder to go from using a lot to using in moderation than it is to go from using a lot to using none going into moderation. It always begins with this period of abstinence. Again, I argue that the neuroscience supports that path. Then in terms of after that month of abstinence and resetting reward pathways, who should continue to abstain and who can use in moderation? I don't even have the ability to predict that. You might think based on past experience that I could predict that, but I've really given up trying to make those types of predictions and I just really try to help patients do the experiments to figure out for themselves. 

What I can tell you is that, if you're going to try moderation, then it's very important to be very specific about what the goal of moderation is. We have data for alcohol, but we don't really have data for anything else. It just comes down to, "Well, what sounds like moderation to you?" Moderation usually means not daily use. It usually means not binge use. People are pretty good at thinking about, "Okay, well, I think I want to smoke this many days in a week or a month under these conditions with this type of substance, or play this many video games under these conditions with this type of video game, or whatever it is." I talk a lot in the book about various self-binding strategies, because I think it's an important point when we're talking about absence versus moderation that there are frankly certain drugs that it's impossible to abstain from. If you're addicted to food, you can't just stop eating. If you're addicted to digital devices, for most people, their work requires them to be on devices to be able to do their jobs. So, then the discussion of moderation becomes a universal one, where we then all need to think about, "Okay, how can I manage my consumption of this thing that I essentially must consume in the modern world or for my survival?"

Melanie Avalon: I love the section on categorical self-binding. I've thought about this a lot, especially being the host of the Intermittent Fasting Podcast. I really think the reason that intermittent fasting works so well for people, especially if you're reading your book is because it's categorical self-binding. You have your eating window, and so, you really can only eat during your eating window, and so it solves or it addresses all the issues of overconsuming all day.

Anna Lembke: Right. I think you mean chronological self-binding as categorical--?

Melanie Avalon: Oh, yeah. Categorical was going gluten free.

Anna Lembke: Yes, that's right, that's right.

Melanie Avalon: Like paleo or something. 

Anna Lembke: Right. 

Melanie Avalon: Yeah. So, what were the different ones? 

Anna Lembke: Yeah. It's physical self-binding or what I call geographical, which are literal barriers in space. There is chronological self-binding, which is using time as a construct and then there are these categorical ones where you say, "Well, I'm going to do this type of food, but not that type of food." But I absolutely agree with you. The intermittent fasting is a really great example of chronological self-binding and how by just putting up these guardrails of saying, "I am going to eat during these times and not during these other times." It sort of releases you. You don't then perseverate in those times of not eating. You're like, "Nope, this is my not eating time." Then in the eating time, you're like, "Yeah, I can pretty much eat whatever I want, because this is my eating time." I think for some people, that works just really, really well and works much better than saying, "Well, I'm going to have-- I'm not going to have cakes and cookies, but I can eat at any time." 

I think the other reason that it works really nicely is, because as we approach the end of our day, we also tend to exhaust our willpower. If we haven't put a hard stop on the time that we are going to stop eating, it can be harder and harder to stop as we want to reward ourselves at the end of day, whereas we say to ourselves, "You know what? Come whatever 5 PM, 7 PM, 9 PM, I can't eat past that." Then it's like, "Oh, there it is. It's Cinderella on her pumpkin. No more carriage, it's a pumpkin." I have found the inter-chronological binding to be super helpful with food as well.

Melanie Avalon: Yeah, people will often say to me that they can ever do intermittent fasting, because it requires too much willpower. My response is, it's the answer to not having willpower, because you don't have to make all those decisions all day. You just have your system.

Anna Lembke: Right. And the other thing, I think, with intermittent fasting is that, we actually wake up with more willpower than we're going to have for the rest of the day. If you're going to exercise your willpower, it is I think in the morning easier to do that. At the end of the day, you can make sure that you have a time when you're eating then, but that also has a cutoff point.

Melanie Avalon: And then, one other last thing that you talk about that was so, so interesting to me was the role of shame and guilt in recovery and this concept of pro-social shame. I was wondering if you could talk just a little bit about that. What is the role of engaging with other people when we're trying to address these addictions?

Anna Lembke: Yeah. I think it's important to acknowledge that one of the things that actually can perpetuate addiction is shame. Feeling shameful about that behavior, and then hiding it from others, and then using more of our addictive substance in order to just deal with the increased shame, then terrible, vicious loop. But it's also very true that shame can be leveraged in a positive way to help launch us into better and more healthy behaviors. An Alcoholics Anonymous is a really good example of a mutual help group that is both de-shaming in the sense that people realize they're not alone and they're accepted for who they are, and their behavior is one that other people understand and share. But at the same time, pro-social shame is leveraged in the sense that then you're engaging in this activity of changing your behavior and working the program with other people. Then there's this desire to not use because it would be shameful to have to go back and say, I relapsed. You want to get your 30-day chip, your 60-day chip, your 90-day chip, you don't want to have to go and tell your sponsor, "Oh, I drank again." 

But importantly, if you do use again and you are honest about it, you will be warmheartedly accepted into the fold. You won't be shunned for that behavior. So, that's really important about pro-social shaming. Shame is one of our most social emotions. It's the fear of abandonment when we admit to the shameful behavior that both motivates us to keep the behavior hidden, which perpetuates it, but also strongly motivates us not to repeat that behavior, because we don't want to have the experience of shame that is so painful to endure.

Melanie Avalon: You also talk about the role of radical honesty and the narrative that we tell about our addictions and also a really cool section on just lying with your patients. What role does honesty about their addictions play? Do you think most people are honest about their addictions or is that possibly one of the biggest hurdling blocks to tackling one's addiction? 

Anna Lembke: Well, whether you have addiction or not, we're all natural liars. I think on average, we tell one to two little white lies per day, unless we're really working hard not to do that. One of the recurring themes that I've seen in my work with patients with severe addiction is that, it is almost impossible to get into recovery without practicing radical honesty. Another way of saying that is that, truth telling is fundamental to recovery. I've heard that whether people get into recovery through AA, which makes honesty one of their most important philosophical doctrines, or they get into recovery on their own, or by other means. Almost everybody in recovery discovers that they need to be radically honest, not just about their drug use and their addiction, but really about everything. That became a source of fascination to me and one that then I tried to incorporate into my own life, "Can I go through a whole day and not lie about anything?" 

The lies that we tell all of us tend to be those lies that cover up things that small acts of selfishness or things we're embarrassed about things that we think would make us look a little bit better in somebody else's eyes. They seem really inconsequential, but I believe-- I've come to believe through my patients that they actually are highly consequential. That fundamental to managing our own compulsive overconsumption in this reward weary world that we live in is and begins with radical truth telling. Actually, setting up a little watchdog organization in our own minds, where we're monitoring whether or not we're telling the truth. 

I try to practice that as do my patients. I talk about all the myriad ways, why I think it's an ingredient for a life well lived. But even I'm practicing it every once in a while, now, I find myself [unintelligible [00:52:41] that wasn't entirely true, was it? It really was two hours, whatever the detail. But I said it was four. It's just so funny when you start observing yourself and going, "Gee, that's so weird. Why should I--? Who cares? Only I care about that." But anyway, it's another very fascinating exercise that I recommend and I do prescribe it to my patients, too, as they're trying to quit their drug of choices. The other thing you have to do this month is to not tell a lie about anything, because it's fundamental to your ability to manage that reflexive pleasure-pain balance.

Melanie Avalon: I love that so much. One of the things that I'm actually most grateful for from my upbringing is, I should ask my mom about this. I don't know why, but her one thing for us that was like the worst was no lying. It was just made so clear that you do not lie. That's stuck with me.

Anna Lembke: Yeah, that's great. Well, give your mama a big pat on the back. I was actually raised in a family, where there was a lot of lies. It took me well into midlife frankly to even realize on some level or that I was lying as much as I was in small ways, and then, quite a bit longer to try to get a hold on it. I'm very fortunate that I married a man, who lies less than average I would say and he really also helped open my eyes to that. 

Melanie Avalon: Well, thank you so much, Dr. Lembke. This has been absolutely incredible. I really cannot recommend not only your book enough, I just want to thank you for everything that you're doing, because it is really, truly life changing. Listeners will have to get your book and I will say just as a complete tangent. Now, I feel they need to reevaluate a lot of the studies they've done on rats on the running wheel, because you talked about how they're actually, potentially addicted to running. 

Anna Lembke: Oh, yeah. That was fascinating. I learned that through the process of reading the book that, neuroscientists used to believe that a running wheel was inert and just a way to measure physical activity of rodents in captivity. But then they discovered that, running wheels are actually a drug and that some animals will run themselves to death. They like it so much. Even animals in the wild will engage in a running wheel in preference to their many natural awards, which I think just speaks volumes to all the ways in which we've now drugified exercise. But that's for another day, maybe. 

Melanie Avalon: It's so, so incredible. It just makes you wonder-- I don't know when they figured that out, but it makes you wonder what other things might be going on as just go to protocols and experiments that might actually have completely different implications. It's fascinating. Thank you so, so much. The last question I ask every single guest on this show and it's just because I realized more and more each day how important mindset is. So, what is something that you're grateful for?

Anna Lembke: Oh, my gosh. I'm grateful for so much, but I probably at the top of the list is my family, and my patients, and my students.

Melanie Avalon: Awesome. Well, thank you, Dr. Lembke. We'll put links to all of your websites and your books in the show notes, and hopefully, you can come back again in the future. This was absolutely amazing.

Anna Lembke: Yeah, a nice conversation for me, too. Thank you so much for having me.

Melanie Avalon: Thank you. Bye.

Anna Lembke: Bye-bye.

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