Understanding & Treating Addiction | Dr. Anna Lembke

The episode opens with an introduction from Andrew Huberman, who identifies as a professor of neurobiology and ophthalmology at Stanford School of Medicine. The guest, Dr. Anna Lembke, is introduced as a psychiatrist and Chief of the Addiction Medicine Dual Diagnosis Clinic at Stanford University School of Medicine. She treats patients with drug and alcohol addiction and with behavioral addictions such as gambling and sex addiction. The introduction sets up two claims the discussion goes on to explore: that a wide range of substances and behaviors can become addictive with a common biological underpinning, and that there is a common path to treatment and recovery from essentially all addictions.

The introduction also notes that Lembke appeared in the 2020 Netflix documentary "The Social Dilemma" and has a new book, "Dopamine Nation: Finding Balance in the Age of Indulgence," due out August 24th, 2021. The book is described as combining patient stories with science in a way meant to be accessible to readers with or without a science background. The host adds that the podcast is separate from their teaching and research roles at Stanford.

The discussion begins with the popular idea of "dopamine hits" from Instagram, likes or praise, and asks what most people misunderstand about the molecule. The answer starts with basics. Dopamine is a neurotransmitter that lets a presynaptic neuron communicate with a postsynaptic neuron. It is closely tied to reward, but also to movement. The explanation links the two: early humans had to move to find water or meat, and even a very primitive worm, C. elegans, releases dopamine when it senses food in the environment. Dopamine is described as a really important molecule for pleasure, though not the only neurotransmitter involved.

The central point is that the brain is always releasing dopamine at a tonic baseline rate. Pleasure corresponds to release above that baseline, and a drop below it is experienced as a kind of pain.

it's really the deviation from that baseline rather than hits of dopamine in a vacuum that make a difference.

Asked whether baseline dopamine relates to a person's general happiness or depression, the answer is hedged. There is evidence that people who are depressed "may indeed" have lower tonic dopamine levels, and "some evidence to suggest that that may be true." A firmer claim, described as the core of the book, is that chronic exposure to substances or behaviors that repeatedly release large amounts of dopamine in the reward pathway can lower the tonic baseline over time, as the brain compensates for more dopamine than "we were designed to experience."

On whether genetics sets the baseline, the response is again qualified: in early development and infancy people are "probably" born with a given baseline, but experiences can have a huge impact on where dopamine levels ultimately settle.

The conversation asks whether dopamine sits at the core of temperament, using the contrast between easily excited people and more cynical ones (and, playfully, a very stable bulldog named Costello). The answer opens by admitting uncertainty: "I don't really think we know the answer to that." What can be said is that people are born with different temperaments that affect their ability to experience joy, which modern psychiatry describes with terms like a dysthymic temperament or chronic major depressive disorder.

Research on risk factors for addiction is described as a "mixed bag," but one finding is stated clearly: more impulsive people are more vulnerable to addiction. Impulsivity is defined as difficulty putting space between the thought or desire to do something and actually doing it.

A question about whether a heightened startle reflex reflects impulsivity draws a distinction. A strong startle response is not necessarily related to impulsivity and can instead be related to anxiety, since high-anxiety people tend to startle more. Impulsivity is about a lack of self-editing or worry about future consequences.

The discussion stresses that impulsivity is not always bad. Intimate interactions are offered as one setting where being disinhibited is desirable, and fight-or-flight or battle scenarios as another, where, as the conversation adds, hesitation can cost a life. This leads to a broader view drawn from 25 years of psychiatric practice: some traits now treated as mental illness might be advantageous in a different ecosystem. In a sensory-rich world that demands constant rational evaluation of consequences, impulsivity becomes a difficult trait, without being bad in and of itself. The exchange ends on the observation that there is a fine line between spontaneity and impulsivity.

Asked what pleasure is, the answer resists a tidy definition. People certainly seek a high or euphoria, but the same substances and behaviors are often used to escape pain. In conversations with people with addiction, the first use of a drug is sometimes about pleasure but very often about escaping suffering. And as addiction develops, even those who started out seeking pleasure end up mainly trying to avoid the pain of withdrawal or the consequences of their drug use. The conclusion is that pleasure is not a unitary thing and is "certainly not just getting a high."

The conversation contrasts dancing for the joy of it with seeking pleasure to eliminate pain, which suggests someone who feels lost, depressed or underwhelmed. It also recalls an earlier remark that many people with addiction feel normal life is not interesting enough and seek a super normal experience, so that even the word "balance" in the book's title can feel aversive to them. This is set against an online culture of leaning hard into life and finding one's passion, with Steve Jobs's Stanford commencement speech cited as an example.

The response argues that life has always been hard for humans but is now hard in unprecedented ways, mainly because it is boring. Survival needs are met, and people above a certain level of financial wellbeing don't even need to leave home to meet every physical need. The argument acknowledges an enormous gap between rich and poor, but claims it is smaller than ever in human history, and that even the poorest have more excess income for leisure goods than ever before.

Leisure time is offered as evidence: people without a high school education are said to have 42% more leisure time than people with a college degree. The claim is that because we don't really have anything we have to do, everyone is forced to "make stuff up," such as becoming a scientist, doctor, Olympic athlete or Everest climber. People vary in how much friction they need, and those who need a lot and don't get it are really unhappy. Many people seen in the clinic with addiction and other mental illnesses are described this way.

They're unhappy, not necessarily because there's something wrong with their brain, but because their brain is not suited to this world.

People in this situation, the discussion suggests, usually don't recognize the mismatch directly. They feel unhappy without knowing why or how to be happier. The "find your passion" narrative is described as partly useful because it gets people out into the world seeking, but also misleading, because people aren't fully aware that the world and life are hard and that "we're all kind of making it up."

The conversation links this to Cal Newport, described as a computer science professor at Georgetown. His book "So Good They Can't Ignore You" argues for building passion through acquiring skills, hard work and feedback rather than by introspection, an idea likened to Carol Dweck's growth mindset. His later books "Deep Work" and "A World Without Email" argue for stepping away from technology and against frequent context switching, mostly for productivity. The aside ends with the observation that neither Newport nor Lembke is on social media, while both are very productive authors.

The core model of the episode is introduced as one of the most significant neuroscience findings of the last 75 years: "pleasure and pain are colocated." The same brain regions process both and act like a balance. Pleasure tips it one way and pain the other. The overriding rule is that the balance wants to stay level, so the brain works hard to restore homeostasis. It does this by producing a tip of equal and opposite size to any stimulus, which the conversation compares to a principle of physics.

A personal example illustrates the model: watching YouTube videos of American Idol tips the balance toward pleasure, and stopping brings a comedown, an equal and opposite tip, felt as the urge to watch one more video.