Anna Lembke, M.D.: Navigating an Addictive Culture
“We are living in a world that primes us all for the problem of addiction. So even though some people come into this world more vulnerable than others, simply being alive in the world today has made us all vulnerable to the problem of addiction,” so says Dr. Anna Lembke. Dr. Lembke is a professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. An expert in all things addiction, Dr. Lembke has published more than a hundred peer-reviewed papers, book chapters, and commentaries; she sits on the board of several state and national addiction-focused organizations, has testified before various Congressional Committees, and does so all while maintaining a thriving clinical practice.
On the podcast, we discuss her instant New York Times Bestseller, Dopamine Nation: Finding Balance in the Age of Indulgence, which explores the many faces of addiction. Dr. Lembke notes that addiction is a spectrum disorder, and though we often attempt to otherize “addicts”, the exact same mental machinery engaged in so-called severe addiction is engaged in the compulsive over-consumption that afflicts many of us. We discuss the way in which our brain is wired to balance pleasure and pain and how to know when our consumption has crossed from healthy, recreational use to addictive, maladaptive use. Finally, Dr. Lembke leaves us with some strategies for recalibrating our neural-balance, including the perhaps counterintuitive remedy of exposing ourselves to pain in order to treat our pain.
EPISODE HIGHLIGHTS:
Identifying the risk factors for addiction…(5:53)
The balance between pleasure and pain…(11:45)
The Dopamine Guideposts…(18:49)
Finding healing stories and re-calibrating the neuro-plasticity of the brain…(28:21)
MORE FROM ANNA LEMBKE:
Dopamine Nation: Finding Balance in the Age of Indulgence
Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop
EPISODE TRANSCRIPT:
(Edited slightly for clarity.)
ELISE LOEHNEN:
One, I liked sort of the way that you get into these concepts of addiction and pain chemically, but obviously there's a through line here of like, what are the underlying issues and the ways that we temper our suffering, or seek relief, that's beyond narrow chemistry. Obviously it's a complicated dance and it's one of those, like, I'd say primary issues of our day, right? And how do we think about addiction too, on a spectrum? Because I have, you know, recovering addicts in my life, where it's very different than as you write about sort of like your fascination with romance novels or my workaholism, which you could almost say is slightly, pro-social? But how do you, when, when you work with people, how do you even find the spectrum in terms of deciding when something is problematic enough to be even diagnosable as a problem?
ANNA LEMBKE, M.D.:
Yeah, I mean, I, I think you're making an important point that addiction is a spectrum disorder and the diagnostic and statistical manual of mental disorders, which is our Bible in psychiatry, even acknowledges that spectrum by ranking it in mild, moderate, and severe categories. And although, you know, it may seem that somebody with very severe addiction, somebody who's adversely impacted their health, their relationships maybe, maybe has legal problems, maybe has lost housing and relationships. It may seem on the surface that those individuals don't have much in common with the rest of us who are struggling with our more minor addictions to our smartphones, or in my case, romance novels. But what I argue in the book is that really the same mental machinery that is being engaged in severe addiction is also being engaged in more modest compulsive over-consumption. And that by understanding and recognizing that we, we it's, it's really powerful and enlightening and can help all of us observe our own addictive types of behaviors better. And in observing those, you know, gain some, some mastery over them. So in comparing minor addictions to severe addictions, I, in no way mean to trivialize suffering of people with severe addiction. Instead, I really hold them up as modern day prophets for the rest of us living in a very addictogenic world.
ELISE:
Yeah, no, I loved that, that quote sort of as the, at that you use at the beginning about, about addicts as prophets, and sort of how we may ignore them, or dehumanize them, or otherize them at our own peril. Because it's such an interesting disease and that it feels like, you know, we don't blame people well, in some circles, people, we do blame people for creating cancer in their bodies. Sort of like some of the toxic New Age language would make it, you know, like your, a symptom of your emotions, right. Or, sorry, you're, you're creating disease with your emotions, which can be problematic. But similarly, with addiction. It's like, we, we want to believe that these things are firmly in people's control that they've chosen to ruin their lives and wreak havoc. And so it's sort of that it's such a strange, and complicated, and fascinating as you say, like also a mirror for society in the sense of the line between personal responsibility, genetics, and trauma, you know, all of these other factors, the, the Venn diagram of addiction. What do you think, I mean, do you think it's really just sort of that type of soup? Or when you meet with people, are you able to sort of parse out all the different sort of intervening factors? Like where do you start in your practice?
ANNE:
Well, I mean, one place to start is acknowledging that there are many different risk factors for addiction. One of them is whether or not you have a biological parent or grandparent with addiction, which increases the risk four-fold compared to the general population, even if raised outside of that addictive home. So there is this strong inherited component. Other risk factors include co-occurring mental illness, childhood trauma, unemployment, poverty. But a really important risk factor that, that I try to bring to the fore in Dopamine Nation is access. If you live in a neighborhood where drugs are sold on the street corner, you're more likely to try them and more likely to get addicted. If you go see a doctor who is free with their prescription pad, you are more likely to be exposed to things like opioids and benzodiazepines, and then more likely to become addicted.
So one of the major points I'm trying to make in Dopamine Nation, which is a departure from prior narratives, is that we are living in a world that primes us all for the problem of addiction. So even though some people come into this world more vulnerable than others, simply being alive in the world today has made us all vulnerable to the problem of addiction. And I really want to highlight that because it is absolutely true that you can have the perfect parents, and the perfect childhood, and the perfect education, and the greatest job, and the most loving spouse, and the most wonderful kids, and still get addicted because we're living in this world of incredible increased access. And it's not to minimize the impact of co-occurring mental illness or childhood trauma or any of those things. But it's to really highlight that even without those things in your personal repertoire, you can get really, really addicted.
ELISE:
No, and I think it, it behooves us all. Cause I think that we want to, we want to, again, sort of be like, that's not me. That couldn't be me or my use of screens, phones, ladies erotica…isn't problematic. Don't assign me that label. Whereas I think we all sort of need to come to a collective just also, so we can understand each other better, because it is so common, right. Including what we would call more severe addictions. And they're so multi-variate, I mean, I thought that your case studies throughout the book were fascinating and I love that you got into sex addiction, because I think that's the one too that…and again, like such a, such a difficult diagnosis, right. Because how do you, how do you define what might be, oh, run of the mill infidelity, with something that's like truly unstoppable. And for us it's like such a human experience, right? So like you can't exactly abstain. It's, it's such an interesting and very not well understood from what I understand, like no one really has a common understanding of sex addiction, right? It stands alone?
ANNA:
There's so much shame around sex addiction. I mean, I mean, I think there's shame around addiction in general, but I would say sex addiction in particular has this additional layer of shame associated with it, especially in the current climate with #metoo. And all of the valid concerns about the way, the ways that, you know, people are victims of sexual aggression. And then, you know, in that context, you know, we're talking about somebody who has a serious sex addiction. Gosh, I mean, the shame is just really, really profound. So I appreciate your saying that about sex addiction, because it was, you know, I, I lead in the book with that and I knew it would be controversial. And in fact, I know I've gotten some pushback. Even my own editors were like, well, are you sure you want to put that in the beginning?
At the very beginning? I said, you know, like this story really captures the central problem here. And it's also the story that I personally relate to the most because you know, men are looking, you know, primarily men are looking at pornography, but there are a lot of women out there that are watching, you know, really graphic Netflix series or reading erotica, which really can slip into, you know, a maladaptive addictive problem. And you asked earlier, you know, how do we know when we've crossed that line? And I mean, everybody's case is a little different, but there are some telltale signs. Like, for example, if you're using more and more over time to get the same effect, if you're having serious consequences, it's interfering with your job, with your family, with your relationships. If you start hiding and lying about your use, because on some level, you know, it's not really the thing that you want to be doing, or it's not consistent with your values. These are some of the telltale signs to look for.
ELISE:
Yeah. And those sort of map and like a lack of enjoyment, right? Like this maps to addiction, right. In some ways, whether it's drugs or alcohol, where originally, initially it might provide some sort of massive relief, it might be fun. It might feel like an escape and pleasurable, and then it becomes quickly something that you have to maintain and that while you're doing it, you're kind of hating it. Yet, you can't stop.
ANNA:
Yes. And this gets to the, you know, the neuroscience of what's happening in the brain, which I really wanted to communicate in the book. And I do that by using this metaphor of the balance, because one of the most interesting things that we found in, you know, recent decades is that the same part of the brain that processes pleasure also processes pain, and they work like a balance. So initially, you know, when I read that romance novel, I get a little tilt to the side of pleasure. Dopamine are reward neuro-transmitters released to my brain and I feel good. But one of the overriding principles governing that balance is that it wants to be level. It doesn't want to be tilted to pleasure or to pain for very long. And it will work very hard to restore a level balance, or what neuroscientists call homeostasis.
And it does that by tipping the balance equal and opposite amount to the side of pain. And I imagine that as these little neuro adaptation gremlins hopping on the pain side of the balance, you know, to bring it level again. That's that moment of kind of falling away when the movie ends or the book ends or the video game is over, or, you know, the come down from alcohol, that's that moment of wanting to stretch out that good feeling and, and not being able to. It's the balance tilted to the side of pain. Now, if we wait long enough, those gremlins hop off and balance is again, restored. But if we repeat that behavior again and again, we eventually get so many neuro adaptation gremlins on the pain side of the balance that we're essentially walking around in pain. And then we need to use our drug not to get high, but just to have a level balance. And this is the essential neuro-biological tipping, literal tipping point. When we cross over from, you know, healthy recreational use to addictive maladaptive use,
ELISE:
It is such a powerful and beautiful idea, and such a metaphor for how also we're instructed to live life now, which is this cult of toxic positivity. And everything's supposed to be amazing, and you should be happy, and you should be happy. And there's no, you know, I kind of almost hate the word happy. I think it's actually not very accurate. I don't even know how to describe that state in my life. And so what I go for is like cultivating moments of joy when you're just laughing and it's really fun. And I know in the same way that pleasure is…it makes so much intuitive sense. I know that those moments of joy will be tempered by moments that are really hard, or lonely, or sad. But I feel like culturally, we're sort of fed this lie that we should always be happy and that it should always be pleasurable.
And that suffering isn't sort of a prerequisite for life. Hard things aren't a prerequisite for life. Like that's how we endure and grow and you can't shortcut it. So it's interesting that in our attempts, even to game that, our bodies will check us in ways that can be, I get it, but also set us up for even more pain. I loved that section of the book too. And sort of the discussion in the context of surgery, even how historically, I can't remember, oh, before the 1900’s doctors didn't want to adopt general anesthesia, right because they felt like it inhibited healing? And that's kind of been, is that been proven out that, that there is evidence? I mean, I don't want to go, I don't want to have general surgery without anesthesia either, but pain can be helpful, right?
ANNA:
So that's a great question. And there's no evidence that I know of that the experience of pain actually expedites tissue healing. Bbut there is evidence emerging now that opioids use to mute pain can delay tissue healing, which is really fascinating. Because we're using opioids in a lot of instances and potentially delaying people's recovery from surgery and other painful procedures and diseases. So there's not direct evidence that pain expedites healing, but there certainly is evidence that using substances like opioids can delay healing. But I want to get back to what you said before, because it was, it was really powerful and I think important about our culture, and this kind of making people feel bad for feeling unhappy in their lives. I think it even goes further than that. We tell people that they're sick if they're not happy in their lives. And we sell them this bill of goods that says that, and by the way, everybody else is really happy and you're only you were unhappy. And that's because you're, you know, doing something wrong, you're not well enough, or you're not taking the right medications, which, you know, I need to prescribe for you. Instead of telling people the truth, which is that life is really hard.
And that, you know, that there's an enormous biological mismatch between our pleasure seeking brains and this pleasure saturated world that we live in. And although we can't help ourselves but to seek out pleasure, because that's how we're wired. In fact, in this modern age, it's a mistake, it's a mistake. And that really, there is no pot of gold at the end of the rainbow. And then you're left with, wow, what, what then? And, and my answer to that is there's no pot of gold, but Hey, there's a rainbow. There's a rainbow and you don't always get to predict or control when it comes. And I think that's kind of what you were getting at, by, you know, you talking about trying to be joyful and joyful moments. Joyful moments come unexpectedly and mostly not within our control. And that's the good kind of joy which we have to be patient and wait for. And that is really, really counter-cultural.
ELISE:
No, it's so true. And it's that loneliness or that feeling of failure when everyone else, you know, it's the famous, don't compare your insides to someone else's outsides. The comparison culture that we live in, the as you keep mentioning sort of the access that we have, whether it's just sugar, drugs, like whatever, it may be porn, and then sort of an understanding that some of this is outside of our control. But you, what I also love about the book is that you, you talk about how, because I think what also becomes overwhelming for people is it's like, oh, I'm using my phone too much, but like, there's no way it's very difficult for me to use it less when it's a prerequisite for staying connected to my job or my children, et cetera. Like we're in this culture sex, right? Like, oh, I can't be intimate because I have, you know, I slide out of control.
So I loved sort of bringing it back to the title of the book, the dopamine guideposts that you've established for working with people in terms of helping them. And you talk about sort of specifically for people who have, I think you talk about it in the context of drugs or maybe alcohol, where they can return to use if they're able to do so in a non, with a less severe form of addiction. But it feels like it's a framework that's applicable to sort of almost anything that creates a more human structure for how we engage with the world. So can we go through it and sort of what DOPAMINE stands for?
ANNA:
So this is the algorithm that I teach my residents, and fellows, and medical students, and that we use when we're seeing patients. And it's just really a way to orient on this problem of compulsive over-consumption, whether you have a minor addiction or a severe addiction. And so I created this, this acronym, DOPAMINE. And the D stands for DATA. And what, what I ask patients to do very first is just to describe their use, how much, how often, what are they doing? And it's amazing the power of relating that to another human being, because it's very often the case that we've sort of closeted those facts in a corner of my mind and of our minds in a place where we don't really have to look at them. But when we open that closet and draw that out, as we, as we must do in order to tell another human being. All of a sudden, it becomes real in a way that it hadn't before. I've had so many patients who will start telling me, well, I have about, you know, four glasses of wine a night and, oh my gosh, you know, that comes to, you know, almost 30 glasses of wine, you know, in a week, I really wasn't even aware I was drinking that much.
So it takes on a realness that, that it, it, it doesn't until we tell somebody then the O, of DOPAMINE stands for OBECTIVES. And with that, what we're getting at is why, why do you do it? What is the reason, what does it do for you? I know for me with romance novels, it was just a glorious escape. And it's not even that I had a life that necessarily I would want to escape from, but, you know, it was the end of the day. I was tired. It was just being, not me for, you know, the hour or two that I was reading before bed. And it seemed really innocent at first. And, you know, at first it was relatively innocent. So, you know, that part is kind of acknowledging what, what it does for us, because we are on some level, even when we do irrational things, there's a rational reason behind it.
But then importantly, you know, the P of DOPAMINE stands for PROBLEMS. So we asked folks to say, well, what, what are the problems that you've noticed with your use? And of course, for me, it got to a point where I was reading instead of interacting with my children, my husband. I was reading late into the night instead of getting the sleep that I knew I needed in order to be effective next day. And at one point I was even like reading in between patients instead of writing notes or processing, you know, what we had talked about. I was further and further in this sort of vortex of just wanting to escape. And then the A of DOPAMINE is really the intervention. So you can have all the knowledge in the world, but there are, there are no actions behind it. It's pretty hollow. So the A is for ABSTINENCE.
And that's where we asked patients to take a dopamine fast. And typically I ask for 30 days of not doing their drug, whether it's alcohol, or cannabis, or orgasms in any form, or reading romance novels, or using their smartphones, or using a certain app on their smart phones. Ask them to delete that and really, um, not do that activity. And, and what I say to patients is it's really hard to do that. It is really hard, because you will experience the universal symptoms of withdrawal for any addictive substance: Anxiety, irritability, insomnia, depression, and intrusive thoughts of all the reasons why you really shouldn't abstain and it's okay to use. But if patients can get through the initial two weeks of that, those feelings and those thoughts, most importantly dissipate, and by the time they get to four weeks, people feel free. They feel like, oh my goodness.
You know, I, I feel so much better than I did because it's the pleasure pain balance, restoring homeostasis. We start to regenerate our own dopamine and our own dopamine transmission. We don't rely on this stimulus from the outside. People are able to be more present, they're able to take pleasure and more modest rewards. And here's a really important piece. They're able to see true cause and effect between their drug use and consequences in their, in their lives, which is really hard to do when in our addiction or in our compulsive use. But that period of abstinence allows them to look back. And then very quickly, the rest of the acronym is just M for MINDFULNESS. That's where you observe your thoughts and feelings without judgment, and without reacting to them, including craving, right? You say, oh, wow, like I'm having an intense desire to check my phone.
It's really intense. It's really intense. You know, and, and we, we teach tricks, people can do in those moments, like actually doing painful things or pressing on the pain side to help restore homeostasis faster. And I talk about that in another chapter. I is for INSIGHT because of, again, our ability to see true cause and effect and gain that insight with abstinence and N is for NEXT STEP. So that's when people come back and say, I feel so much better. I'm so glad I abstained. I say, great. What do you want to do next month? Do you want to abstain again? Mostly they say, no, I don't want to abstain again. I want to go back to using, but I want to use differently than I did before. I want to use less. I want to use in a way that doesn't have these consequences. And then finally the E of dopamine stands for EXPERIMENT and say, okay, let's put in some self-binding strategies. Barriers between you and your drug of choice and specific goals for how you want to use this device or this drug so that you don't teeter into that compulsive vortex.
And what we know from both the neuroscience, and patient experience, and experience of people in recovery is that it's, it is possible for some people to use these highly rewarding drugs without becoming compulsive, as long as they put enough time in between use. So you want to avoid daily use. You want to avoid super potent forms. You want to make sure that there's actually some barrier between you and your drug so it's not that easy to get. Those are all the kinds of tricks. So people then go back out and they try that. And if it works great, and if it doesn't, then we, you know, we tweak it again. Okay. That didn't work. You know, do we need biochemical barriers? Should we give you this medicine, like Naltrexone that blocks your opioid receptor, that makes things like drinking less rewarding so that, you know, you can have just one or two and don't have four or five. So that's kind of the idea.
ELISE:
You talk about AA and other recovery programs in a way that certainly doesn't denigrate them, and their success for some people like they're certainly life-saving programs. But I think for others who are like, am I like, is this, am I defined by my addiction? Is this the sort of thing where like, I need a daily practice of calling myself out as this as an addict in order to not engage, or is there a way for me to have a glass of wine socially and just stop the, you know, drinking through dinner every single night. Which I think, I think people need those, those sorts of tools, which obviously, like it's not a one size fits all solution for such a complicated disease, or problem, or problem that becomes disease, et cetera. And you also talk a little bit, you talk a little bit about AA and the concept of drunkalogues and sort of when people can get really hooked to their story right. And that it can become so defining and these, that the story of their escapades can become in its own way, sort of the way you described it its own way kind of a new addiction. So can you talk a little bit, you talk, I loved the conversation that you had about how to help people tell healing stories. And how do you get people to the point where they feel like they can put…that the old stories are resolved enough that they can put them down.
ANNA:
Yeah. Yeah. Great. So one of the things that I've learned over the last 25 years is that if, if people tell their life stories in a way that portrays them solely as victims of what's happened in their lives, those people do not get better. And I've just empirically observed that. Whereas when people can start to own their part of it and what they contributed to the problem, even in some cases, if it was just sort of showing up or being there, but usually it's more than that. Usually, you know, it's some intersection between the circumstance and our own character defects. Then those become stories that allow people to really move forward. And in therapy, the way to get people there is to, of course, first explore the trauma and, you know, empathically validate, people's suffering. People come in because they're suffering and they're in pain.
And so to really let them know that they are heard and there's tremendous power again, and just narrating your story to another human being and have them understand it. But that is not sufficient. So, you know, insight alone is not sufficient. We then need to move toward action. And that action really begins with acknowledging what we've contributed to the problem. And I think that's a really clarifying and important moment. And it does largely track the 12 steps of Alcoholics Anonymous, where step four is recognizing, you know, our own character defects and, and, and, and what kind of, what, what we've done. So, so that's basically what, what, what I try to do. Now again, depending on the person, you know, it may be a long time before they can move to that place. And while they're actively in their addiction, they're probably not going to move into that place. They really need to engage with recovery in order to get there.
ELISE:
That's interesting. And so when you, is it, I don't know if you know Terry Real, but I love he has this model for male depression, which is like, he believes it's it's trauma wrapped in an addictive defense and covert depression that when you remove the pin of the addiction can then become overt, then they move through grief. Then you can address the trauma, which I think is really interesting. And with addiction, obviously, as we, as you were talking about that, that unbalanced pain/pleasure spectrum, does that with enough abstinence…can people, will people's minds or chemistry rebalance, or are there mechanisms? I think you'd mentioned like there are, there's some early studies in mice using light to recalibrate sort of the neuroplasticity of the brain. But is that something that eventually does come back into balance where like pain reception starts to calm down?
ANNA:
Yes, absolutely. And we preserve our brain plasticity, you know, well into older age, we have more plasticity when we're young, but we preserve it lifelong there's in neuronal neurogenesis, meaning the birth of new neurons throughout our lives. And by the way, that's a new scientific discovery. We used to think that by the time you were 25 you were never going to make another neuron again. And we know now that's not at all true. And there are activities like exercise that promote neurogenesis. Cold promotes neurogenesis. So, so interesting. This whole science of hormesis or painful things promoting neurogenesis. But absolutely when we abstain from our drug of choice, we are promoting neurogenesis and we can recalibrate the balance, the gremlins hop off, and homeostasis can be restored and we can start from a level place that is a place of healing.
So it's very possible. My colleague Edie Sullivan, who's done very interesting work, trying to figure out what's actually happening in the brain in this recovery process. Her data show that it's very likely that what is happening is that new neural pathways are being created. So the damage we've done to some of our existing neural pathways, probably on some level never goes away. Like we have an incredible, retained neuro-biological memory for this addictive process, but we can create new neural pathways that detour around these damaged areas to give us all hope for recovery. And of course we know recovery happens because we, you know, we see it all the time. You know, it's a myth that people don't get better from even severe addictions. They do. And these recoveries are, you know, courageous and miraculous and wonderful. And these individuals often have such a wealth of wisdom because they've, you know, sort of been to hell and back.
ELISE:
And when you talk about relapse, is it that those, those neuro, those ruts are still there and they're so easy to sort of access and exploit. Is that why, when people who do relapse tend to relapse so quickly? That they're, they're not treading new paths through the brain, but the brain is like, oh, I recognize this. I know this. And suddenly they're fully back into it.
ANNA:
Yes, that's exactly right. That those somehow there is like a latent echo that never goes away. And there's a very interesting experiment in mice where mice were given cocaine every day for seven days. And on the first day, the mice started to run around, you know, in the, in the space, in the cage, leaving the walls where they would normally hang out and sort of run across. And this was measured by how many times they broke a beam of light. And as the cocaine administration progressed over that course of the week, the, the mice ran faster and faster and faster until by the seventh day, they were in a running frenzy. And then cocaine was discontinued for a year. And a year is just about a mouse's lifetime or a rat's lifetime. And then the cocaine was readministered at one year. And what, what the scientists saw is that with that single administration of cocaine, a year later, the rats were immediately in a running frenzy. So there was no ramp-up period. They were right back in it, which tells us that there is some permanent change that occurs in the brain, and that can be reignited with re-exposure.
ELISE:
Got it. But it is possible to sort of create pathways around it to make life tolerable and probably seemingly like, I don't like the word normal, but more baseline, right. More balanced.
ANNA:
Absolutely.
ELISE
I just wanted to go back to what you had said about cold exposure and pain exposure. Is there with addiction, particularly for people who medicate through pain maybe were prescribed opioids to address pain, and then it gets out of control. Is there an idea that sort of pain, their pain response is already off-kilter or is it immediately made off-kilter by the drugs? And then when you mentioned sort of introducing pain, you talk about cold exposure and other sort of not necessarily extreme exposure therapy in some ways, is that what it is and is that, is that what's what's happening?
ANNA:
So, I mean, you know, the pleasure pain balance… it sort of assumes that everybody starts off with a level balance, but of course that's not true. You know, some people start off with a balance tip to the side of pain because they have a disease process that gives them pain, or they have a psychological condition that gives them pain. And of course, those individuals, you know are going to seek out some relief for their suffering. But unfortunately the pleasure pain balance doesn't really discriminate between why you're using an opioid. It works in the same way in terms of the development of tolerance, the neuro adaptation gremlins that ultimately tip that balance even further to the side of pain with repeated opioid use than where that person started. Which is why people who take opioids every day for very long periods of time can develop this phenomenon called opioid induced hyperalgesia, where their pain actually gets worse because of the opioids, because they're, you know, a pleasure pain threshold has, has been altered.
So, you know, it's, we don't have very good treatments for chronic pain, unfortunately. But there is a very interesting area of exploring using small amounts of pain in order to treat pain. And that's been known for a really long time, but, acupuncture is in fact, one example. So one of the ways that acupuncture may work is actually to instill a tiny little bit of pain in the puncture area, which then triggers our own endogenous endorphins, which are the opioids that our own body makes. There are experiments I talk about in the book where if you subject an individual to a painful stimulus and they rate that painful stimulus, and then at the same time, you subject another painful stimulus on another part of the body, then they'll rate that primary stimulus as less painful than it was previously. So, I mean, you know, it's, it can certainly to all kinds of jokes and things, you know, if you're, if you cut off your leg and your finger won't hurt anymore, but, but, but actually from a neuro-biological perspective, it's, it's actually true, you know, and it's also, um, contrary to what we typically think.
We typically think of wow, if I'm, um, you know, struggling, or if I'm feeling uncomfortable in some way, I should try to make myself more comfortable. When in fact what probably works better is doing something that's really hard and even potentially physically painful. So just one concrete example in, in dialectical behavioral therapy, one of the skills that we teach patients when they're feeling overwhelmed and emotionally disregulated is to stick their face in an ice cold water bath. Now that's really painful, but what it does is it kind of snaps them out of that emotion disregulation by, you know, by imposing this really painful stimulus that then draws all of their attention. Probably it releases some endogenous endorphins, and then re-regulates them. Of course, you can take that too far. There are people who cut on themselves and they have a sudden intense pain that releases endorphins, but, you know, so that's not good. But small ways to use this pain response can be healthy.
ELISE
Yeah, no, it makes so much sense. I was just a Montana and one of the activities is like you innertube down this freezing cold river and just putting your butt in the water is so shocking. And it feels extreme. I don't, I really don't like being in wet cold, but you also notice you're like the clench, like my response to this is making it so much worse. And the minute that you can sort of allow it and relax into it, it does, it actually starts to feel quite pleasant.
ANNA:
It's been studied that although the initial response to cold, cold water is pain and adrenaline, what you get is the body's own re-regulating mechanism to counteract that and protect you is the release of dopamine, serotonin, norepinephrine, endorphins. So that's it, you're getting your dopamine through the opponent process reaction rather than from the immediate stimulus itself.
ELISE:
Right? So rather than just eating the candy, you're getting it from inspiring a natural process within your body to sort of balance out. Now it makes so much, so much sense. Well, it has been such a pleasure. I loved your book. I thought it was both fun and informative, which is always a hard needle to thread. And I read it in the span of a flight, which is also hard. It's really hard to do that in a way that's where you're getting into it enough without overwhelming people. But I thought it was really accessible and very human and warm in a space that desperately needs those sorts of voices. So thank you for, thank you for writing it and for your work.
ELISE:
Thank you so much. And it's been a pleasure to talk to you. The time has gone fast.
ELISE:
I love, I really do love Anna Lembke’s warm and thoughtful approach to addiction. As mentioned, I think it's as someone who, you know, knows a lot of people in recovery, loves a lot of people in recovery, and then struggles with my own sort of not, not very extreme, but my own human struggles with not overusing technology, or video games, or whatever it may be that is so numbing and fun in the moment. And yet not very productive. I think Dopamine Nation is such an interesting, contextual resource for how we think about this, both in terms of having compassion for those who are really afflicted and also having compassion for ourselves and understanding where we may set on that spectrum. And it has a lot of useful tools, as you probably noticed, we talked about for example, self binding, which we mentioned pretty quickly, but that's this idea. She talks about physical self binding, like the way that Odysseus tied himself to the mast so he could hear the Sirens without going to them. She talks about chronological self binding. So that's an idea of like, oh, I can only do this on Sundays. And then categorical self binding, which is, oh, I can't do any of this, but I could do this. So maybe I can't do Word Searches, but I can do Crossword Puzzles. Anyway, I heartily recommend this book and thank you again for joining us.