Essentials: Understanding & Treating Addiction | Dr. Anna Lembke

The pleasure-pain balance and dopamine deficit state

Dr. Anna Lemke explains how pleasure and pain are co-located in the brain and work like a balance - every pleasurable stimulus triggers an equal and opposite pain response. Chronic overindulgence resets the balance toward pain, creating a dopamine deficit state that mimics clinical depression.

"One of the most significant findings in neuroscience in the last 75 years is that pleasure and pain are co-located, which means the same parts of the brain that process pleasure also process pain. And they work like a balance."

The 30-day dopamine reset for breaking addiction

Lemke describes the clinical protocol for resetting the dopamine system - 30 days of complete abstinence from the addictive substance or behavior, with the first two weeks being the hardest before improvement begins in week three.

"30 days is in my clinical experience, the average amount of time it takes for the brain to reset reward pathways for dopamine transmission to regenerate itself."

Why addicts relapse when things are going well

Lemke reveals a counterintuitive trigger for relapse - success and good times. The dopamine spike from a win creates a deficit state that drives craving, and the relaxation of the hypervigilant state needed to stay sober leaves people vulnerable.

"So we hear about successful transitions through this, at least anecdotally, and maybe some clinical say, what is going on? What is going on? It doesn't make any sense to me. Yeah. So I think it's good that you're skeptical. I think we all should be skeptical. Having said that, there are clinical studies showing, and these are small studies and they're short duration, small number of subjects, but, you know, taking people, for example, who are addicted to alcohol and then having them have this, let's say, psychedelic experience in a very controlled setting. So either typically it's a high dose psilocybin or three dose, as I saw it for the MAP study of MDMA, of ecstasy. Those are sort of the, seem to be the kind of bread and butter of this kind of work. Right. But the thing to really keep in mind is that this is completely interwoven with regular psychotherapy and that these are highly selected individuals. And clinical trials. Right. Right. We're referring to legal clinical trials. Right, right. When it works, it's a transformational experience because it gives the person another lens through which to view their lives, which I think for some people is positive and powerful because they can come back from that and be like, oh my gosh, I care about my family and I want X, Y, or Z for them. And I realized that my continuing to drink is not going to achieve that. So it's almost like a spiritual or values-based. So I think it can be very powerful. But having said that, I truly am quite skeptical because addiction is a chronic relapsing and remitting problem. It's hard for me to imagine that there's something that works very quickly short-term that's going to work for a disease that's really long-lasting. Yeah. The two addicts I know that did MDMA-assisted psychotherapy as part of this thing both got worse. Yeah. But the people I know who had severe trauma who took this approach seemed to be doing better. Okay. Interesting. And so I think that the discussion as we hear it now is just sort of psychedelics, which is a huge category that includes many different drugs and compounds with different effects. And we hear about trauma and addiction lumped together. And I think it's going to be important for people to know that this is definitely not a one-size-fits-all kind of thing, but it sounds like it may have some utility under certain conditions. Yeah, I think so. I think we, I'm trying to be very open-minded about its potential utility for certain individuals, but I can tell you in my clinical work, what is a very concerning, unintended consequence of this narrative is I have a lot of people who are looking for some kind of spiritual awakening who on their own, not in the context of any kind of therapeutic psychological work, you know, microdose or want to try, you know, psilocybin or MDMA with a friend or wherever so they can have this, you know, spiritual experience that they can figure out their lives. That's a disaster and almost never works out well. And I can just tell you that the downstream effect for the average person is that they've misconstrued the data on the use of psychedelics for mental health conditions to this idea that they're safe or that anybody can take them in any circumstance and have this kind of awakening. And that's not what the data show, right? The data are these highly controlled settings. There are a couple other things I just want to touch on, but they all relate to social media. Okay. I have to imagine that we need to regulate, not necessarily eliminate this behavior. How addicting is it? And what is healthy social media behavior? The first message I would want to get across about social media is that it really is a drug and it's engineered to be a drug, which doesn't mean that we can't use it, but we need to be very thoughtful about the way we use it. And so that means with intention and in advance planning our use, right? And trying to use it as a really awesome tool to potentially connect with other people and not to be used by it or get lost in it. We do need to figure out, you know, how to make this tool something that's, you know, going to be good for us and not ultimately harmful. As more and more of us are spending more and more time on social media, we're divesting our libidinous energies, etc., from real-life interactions. So I think our collective challenge, and it should be our mission, is to make sure that we are preserving and maintaining offline ways to connect with each other. So this is the key. You have to, with intention, prior to being in that situation, think of literal, physical, and metacognitive barriers that you can put between yourself and your phone or whatever your drug is to create these intentional spaces where you're not constantly interrupting yourself essentially and distracting yourself. Because I really do think we're losing the ability to have a sustained thought, right? I mean, we get so far and then you get to that point in the thought where it's a little bit hard to know what's coming next. And it's very easy to check your phone or check your email or look something up on the internet. And then you never get that opportunity to finish that thought, which is really the source of creative energy and an original thought, right? You're not just reacting to what's coming at you. Right. And something that could contribute to the world. I know a number of people are going to have questions and want to get in contact with you. You are not on social media. That's correct. Yes. You're true to your ideology. That's great. Thank you so much for sharing this information. And I know I learned a ton and I know everyone else is going to learn a lot more about addiction and the good side of dopamine that's right thank you for having me it's been really really great to talk with you and as mentioned at the beginning of today's episode we are now partnered with momentous supplements because they make single ingredient formulations that are of the absolute highest quality and they ship international."

Truth-telling strengthens prefrontal cortex circuits in recovery

Lemke explains how radical honesty - not just about drug use but about everything - may strengthen prefrontal cortical connections to the limbic brain that get disconnected during addiction, and why social media should be treated as an engineered drug.

"So we hear about successful transitions through this, at least anecdotally, and maybe some clinical say, what is going on? What is going on? It doesn't make any sense to me. Yeah. So I think it's good that you're skeptical. I think we all should be skeptical. Having said that, there are clinical studies showing, and these are small studies and they're short duration, small number of subjects, but, you know, taking people, for example, who are addicted to alcohol and then having them have this, let's say, psychedelic experience in a very controlled setting. So either typically it's a high dose psilocybin or three dose, as I saw it for the MAP study of MDMA, of ecstasy. Those are sort of the, seem to be the kind of bread and butter of this kind of work. Right. But the thing to really keep in mind is that this is completely interwoven with regular psychotherapy and that these are highly selected individuals. And clinical trials. Right. Right. We're referring to legal clinical trials. Right, right. When it works, it's a transformational experience because it gives the person another lens through which to view their lives, which I think for some people is positive and powerful because they can come back from that and be like, oh my gosh, I care about my family and I want X, Y, or Z for them. And I realized that my continuing to drink is not going to achieve that. So it's almost like a spiritual or values-based. So I think it can be very powerful. But having said that, I truly am quite skeptical because addiction is a chronic relapsing and remitting problem. It's hard for me to imagine that there's something that works very quickly short-term that's going to work for a disease that's really long-lasting. Yeah. The two addicts I know that did MDMA-assisted psychotherapy as part of this thing both got worse. Yeah. But the people I know who had severe trauma who took this approach seemed to be doing better. Okay. Interesting. And so I think that the discussion as we hear it now is just sort of psychedelics, which is a huge category that includes many different drugs and compounds with different effects. And we hear about trauma and addiction lumped together. And I think it's going to be important for people to know that this is definitely not a one-size-fits-all kind of thing, but it sounds like it may have some utility under certain conditions. Yeah, I think so. I think we, I'm trying to be very open-minded about its potential utility for certain individuals, but I can tell you in my clinical work, what is a very concerning, unintended consequence of this narrative is I have a lot of people who are looking for some kind of spiritual awakening who on their own, not in the context of any kind of therapeutic psychological work, you know, microdose or want to try, you know, psilocybin or MDMA with a friend or wherever so they can have this, you know, spiritual experience that they can figure out their lives. That's a disaster and almost never works out well. And I can just tell you that the downstream effect for the average person is that they've misconstrued the data on the use of psychedelics for mental health conditions to this idea that they're safe or that anybody can take them in any circumstance and have this kind of awakening. And that's not what the data show, right? The data are these highly controlled settings. There are a couple other things I just want to touch on, but they all relate to social media. Okay. I have to imagine that we need to regulate, not necessarily eliminate this behavior. How addicting is it? And what is healthy social media behavior? The first message I would want to get across about social media is that it really is a drug and it's engineered to be a drug, which doesn't mean that we can't use it, but we need to be very thoughtful about the way we use it. And so that means with intention and in advance planning our use, right? And trying to use it as a really awesome tool to potentially connect with other people and not to be used by it or get lost in it. We do need to figure out, you know, how to make this tool something that's, you know, going to be good for us and not ultimately harmful. As more and more of us are spending more and more time on social media, we're divesting our libidinous energies, etc., from real-life interactions. So I think our collective challenge, and it should be our mission, is to make sure that we are preserving and maintaining offline ways to connect with each other. So this is the key. You have to, with intention, prior to being in that situation, think of literal, physical, and metacognitive barriers that you can put between yourself and your phone or whatever your drug is to create these intentional spaces where you're not constantly interrupting yourself essentially and distracting yourself. Because I really do think we're losing the ability to have a sustained thought, right? I mean, we get so far and then you get to that point in the thought where it's a little bit hard to know what's coming next. And it's very easy to check your phone or check your email or look something up on the internet. And then you never get that opportunity to finish that thought, which is really the source of creative energy and an original thought, right? You're not just reacting to what's coming at you. Right. And something that could contribute to the world. I know a number of people are going to have questions and want to get in contact with you. You are not on social media. That's correct. Yes. You're true to your ideology. That's great. Thank you so much for sharing this information. And I know I learned a ton and I know everyone else is going to learn a lot more about addiction and the good side of dopamine that's right thank you for having me it's been really really great to talk with you and as mentioned at the beginning of today's episode we are now partnered with momentous supplements because they make single ingredient formulations that are of the absolute highest quality and they ship international."