A Practical Guide to Controlling Addiction & Dopamine | Dr. Anna Lembke | Knowledge Project 159

Introduction to Addiction

Overview: This section introduces the concept of addiction and its prevalence in society. It also introduces Dr. Anna Lemke, a psychiatrist and author, who helps uncover the mysterious gap between pain and pleasure that is so often filled with addiction.

Dopamine

• Dopamine is a neurotransmitter that bridges the gap between neurons and is the most important neurotransmitter for the experience of pleasure, reward, and motivation.

• Anything that is reinforcing releases dopamine in a specific circuit of the brain called the reward circuit. The more dopamine it releases and the faster it releases dopamine, the more reinforcing and potentially addictive that substance or behavior is.

• Dopamine is also related to motivation, as it was originally thought to be primarily related to the experience of pleasure. However, experiments suggest that dopamine may be even more important for motivation than for the experience of pleasure itself.

Pain and Pleasure

• Pain and pleasure are co-located in the brain, as the same parts of the brain that process pleasure also process pain.

• Dopamine is released when we are reminded of our drug of choice, creating a desire or craving to want to do the work.

• Once people become addicted, what's salient is not so much the release of dopamine when they're getting high or experiencing pleasure, but it's actually the decrease in dopamine in between or the dopamine deficit state that leaves them in a constant state of craving.

• This decrease from a baseline is essential to understand, as our brains will work very hard to restore a level balance with any deviation from neutrality.

Treatment

• 30 days is the bare minimum to begin to reset reward pathways, while two weeks is almost never enough.

• Warning signs and treatment for addiction should be taken seriously, as it is a serious issue that can have long-term consequences.

Understanding Addiction

Overview: This section covers the basics of addiction, including the concept of homeostasis, the universal symptoms of withdrawal, and the two rules of the balance.

Homeostasis

• Addiction is caused by an imbalance in the brain, with the urge to find and use more of a drug of choice overwhelming.

• If we don't wait for homeostasis to be restored, we accumulate more and more Gremlins on the pain side of the balance until we are in an addicted brain.

• This leads to universal symptoms of withdrawal such as irritability, insomnia, dysphoria, and craving.

Two Rules of the Balance

• The first rule is that for every pleasure we pay a price and that price is pain.

• The second rule is that with repeated exposure to the same or similar stimulus, the initial response to pleasure gets weaker and shorter and the after response to pain gets stronger and longer.

Recovery

• The primary goal of recovery from addiction is to restore homeostasis or a level balance.

• This is usually done by abstaining from the drug of choice for long enough for all of those Gremlins to hop off.

• In cases where abstinence is not possible, medications can be used to help restore homeostasis.

Modern World

• This finely-tuned neural circuitry evolved over millions of years of evolution and remains unchanged across species.

• However, it is maladapted for the world of overwhelming abundance we live in now, where almost every human activity has become drugified in some way.

• This makes it difficult to thrive as humans, as we are not adapted for the world we have created.

Defining Addiction

• When talking about addiction, it is important to distinguish between casual and clinical use of the term.

• Clinically, addiction is defined as the continued compulsive use of a substance or behavior despite harm to self and/or others.

• The DSM has 11 criteria for making this diagnosis, which can be summarized as the four C's: control, compulsions, cravings, and consequences.

• Quantity and frequency are not included in the criteria, but they do matter when it comes to addiction.

Understanding Dopamine and Addiction

Overview: This section discusses the role of dopamine in addiction, the inter-individual variability in dopamine release, the drugification of healthy activities, and the factors that lead to addiction.

Dopamine and Addiction

• In general, the more dopamine a substance or behavior releases in the reward circuit and the faster it releases dopamine, the more likely it is to be addictive.

• There is enormous inter-individual variability in dopamine release, and some people find regular intoxicants aversive.

• With the increased availability of drugs, we are all more exposed to potential drug of choice and hence more vulnerable to addiction.

Motivations for Drug Use

• People use drugs for pleasure, but also to solve problems such as anxiety, depression, insomnia, poor concentration, loneliness, boredom, and existential crisis.

• People with co-occurring psychiatric disorders are at higher risk of developing addiction.

Dopamine Deficit State

• People who take drugs regularly eventually end up in a dopamine deficit state, where they have changed their reward threshold.

• The compulsive, repetitive nature of drug use is to get out of pain or restore level balance.

• Tolerance is a marker of a brain entering a dopamine deficit state, but it is not sufficient to make the diagnosis of addiction.

• Chronic exposure to drugs can lead to chronic dysphoria.

Clinical Scenario

• Patients often come in for depression or anxiety, but upon further screening, it is discovered that they are using drugs to solve a problem.

• I suggest to them that their depression and anxiety is being caused by their compulsive consumption of their drug of choice.

• Abstaining from their drug of choice for a month can help reset reward pathways and alleviate symptoms of depression and anxiety.

Overview of Withdrawal Symptoms

Overview: This section provides an overview of the universal symptoms of withdrawal from any substance or drugified behavior, as well as the importance of abstaining for at least 30 days.

Universal Symptoms of Withdrawal

• Anxiety

• Irritability

• Insomnia

• Dysphoria

• Craving

Importance of Abstinence

• Imaging studies have shown that two weeks after stopping using, people are still in a dopamine deficit state.

• A study by Shuck and Brown showed that 80% of individuals no longer met criteria for major depressive episode after four weeks of abstinence.

Understanding Addiction

Overview: This section provides an overview of the various doorways into addiction, as well as the importance of recognizing addiction as its own primary progressive disease.

Doorways Into Addiction

• Seeking out substances to have fun

• Self-medicating a psychological problem

• Escaping a traumatic situation

Recognizing Addiction

• Addiction is its own primary progressive disease, and cannot be resolved by treating the underlying depression or trauma.

• Addiction requires biopsychosocial treatment in order to get into recovery.

Early Warning Signs of Addiction

Overview: This section provides an overview of the early warning signs of addiction, such as the double life or lying habit.

Early Warning Signs

• Double life or lying habit - lying about what is being consumed, how much, and how often.

• Minimizing in one's own mind how much and how often substances are being used.

Understanding Addiction and Treatment

Overview: This section covers the basics of addiction, including the four C's of addiction (out of control use, compulsive use, narrowly focused on the drug, and craving), as well as the biopsychosocial approach to treatment.

The Four C's of Addiction

• Out of Control Use: Using more than planned on any given occasion.

• Compulsive Use: Automatic initiation of use, even when not planned.

• Narrowly Focused on the Drug: Mental real estate occupied with thoughts of using the drug.

• Craving: Overwhelming feelings of wanting to use, manifested as intrusive thoughts or physical symptoms.

Biopsychosocial Approach to Treatment

• Biological Interventions: The first step is to restore homeostasis or baseline dopamine firing, typically through 30 days of abstinence from the drug of choice.

• Psychological Interventions: Openness and willingness to listen to the impact of consumption on oneself and those around them.

• Social/Contextual Interventions: Insulating oneself from triggers and reminders of the drug of choice.

• Medications: Naltrexone is an opioid receptor blocker used to treat opioid and alcohol addiction. It limits the reinforcing effects of craving.

Addiction Treatment Overview

Overview: This section provides an overview of addiction treatment, including the importance of human connection, social peace, and radical honesty.

Human Connection

• Addiction treatment is about re-teaching people how to be in meaningful, gratifying, and intimate connections with others.

• Having a sober social network of friends can help people avoid using drugs.

Social Peace

• Addiction treatment should also address contextual reasons and stressors that lead to addiction.

Radical Honesty

• In addition to abstaining from drugs for 30 days, patients are asked to practice radical honesty and not tell any lies.

• Radical honesty helps people break the cycle of addiction by resetting reward pathways and making it easier to make healthy choices.

Abstinence

• For some people, 30 days of abstinence is too much and they may need a higher level of care such as an intensive outpatient program or residential treatment facility.

• People with severe addiction may need a restricted environment to get their frontal lobe back in line and make healthy choices.

• Patients who want help are often willing to try abstinence for 30 days if they understand the promise of what might get better if they do.

• It is important to prepare for the difficulty of the first two weeks and let support structures know that the patient may not be well.

• In addition to radical honesty, patients are encouraged to do things that are hard during this time to reset reward pathways.

Stress and Addiction

Overview: This section discusses the relationship between stress and addiction, and how living in a world of overabundance can be its own source of stress. It also looks at how poverty and unemployment are serious forms of stress, and how poor people living in Rich Nations have access to highly potent cheap forms of dopamine.

The Definition of Stress

• Stress is any deviation from homeostasis or our neutral Baseline position.

• Constant stimulation and hits of pleasure from our phones, coffee, donuts, Netflix, etc. can cause stress.

• Social dislocation, multi-generational trauma, poverty, and unemployment are all sources of stress.

The Nexus of Risk Factors for Addiction

• Poor people living in Rich Nations have access to luxury goods and highly potent cheap forms of dopamine.

• Animal experiments show that if a rat is addicted to Cocaine, taking the cocaine away will eventually extinguish the behavior.

• Severe pain can trigger relapse due to the huge dopamine release it causes.

Alcoholics Anonymous

• Alcoholics Anonymous was started in the 1930s by two men who were addicted to alcohol.

• It has its own philosophy, the 12 steps and 12 traditions, and is not a religious organization.

• A Cornerstone of the philosophy is the idea of surrendering to a higher power.

• It is successful because it is unaffiliated with any Financial, political, or other external organization.

• It is about talking to each other and sharing their lived experiences.

• Part of what drives addiction is self-will run Riot or narcissism, and letting go of being the person who's willing our lives.

• Millions of people have gotten into recovery through Alcoholics Anonymous.

Leveraging Pro-Social Shame in Addiction Recovery

Overview: This section discusses how pro-social shame can be used to motivate people to get into recovery and how Alcoholics Anonymous leverages this concept.

Shame as a Motivator

• A lot of what can both drive addiction but also motivate people to get into recovery is the shame they feel for their behaviors related to their use.

• Alcoholics Anonymous has a huge de-shaming process that happens when people join, as they realize they are not alone and not some horrible human.

• Alcoholics Anonymous has a lot of behaviors it asks people to do, such as counting their days and going to a meeting every day, which can help motivate people to not use.

• There is a lot of support and celebration of abstinence, and internalized anticipated shame if they were to relapse.

Rituals and Focus

• Rituals can act as a counterbalance to feeling isolated and alone.

• There are many ritualistic aspects to Alcoholics Anonymous, such as going to meetings, telling stories, and getting chips for days without using.

• The most critical period is the beginning, where you're going through the abstinence and your brain starts to reset.

• Focus is important, as focusing on the gap between now and 30 days from now can seem insurmountable.

• AA's famous saying "take it one day at a time" is biochemically important, as willpower is not inexhaustible and needs to be renewed after sleep.

Understanding Substance Use Rituals

Overview: This section discusses the common rituals associated with substance use, such as using at the end of the day or using to reward oneself. It also looks at how people can normalize their substance use by affiliating with others who use similarly and in heavy amounts.

Using at the End of the Day

• Many people use at the end of the day as a way to reward themselves after a hard day's work.

• Over time, this reward can become less effective and lead to disappointment.

• People may also use at the end of the day due to being tired, hungry, lonely, or angry.

• Some people use first thing in the morning, while others have different using rituals.

Normalizing Substance Use

• People may normalize their substance use by affiliating with others who use similarly and in heavy amounts.

• They may also rationalize their use by saying they only use on special occasions or at parties.

• However, this can lead to finding a party every night of the week and normalizing problematic use.

How Dr. Goldstein Got Interested in Addiction Treatment

Overview: This section looks at how Dr. Goldstein got interested in addiction treatment. He initially wasn't interested in treating patients with addiction, but he had a patient who was frequently nodding off in sessions and he realized he had missed the signs of opioid addiction. After this experience, he decided to learn as much as he could about addiction and started attending California Society of Addiction Medicine meetings.

Dr. Goldstein's Experience

• Dr. Goldstein initially wasn't interested in treating patients with addiction.

• He had a patient who was frequently nodding off in sessions and he realized he had missed the signs of opioid addiction.

• He had not asked her about drugs and alcohol and had misread her falling asleep as a response to Paxil.

• After this experience, he decided to learn as much as he could about addiction and started attending California Society of Addiction Medicine meetings.

Insomnia and Addiction

Overview: This section discusses the difficulty of teaching medical fellows to adjust to having more time with patients, as well as the challenge of knowing when healthcare providers are helping or enabling their patients' addiction. It also covers the concept of motivational interviewing and how it can be used to help motivate people to make a change.

Adjusting to More Time with Patients

• Many medical fellows come from backgrounds where they are used to having 15-30 minutes with patients, so adjusting to 30-60 minutes to discuss psychological and emotional problems, including addiction, can be difficult.

• Once they start to do it and learn to do it, many of them don't want to go back to practicing primary care because of the depth of the connection and meaningfulness of the interactions.

Knowing When to Help or Enable

• It is important to be alert to when healthcare providers are helping or enabling their patients' addiction.

• If a patient is asking for help but not really showing up psychologically, it is important to have a discussion about what they want and how to help them get there.

• One red flag is if the healthcare provider is working harder for the patient than the patient is working for themselves.

Motivational Interviewing

• Motivational interviewing is a way to package certain psychotherapeutic techniques that have existed for many decades in a way that can help move people from not being motivated to address a certain problem to being motivated to do it.

• It involves asking people questions, giving feedback, rolling with resistance, and exploring their motivations.

Example

• The speaker shares an example of her own trouble with sleeping and insomnia, which began when she stopped nursing her last child.

• She discovered a certain genre of romance novels that allowed her to deal with the time between trying to go to sleep and actually falling asleep.

• She eventually became physically dependent on this behavior and realized she was addicted to it when she started wanting to read romance novels instead of engaging in other activities.

• She decided to stop for 30 days to take the advice she gives her patients, and found it incredibly difficult.

Sleep Struggles

Overview: This section discusses the speaker's struggles with sleep and how they have learned to cope with it.

Sleep Habits

• The speaker has struggled with sleep for many years, but has been able to improve their sleep habits over time.

• They still experience peak anxiety when trying to fall asleep, but have learned to accept it and know that it doesn't occur every night.

Sleep Expectations

• The speaker believes that people's expectations around sleep in the modern world are too high.

• It is normal to have intermittent awakenings throughout the night, and it is also normal to wake up in the middle of the night.

• Exercise is the most potent sleeping pill, but it is not foolproof.

Success

• The speaker defines success as having a good day, which is made up of a lot of small accomplishments.

• Examples of a good day include feeling a sense of accomplishment from a project or having dinner with family.