The Exchanges

Q us are addicted too, myself included. Together we explore dopamine, what it is and how it works, addiction and why behaviors can be as addictive as drugs, early warning signs to look for in yourself and others, treatment, and her struggles with insomnia. Let's take a simple idea and take it seriously. It's time to listen and learn. Let's just jump right in. What is dopamine? How does it work?

A So dopamine is a chemical that we make in our brain. Um, it's a neurotransmitter, and neurotransmitters are the molecules that bridge the gap between neurons, and that gap is called the synapse. So neurotransmitters allow for fine tuning of the electrical circuits that are conducted by the neurons themselves. Dopamine is the most important neurotransmitter for the experience of pleasure, reward, and motivation. It's not the only neurotransmitter involved in that process, but it is the common pathway for all reinforcing substances and behaviors. Anything that's 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.

AI assessment note: “dopamine is a chemical that we make in our brain. Um, it's a neurotransmitter”

Q Can you go deeper on that, that the decrease from a baseline I'm assuming?

A Sure. So to, in order to understand that, it's, it's essential to appreciate that pleasure and pain are co-located in the brain. So the same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance. If you imagine like a central fulcrum and a beam on that fulcrum, something like a teeter-totter in a kid's playground, and that represents how we process pleasure and pain. And there are three rules governing that balance, and the first and most important rule is that the balance wants to remain level. It doesn't want to be tilted very long to the side of pleasure or pain, and our brains will work very hard to restore a level balance with any deviation from neutrality. So for example, let's say I read a romance novel, I get a release of dopamine in my pleasure pathway or my reward circuit, and my balance tilts to the side of pleasure. No sooner has that happened than my brain starts to adapt to that increased dopamine by downregulating my own dopamine receptors and my own dopamine production, not just to baseline levels, but actually below baseline levels, and this is really the key piece of neuroadaptation. I like to imagine this as these little neuroadaptation gremlins who hop on the pain side of the balance to bring it level again, but the gremlins really like it on the balance, so they don't get off as soon as the balance is lev…

AI assessment note: “downregulating my own dopamine receptors... not just to baseline levels, but actually below baseline levels”

Q There's a couple of interesting things you said there. One, motivation. So what's the correlation or tie between dopamine and motivation?

A Well, it was originally thought that dopamine was primarily related to the experience of pleasure, euphoria, getting high, but a series of important experiments suggest that dopamine may be even more important for motivation, that is our willingness to do the work to get high, uh, than for the experience of pleasure itself. And one very important seminal study, uh, Bioengineered rats to have no dopamine receptors in their reward circuit. And what the researchers discovered is if they put food in that rat's mouth, it would eat the food and seem to get pleasure from the food. But if they put the food even a body length away, the rat would starve to death. So the absence of dopamine in that reward circuit essentially took away uh,, ah, that uh,, ah, that rodent's desire to strive uh,, ah, to do the work to get the reward.

AI assessment note: “dopamine may be even more important for motivation, that is our willingness to do the work”

Q So, so that's just it, right? So the, the motivation part of this is. We have a goal, we want to do something, and we get a dopamine response from that, so we're motivated to do it.

A Well, it's first of all that we have to have been exposed to that stimulus and have experienced it as reinforcing in some way, and then that lays down really a very permanent lifetime memory of that experience and the desire to recreate it in order to, uh, again, experience the release of dopamine. Once we are reminded of our drug of choice, we actually get a little bit high, or we get a little release of dopamine in the reward circuit that then also creates the desire or craving to want to do the work. The other thing is that, uh, that's very important here is that once people start to become addicted, what's salient is not so much the release of dopamine when they're getting high or experiencing pleasure, but But it's actually the decrease in dopamine in between or the dopamine deficit state that leaves them in a constant state of craving that then motivates them to want to do the work.

AI assessment note: “Well, it's first of all that we have to have been exposed to that stimulus”

Q And so we can be addicted to substances and addicted to behaviors. It's almost as if there's a spectrum. Is there something that makes one particular thing more addictive than another?

A Yeah, so this is a great question. 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. However, the huge caveat to that is that there's enormous inter-individual variability. So what might release a lot of dopamine in your reward circuit might not release a lot of dopamine in my reward circuit, and vice versa. In general, intoxicants tend to be intoxicating for the, the majority of people, but, you know, there are people for whom, uh, regular intoxicants are actively aversive, and they would not seek those intoxicants out again. Um, also importantly, you know, speaking to sort of the, the world we live in now, there are so many more drugs than there used to be, and even, you know, healthy activities have become drugified, And the result is that we're all more exposed to a potential drug of choice, and hence also all more vulnerable to the problem of addiction.

AI assessment note: “the more dopamine a substance or behavior releases in the reward circuit, and the faster”

Q So two, two follow-ups there. One is, is there a component of treatment that involves, uh, addressing the double life or the honesty with yourself?

A Well, what I've developed over the years is asking, explicitly talking about the double life, which is familiar to many people with addiction. But one thing that I do is I actually prescribe honesty, uh, or what I call radical honesty. So in addition to asking patients to abstain from their drug of choice for Um, in order to reset reward pathways, what I also say to them is, and you can't tell any lies this month. Um, and these aren't, I don't just mean you can't lie about your use. Um, I mean, you can't lie about anything, which turns out to be really hard to do, because the average adult tells one to two lies per day. Um, and usually it's little lies about sort of why we were late for a meeting. Um, but even those little lies can trip us up and get us telling the bigger lies related to our addiction.

AI assessment note: “one thing that I do is I actually prescribe honesty, uh, or what I call radical honesty”

Q I want to come to sort of some of the factors that lead to addiction, but before we do that, when we seek out dopamine, are we trying to get pleasure, or are we trying to avoid pain?

A Really, initially, it's about either getting pleasure or solving a problem. So some people use, you know, not because they're looking to have fun, although that's definitely a reason that many people use. Some people are actively using drugs and drug, drugified behaviors, uh, in order to solve a problem, and that problem can range from, you know, anxiety, depression, insomnia, poor concentration, to loneliness, uh, Boredom. Existential crisis. So there are lots and lots of, um, sort of reasons that people use to get out of a dysphoric state, which also explains why people with co-occurring psychiatric disorders are generally at higher risk of developing addiction than people without those disorders because individuals with psychiatric disorders are more likely to turn to a substance to try to solve that psychiatric, psychological, or emotional problem. Once people have started to take their drug regularly, whether or not they started for fun or to solve a problem, they will eventually end up in this dopamine deficit state where they've changed their reward threshold, and then the drug use, especially the compulsive, repetitive nature of the drug use, is essentially to get out of pain or restore level balance. So in other words, in other words, we start chasing our tail.

AI assessment note: “Really, initially, it's about either getting pleasure or solving a problem.”

Q What are the, the early warning signs that, uh, we can look for in ourselves for addiction?

A One important early warning sign is something called the double life or the lying habit. This is where we start to lie about what we're consuming, how much and how often. Um, and we're lying to other people, but we're also in a way lying to ourselves. It's very easy to minimize in our own minds, um, how much and how often we're consuming our drug of choice. And it's very hard to see the true impact of our drug use on our lives while we're chasing dopamine. So an early indicator is that we need to, uh, you know, pay attention to when we're, um, You know, lying, even if we're just sort of telling the truth about using, but we're minimizing the amounts or the frequency. One of my very beloved patients once told me that when he was in addiction, he developed the lying habit, which, which meant that he was lying not just about his drug use, but really about all kinds of things, even unrelated to his drug use. So for example, if he was having lunch at Burger King and a friend called and said, where are you? He'd say, oh, I'm at McDonald's. If he was at McDonald's, he'd say, I'm at Burger King. And it didn't make any sense, and there was no reason to lie, but his brain had just sort of flipped into the lying habit, so I think that's a really important thing to pay attention to. The other things are the, you know, just the four C's. Out of control use, using more than we plan to on any…

AI assessment note: “One important early warning sign is something called the double life or the lying habit.”

Q The second question was sort of around the, you know, abstinence for 30 days. It's one thing to say that, but people are, there's an addiction here. How is it, are there sort of like, uh, ways that people can, uh, do this that they're unaware of? Cause I mean, it sounds like 30 days sounds like this incredibly long period of time.

A Well, first of all, I, I want to acknowledge that for some people that ask is too much and that people with severe addiction You know, in, remaining in their usual environment will be unable to do that. And, and, you know, it, it becomes pretty obvious pretty early who those people are. They'll just say, I, there's no way I can do that, or I've tried that a million times and it doesn't work for me. And that's where we then recommend a higher level of care. So for example, an intensive outpatient program where people go all day and go home at night, or an even higher level of care where they go and they stay in a residential facility where they don't have access to their drug. And you know, the rehab is sort of like the butt of many jokes these days, but I can tell you as an addiction treatment provider, I'm very grateful for residential treatment settings and for rehabs because I have many patients who would never have been able to get into recovery without a restricted environment that allowed them to get their frontal lobe back in line so they could actually make choices about their lives. That's what people don't understand. They think that people are choosing to use, but once people Are addicted. Their, their reward centers have essentially been hijacked and they've lost a great deal of their autonomy and their ability to choose. They can even, they can want to stop and yet…

AI assessment note: “And that's where we then recommend a higher level of care.”

Q With your fellows, I'm super curious as to what's the hardest thing to teach them, or hardest thing for them to learn?

A My fellows come from many different backgrounds. Some are psychiatrists, but many of them are family medicine and internal medicine doctors. For those doctors, the hardest thing for them is To adjust to having more time with patients. They're used to having, you know, 15 to 30 minutes where they have to go through a list of 10 significant health problems, and for them to have, you know, 30 to 60 minutes to really open up Pandora's box about, um, psychological and emotional problems, including addiction, is, is very, very strange, and it can make them very anxious, but once they start to do it and learn to do it, they love it, and then many of them sort of don't want to go back Practicing primary care, uh, because they just feel like the depth of the connection and the meaningfulness of the interactions is so much more powerful. Um, I think that then, you know, just generally for all fellows, I think the hardest thing is, um, to know, you know, when we're helping patients and when we're enabling them, um, because there are ways in which we as healthcare providers can enable our patients' addiction, um, And so trying to, it's important to be really alert to that. You know, for example, uh, let's say a young person who comes to see us, not because they really wanted to get into recovery, but because their parents insist they come. And so they show up and they're checking the box a…

AI assessment note: “the hardest thing is, um, to know, you know, when we're helping patients”

Q Addiction, like, We seem to use this term very cavalierly, which leads us to sort of discount addiction. Like we even joke around about how we're addicted to something like addicted to going to the gym, or how do you define addiction?

A So when I use the word addiction, I'm really, um, talking about a severe form of psychopathology that is defined as the continued compulsive use of a substance or behavior despite harm to self and or others. When we make this clinical diagnosis, we use the Diagnostic and Statistical Manual of Mental Disorders, which has these 11 criteria. The more criteria you meet, the more addicted you are on a spectrum of mild, moderate to severe, and those criteria can, ah, simply be summarized as the four C's. Control, compulsions, cravings, and consequences. Importantly, um, quantity and frequency are not in those criteria. It's not because quantity and frequency don't matter. If you use more of a drug and you use it more often, you're more likely to get addicted. Uh, but the reason that it's not in the DSM, which is our sort of Bible of diagnosis, Is because they wanted a unifying diagnosis for all different forms of addiction, and so they didn't want to put quantity and frequency in there. Also, we don't really have good data for how much is too much, except for alcohol, where we have pretty good data for that. So quantity and frequency matter. They're not technically in the diagnosis. The diagnosis is based on these complex behaviors that ultimately lead to significant consequences. And the person's inability to stop in the face of those consequences. I think when people use the term a…

AI assessment note: “defined as the continued compulsive use of a substance or behavior despite harm”

Q of like, does that come across with alcohol when, uh, people say their tolerance is going up, right? So originally you have like one drink of wine and maybe you get a little buzz out of it and you're happy, but, you know, fast forward a couple of years and now all of a sudden it takes three glasses of wine to get to the same sort of mental state.

A Yes. So tolerance is definitely a marker of, um, a brain that is, um, entering, you know, that dopamine deficit state chronically, and therefore, um, you know, at risk of addiction, but tolerance alone isn't sufficient to make the diagnosis of addiction. Um, it must be associated with these compulsive out of control behaviors in the face of ongoing consequences. And the other thing is that tolerance is just one aspect of this dopamine deficit state. I think what people really underestimate is the kind of chronic dysphoria that results from chronic exposure to drugs of all kinds. And let me give you an example of a very common clinical scenario that I encounter. I have a patient who comes in, and they're here to see me for depression or for anxiety, which they Identify as part of a major depressive disorder or generalized anxiety disorder, panic disorder, what have you. And I discover in the course of my clinical screening that this person is smoking cannabis every day, or compulsively masturbating to pornography every day, or playing video games for hours on end every day. And what I suggest to them, based on what I know about the neuroscience of pleasure and pain, is that their depression and anxiety Uh, is potentially actually being caused by their compulsive consumption of their drug of choice, and that they've driven their brains into this dopamine deficit state as their br…

AI assessment note: “Yes. So tolerance is definitely a marker of, um, a brain that is”

Q And how long do we have to stop? What is long enough? Is this like seven days, 30 days, half a year?

A It probably differs, you know, from situation to situation, but I can tell you after decades of clinical work, um, and this, this, this is supported, this idea is supported by many of my colleagues and also by, uh, some of the, uh, early neuroscience into this area, is that for people who have become addicted, um, Um, 30 days is the bare minimum to begin to reset reward pathways. Two weeks is almost never enough. What happens when we first stop our drug of choice is that our pleasure pain balance slams down to the side of pain. We experience the universal symptoms of withdrawal. Some are unique to that drug, uh, but, but the others, the psychological ones are universal, and those, um, will persist for about two weeks, and then once people get to week three or week four of abstinence, the sun starts to come out. People start to, Notice improvements in their baseline mood, anxiety, and functioning, sleep, concentration, everything. So in general, I advise 30 days of abstinence. This is, um, also supported by some preliminary work by Nora Volkoff of the National Institute of Drug Abuse, which has, she has shown in imaging studies that if you image the nucleus accumbens, which is the, one of the key areas of the reward circuit, if you image the nucleus accumbens two weeks After individuals who have been addicted to a variety of drugs have stopped using, and you compare their dopami…

AI assessment note: “30 days is the bare minimum to begin to reset reward pathways.”

Q So at a high level, what does sort of treatment look like from your point of view? Are there sort of steps that people commonly go through, uh, you know, abstinence seeming to be one of them?

A So the treatment is a biopsychosocial treatment because it's a biopsychosocial disease, and that means there are biological origins and interventions, there are psychological origins and interventions, and there are social or contextual origins and interventions. So when I think about biological interventions, the first and most important step is to restore homeostasis or baseline dopamine firing, and typically the way we do that is we ask patients for 30 days of abstinence from their drug of choice. Now, importantly, we would not ask this of somebody who was at risk for life-threatening withdrawal. So, for example, um, people can have life-threatening withdrawal from alcohol, from benzodiazepines like Xanax, from opioids like OxyContin. So, in those situations where there was risk of that, we would want to medically manage detox to get people Off of the drug. Or in some cases, we would actually want to use a drug in order to restore homeostasis. The classic examples of that are using methadone maintenance or buprenorphine to restore a level balance in people with severe opioid use disorder. They're not getting high on those opioids. They're basically just getting a level playing field to be able to, you know, enter other aspects of recovery. Um, Um, so that, that biological piece is, is really important, but even after restoring homeostasis, um, you know, it's not like the sol…

AI assessment note: “the first and most important step is to restore homeostasis or baseline dopamine firing”

Q Alcoholics Anonymous seems to be sort of one of the best methods of treatment available for a lot of people. What is it and why is it so successful? What are the, the inherent components of it that make it more likely to succeed?

A So Alcoholics Anonymous was started in the 19 thirties by two men who themselves were, uh, addicted to alcohol, Dr. Bob and Bill W. And they came together in desperation and realized that by talking to each other and sharing their lived experiences, they managed amazingly not to drink, even when all these other medical interventions hadn't been helpful. So they essentially started going around and finding other alcoholics and talking to them about their experiences and having them talk about their experiences and found that through that process they were able to remain sober. So they founded Alcoholics Anonymous. It's, uh, it's got its own philosophy, the 12 Steps, as well as the 12 Traditions, um, and it's, um, not a religious organization, but a cornerstone of the philosophy is this idea of Of surrender to a, um, a higher power. Now that higher power can be really anything you want it to be, as long as it's not you. Part of the, um, philosophy of Alcoholics Anonymous is that part of what drives addiction is what they call self-will run riot or narcissism. And letting go of being the person who's, um, willing our lives and instead surrendering it, surrendering it to a higher power, which can, you know, again, be a, a supernatural power, or can be just the fellowship itself, or can, as they joke in A, can even be the doorknob, as long as it's not you, is something that, that is…

AI assessment note: “realized that by talking to each other and sharing their lived experiences”

Q It sounds like focus is also important, and I'm sort of reading between the lines here. If, if, I focus on the gap between now and 30 days from now. That seems almost insurmountable. And so it's like, why bother trying? But if I focus on, uh, what can I do today? Talk to me a little bit about how, where people focus changes their ability to accomplish things.

A Yeah. Well, one of the very famous AA sayings is take it one day at a time. And there is something really biochemically important and magical about the 24 hour cycle. Our willpower is not, you know, an inexhaustible resource. We wake up in the morning, whenever our morning is, with more willpower than we'll have at the end of the day because we've tired it out. So we can't exclusively rely on our willpower. We have to really, um, you know, put what I call self-binding strategies or barriers between ourselves and our drug of choice that allows us to press the pause button between desire and consumption and But amazingly, you know, after sleep, after a night of sleep, we're renewed again, you know, we, we can start over. So there's something very, very powerful about just saying, if I can just make it through today without using, you know, I can start again and be reborn again tomorrow. And that really does happen biochemically.

AI assessment note: “take it one day at a time. And there is something really biochemically important”