Anna Lembke, MD Facing Addiction

Montare Media presents Season 2, episode 21 of the Discover U Podcast with JD Kalmenson:  Facing Addiction with Anna Lembke, MD

Learn More about Montare Behavioral Health: https://montarebehavioralhealth.com/about/digital-library/

JD Kalmenson’s interviews Dr. Anna Lembke about her latest book, Dopamine Nation: Finding Balance in the Age of Indulgence, which explores why our relentless pursuit of pleasure ultimately leads to pain. Living in a time of unprecedented access to high-reward, high-dopamine stimuli, how do we resist overconsumption, and find true happiness?

​​Anna Lembke, MD is professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar, she is the author of more than a hundred peer-reviewed publications, has testified before the United States House of Representatives and Senate, has served as an expert witness in federal and state opioid litigation, and is an internationally recognized leader in addiction medicine treatment and education.

In 2016, she published Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop (Johns Hopkins University Press, 2016), highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic (Zuger, 2018). 

Dr. Lembke appeared in the Netflix documentary The Social Dilemma, an unvarnished look at the impact of social media on our lives. 

Her latest book, Dopamine Nation: Finding Balance in the Age of Indulgence (Dutton/Penguin Random House, August 2021) was an instant New York Times bestseller and explores how to moderate compulsive overconsumption in a dopamine-overloaded world.

Host Kalmenson is the CEO/Founder of Renewal Health Group, a family of addiction treatment centers, and Montare Behavioral Health, a comprehensive brand of mental health treatment facilities in Southern California. Kalmenson is a Yale Chabad Scholar, a skilled facilitator, teacher, counselor, and speaker, who has provided chaplain services to prisons, local groups and remote villages throughout the world. His diverse experience as a rabbi, chaplain, and CEO has inspired his passion and deep understanding of the necessity for effective mental health treatment and long-term sobriety.

Follow JD at JDKalmenson.com

Transcript

JD Kalmenson:

Welcome to another episode of Discovery U, our podcast, exploring innovative solutions to issues in behavioral health. I'm JD Kalmenson, CEO of Montare Behavioral Health, a family of dynamic mental health treatment centers in Southern California. I am so honored and excited to introduce you to our wonderful guest today, Dr. Anna Lembke. Dr. Lembke is Professor of Psychiatry at Stanford University School of Medicine and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, a clinician scholar. She has published more than a hundred peer review papers, book chapters, and commentaries. She sits on the board of several state and national addiction focused organizations, has testified before various committees in the United States House of Representatives and Senate, keeps an active speaking calendar and maintains a thriving clinical practice. In 2016, she published Drug Dealer md, How Doctors Were Duped, Patients Got Hooked, and Why It's so hard to Stop, which was highlighted in the New York Times as one of the top five books to read in understanding the opioid epidemic. Dr. Lembke recently appeared in the Netflix documentary, The Social Dilemma, An unvarnished look at the impact of social media on our lives. Her most recent book, Dopamine Nation, Finding Balance in the Age of Indulgence, an instant New York Times Bestseller, explores how to moderate compulsive over consumption in a dopamine overloaded world.

Welcome, Anna. So happy to have you with us today. And thank you for taking the time to talk with us about your compelling work, exploring the dynamics of pleasure-seeking, pain avoidance, and addictive patterns in our modern times. I just wanna say that at Montare and Renewal, we've been treating addiction, at Renewal Health Group for almost seven years. And your book, Dopamine Nation, which I have right here in front of me, it's a must read. And we are going to, at our organization, make this mandatory reading for our clinicians because it really just lends a degree of sophistication and nuance to this really powerful life and death genre of behavioral health addiction. 

So, first of all, thank you for this, for this incredible contribution to, to the field. There hasn't been, you know, a whole bunch of innovation in the addiction space in the last you know, several decades. So this, this, I, I, I really hopefully will make an impact and a dent on these sort of dismal success rates in the field. 

Anna Lembke: 

Well, thank you. I am, I'm very honored to be here. I'm honored that you read the book. I am, I'm humbled by your reaction. Thank you. It means a lot to me. I've been treating addiction for more than 20 years, and you know, the reason for writing the book was to help people. And so it's a very gratifying to think that I, I might have accomplished that in some small way. 

JD Kalmenson:

Yes. I, it's such a baffling topic. I think even in the aa terminology, it's something like baffling and cunning and maybe you know, so it's, it's a very elusive disorder, and you approach it with something really special and unique, which is compassionate competency. There is neuroscience, there is the, you know, the complex neuroscience packaged in a way where the layman can appreciate it, can understand it, and there is the application and integration into a behavioral platform of change of recovery. So it's not just the science, but it really draws it down. So let's jump right in. You know, the beginning of the book, you really talk about how we are a dopamine nation, even those who don't identify as being addicted to a drug of choice, to a substance, to something lethal and dangerous. We all are chasing dopamine as a society, as a culture in the Western hemisphere and specifically in America. I feel like a lot of the, the research that you've been doing is or, a lot of that portion of the book is referring to what we have in our country. Could you, could you share with us a little bit about that?

Anna Lembke: 

Sure. I mean, I think the hallmark of the modern age is the incredible overabundance that we live in. We now have access to all of our basic survival needs being met very easily. We have more disposable income and more leisure time than at, at any point in human history. And we have this ever-expanding quantity and variety of highly reinforcing drugs and behaviors. And when I talk about drugs, I'm not just talking about things we ingest, I'm talking about things that we do, shopping, gambling, gambling, gaming, sex, pornography. In the book, I talk about my own addiction to romance novels, the ways in which reading has now become drugged by the infinite quantity of books, the way that each chapter is engineered to end on a cliff hanger. The way that I can access those books at the touch of a finger through an e-reader, the way that Amazon gives out free books because every good drug dealer knows the value of a free sample. So you know, we're living in this age of unprecedented access to highly reinforcing drugs and behaviors at the same time that we're highly insulated from pain where we don't, in general, people living in rich nations don't experience hunger. They don't experience physical pain, cold other forms of physical discomfort. And, and as a result, we've literally reset our thresholds for experiencing pleasure and pain. And I think that's a major source of our unhappiness. 

JD Kalmenson:

That's right. And even though you would think that with greater abundance, we would have a happier disposition and a more optimistic outlook, the reverse is true. 

How many of us are, we will turn on the radio or turn on some background noise, just not to be quiet. And you, you, you know, you reference that the, the, the inability to just sit with ourselves in comfort because of all these various distractions.

 Happiness is, is something that is being chased. After that, the most popular courses in Harvard and Yale haven't been in business school or in any other of the sciences. They were both respectively courses about happiness. So happiness is, is something that we are clearly chasing. But it, it seems that it's a, it's a futile exercise because it, it, you know, it, it's not something that's going to be externally stimulated and generated. It does really have to come from a very deep place within. But if we're so busy running away from that deep place from within, there's gonna be a, a very hard time getting there. You know, I think it was Yogi Berra once said, “The hard thing about not knowing where you're going is that you'll never get there.” You know, <laugh>. So, so, so, is the pursuit of happiness a positive trend, or is it something that maybe we should, we should repackage and, you know, and present it in a different light altogether? 

Anna Lembke:

I think it's important to have compassion for ourselves around this problem, because we have been designed over millions of years of evolution to reflexively approach, pleasure and avoid pain. We don't need to think about it. We do it instinctively. And it's what's kept us alive and thriving as a species over the millions and millions of years of evolution. The problem is that we are in a time of unprecedented wealth, abundance, access to pleasure, such that this age-old mechanism, which was so previously adaptive, is now the source of so much of our suffering. And so, I do think we need a major reframe. The ways in which we try to pursue happiness, which I think in and of itself is perhaps not a bad goal, except that when we think about happiness in the modern age, what we're thinking about is how can I relax more? How can I have more comfort in my life? Or how can I even feel high? And if we pursue those things then happiness itself will become more and more elusive, because we are just not designed really for happiness in a fundamental way. We're, we're designed to be strivers. We're designed to have a goal, we're designed to tolerate an enormous amount of pain in pursuit of something else, not happiness. So, but at the same time, we're reflexively wired to approach happiness and avoid pain to survive. So, so it's very much a paradox. 

JD Kalmenson: 

Very interesting. And just to, to give our audience a complete picture of the unique relationship that pain and pleasure have. 

Maybe you could just give us a brief description of that the relationship that they have and, and, you know, and, and how we're constantly trying to create a sense of equilibrium to create a balance between them.

Anna Lembke:

Sure. So, so one of the most exciting findings in neuroscience in the past 75 years is that pain and pleasure in the brain are co-located, meaning that the same parts of the brain that process pleasure, also process pain. And they work like opposite sides of a balance. So if you imagine that in your reward circuitry, there's a balance, like a teeter-totter in a kid's playground, when we experience pleasure, the balance tips one way, when we experience pain, it tips the other. But there are certain rules governing this balance. Rule number one, the balance wants to remain level. And with any deviation from neutrality, our brains will work very hard to restore a level balance, or neuroscientists call homeostasis. And the way the brain does that is first by tilting an equal and opposite amount to whatever the initial stimulus was. So, for example, I eat a piece of chocolate, I get the release of dopamine, our reward neurotransmitter in the specific reward circuit in my brain, and my balance tilts to the side of pleasure. But no sooner has that happened than my brain adapts by downregulating my dopamine transmission, not just to baseline dopamine levels of firing, but actually below baseline. This is called neuro adaptation. And I like to imagine that as these little neuro adaptation gremlins hopping on the pain side of the balance to bring it level again. But the gremlins like it on the balance, so they don't get off as soon as I'm level, they stay on until I'm tilted an equal and opposite amount to the side of pain. That's the come down, the hangover, the after effect. That might just be that moment of wanting a second piece of chocolate. Right? As I'm finishing the first or that moment of wanting to watch one more TikTok video, even before that first TikTok video has run out, it's the gremlins on the pain side of the balance, the downregulation of dopamine.

Now, if we wait long enough, those gremlins hop off, homeostasis or a level balance is restored, and that urge to repeat the behavior goes away. But of course, there's still that moment of wanting, which, if we have ready and easy access to more of our drug, we will naturally reach for it. So what happens then? This brings us to the second rule of the balance, which is that with repeated exposure to the same or similar reinforcing stimulus, that initial deviation to pleasure gets weaker and shorter. But that after response to pain gets stronger and longer. In other words, more and more gremlins start to accumulate on the pain side of the balance, until I have enough gremlins to fill this whole room. And now they're camped out there with tents and barbecues in tow. And that is what happens in the brain as people become addicted, they essentially change their hedonic or joy set point, such that they end up in a chronic dopamine deficit state. So now they need more and more of their drug not to get high and feel pleasure, but just to level the balance and feel normal. Other more modest rewards are no longer rewarding because they can't outweigh the gremlins camped out on the pain side. And when we're not using our drug, we're walking around in a state of withdrawal and the universal symptoms of withdrawal from any addictive substance, including our iPhones, are anxiety, irritability, insomnia, depression, and craving. 

JD Kalmenson:

Right, Right. And one of the things that you reference in your book, which is, is a, is a well-known you know, is a well-known fact, is that biological genetics can play a factor, at least in increasing the risks of a child. You know, and being, making that child more susceptible and vulnerable to addiction. Now, I just wanna get into that for a moment. Is that risk factor purely genetic? Does it have anything to do with the environment that the child was brought up in, say that the parent recovered or is in recovery from that addiction before the child is born? Say, for example, the parent has an addictive personality, but circumstantially has never become addicted. Does this still increase the risk factor for the child, rendering the child more susceptible and vulnerable to addiction?

Anna Lembke:

A short answer is yes. There's a biological or inherited vulnerability to addiction that is independent of the environment that you're raised in. This is based not just on family studies, but also family studies of a child who is adopted out of that family at birth to a family where there is no substance using or no addictive kind of culture. So we do know that if you have a biological parent or grandparent who is addicted to alcohol, you are at increased risk of becoming an alcoholic yourself. Even if raised outside of that alcohol using home. It's likely, it is certainly a polygenetic you know vulnerability. It's not gonna be one gene. It probably involves the trait of impulsivity that is difficulty putting a pause button between the thought or desire to do something and actually doing it. It's probably related on some level to emotion dysregulation, inability to delay gratification. On the other hand, I will say that some of the people with the most severe addiction that I've treated in, in my career have been people who are very, very good at delaying gratification. You know, highly successful people in their career for whom the, the addiction became the thing that they rewarded themselves with after a day of delayed gratification. But, but in general, it's a complex polygenic phenomenon. And it, it is distinct from the environment that you're raised in.

JD Kalmenson: Fascinating. Does it, does it last more than one generation?

Anna Lembke:

Probably, and this is from animal studies looking at epigenetics as well. The ways in which you know, non-inherited base pairs can change over the course of a lifetime, then be inherited in the offspring. So that's why, you know, the, the multi-generational facet is, is important.

JD Kalmenson:

Wow. And so essentially the, you know, the, the individual might be born at a disadvantage and really has nothing to do with their willpower, their discipline, their values, or any of their, you know, upbringing.

Anna Lembke:

That's exactly right. Which is why I think of people in recovery from severe addictions living in the world today as modern-day prophets for the rest of us. Because if people with that innate genetic vulnerability to addiction can navigate this crazy world that we're living in now, they really have acquired a massive amount of wisdom that they can share with those of us who are not necessarily genetically vulnerable to this problem. But of course, now we've all become vulnerable because of the environment.

JD Kalmenson:

Interesting. Very interesting. And when you talk about a father being an alcoholic, increasing the likelihood of the risk factor for a child becoming an alcoholic,  are you specifically referring to a specific DOC, drug of choice, like alcohol or opiates, or is it just addiction in general? And if a father's an alcoholic, the child can end up being a gambler or, you know, addicted to any other illicit substance?

Anna Lembke:

So the data that we have is most robust for alcohol addiction. We don't have as much data on other addictions, but in general when people are vulnerable to the problem of addiction, there's usually the vulnerability is to multiple drugs. It's the behavior itself, the addictive nature of the attachment that tends to be, you know, at the core. On the other hand, there is this concept of drug of choice, which is to say, one's person, what, what, what releases a lot of dope mean in one person's brain may not necessarily release a lot of dopamine in another person's brain. For example, I myself thought I was relatively immune to the problem of addiction. Alcohol, it gives me a headache. Caffeine doesn't wake me up. So I thought, Oh, I just don't have that addiction, gene. The truth is, I just hadn't yet encountered my drug of choice, which turned out to be social, a socially sanctioned form of pornography for women.

That is to say romance novels and you know, erotica. So it was very strange for me in midlife to find myself falling into this kind of addiction when I had thought that I, that I didn't have the addiction gene. And my point there is that we are now living in a world where not only are there more abundant and more potent forms of traditional drugs, but we also now have drugs that didn't exist before. We've drugged human connection through social media. We've druggified games. We've certainly you know, made sex addiction more potent. We've druggified shopping, we've druggified food you know, we have things like video games that that didn't exist before. So we've got more and more people vulnerable to the problem of addiction because we have so many more drugs.

JD Kalmenson:

That's right. You know, one of the things that fascinated me about about your book is this ancient debate within the recovery community about whether it's possible to fully recover, or you're constantly in recovery, whether you subscribe to the aa community's values and cultural sort of sentiments that you constantly identify as an addict, whether it's 10 years later or 30 years later, or whether you take some of the alternative methods of intervention and treatment, like medication assisted treatment, or some of the more scientific ones, whatever they might, you know, look like, and the belief inherent in them that it's possible to fully recover. 

What very often happens in my experience is somebody will relapse and then they lose faith in the system, or they somehow allowed the relapse to paint and taint all their initiatives and all the hard work that they did, and cast the degree of insincerity and say, I'll never get this right, because, look, I tried so hard, and obviously it didn't work. So knowing the neuroscience behind it and how it might have just been a certain circumstance that came up at a later point in time that led to a dopamine deficit, really helps them restore the faith, not just their faith in the recovery process, but in themselves, just understanding that there were so many variables and, and nuances here that are, that are at play. 

Anna Lembke:

I think it's really important to acknowledge that addiction is a chronic relapsing and remitting disease. Some people will relapse a lot, other people will get into recovery and stay into recovery in recovery the rest of their lives. That's true for many different types of diseases from, you know, cancer to heart disease to diabetes, right? So it's important to acknowledge the individual differences, the chronic nature of it, but also to be open to different goals for different people. That abstinence may be the necessary goal for some people with addiction, but others might be able to go back to using their drug of choice after a period of abstinence and use that drug in moderation. And that's very you know, that's, that's not consistent with AA philosophy. That's a very, that whole concept of moderation is very new. But I think very important to talk about and think about in part because we have data showing that some people who have met criteria for alcohol addiction can and have gone back to using alcohol in moderation. It's not a large subset. And of course, for the most severely addicted, abstinence will be the only path. But we need to talk about moderation because we are dealing now with addiction to drugs like addiction to technology that we can't just simply eliminate from our lives. People are not going to be able to put the technology genie back into the bottle. So we have to learn and think about how to moderate our technology consumption, how to live in a healthy way with this technology. Absence is not really an option. I also really agree with you that it's so important to recognize what's happening in the brain. You know, as people both become addicted, but also as they get into recovery.

And my colleague here at Stanford, Eddie Sullivan, has done some really important work showing that in recovery, what happens is that new neural networks are created that reroute around the damaged areas. The implications for this are many. Number one, it means that some of that damage is permanent, and that for our entire lives, then we potentially remain vulnerable to relapse from our drug of choice because of the latent permanent changes in the brain as a result of our addiction. But the hopeful story is that we can overcome that, and we can create new neural networks that go around those damaged areas. And that's essentially what recovery work is all about. You know, restoring those, those new neural networks. I also agree with you that you know, even if a person relapses, their time in recovery is never lost. They had that time. They knew what it felt like to be in recovery. They can always, always harken back to that as a kind of a touchstone to empower them and give them hope. And they know what they're shooting for. They know what it felt like. So, that's time that's never lost.

JD Kalmenson:

Have you, have you seen any indicators to help, let's say a clinician be able to identify a client sitting in front of them, that this is somebody who could potentially recover fully, versus this is somebody who we have to really convey the recovery processes being long term and perpetual because they possess indicators that allow us to believe they'll never be able to fully recover. In other words, having that knowledge, if we can somehow identify, you know, what their, what, what category they might belong to, would immensely help the intervention, the treatment, and what the standards of aftercare ought to look like when we try and help them recalibrate and go back into the world. 

Anna Lembke:

Well, the qualitative differences that I've observed between people who get into robust and long-term recovery, and those who are less likely to do so are not something that you would necessarily read in, in your average textbook. What I have observed over, you know, more than two decades, is that the way that people tell their autobiographical narratives has a huge impact on whether or not they are able to get into and stay into recovery. And here, here's namely what I've observed, that people who tell stories in which they remain the victim of other people and circumstance as the explanatory engine behind their addiction, are people who are not going to get into recovery. Whereas people who begin to tell a story that adheres more, more to objective reality, including the ways that they've contributed to the problems in their lives, those are people who I'm very optimistic about in terms of their ability to get into and stay in recovery.

And of course, the corollary to that is telling the truth or being honest. What I've learned from my patients who are in a good and sustained recovery, is that they can't lie about anything. They, of course, can't lie about their drug use, but they also can't lie about other little things that most of us lie about. So the average adult tells one to two lies per day. We tend to tell lies that we hardly notice or recognize that just sort of cover up our laziness, our selfishness, or our character flaws. But people with addiction have learned that they can't do that. Because once they do that, they will get into the lying habit. And once they're in the lying habit, they're very likely to relapse. And so I think that's fascinating, and it works on many different levels. And I've tried to incorporate it in my own life and in my parenting, this kind of radical honesty, telling the truth about all things, even when it hurts, or especially when it hurts, as a way to live a better life, and also to better regulate our consumption, to be in recovery ourselves you know, in, in a world that's constantly tempting us to over consume. 

JD Kalmenson:

Yeah. I just, I I, and it makes so much sense. You know, honesty is, is really the antithesis to compartmentalization, which is what the addict thrives on. 

There's a story about a couple who comes to the marriage counselor seeking a divorce, and a marriage counselor says, What's, what, what's the issue? And after conversing with them for a half hour, discovers that the husband is just too honest,

Anna Lembke:

<Laugh>

JD Kalmenson:

She, she'll say, “How was dinner”? He says,” Well, you know, eh, it was..”

Anna Lembke:

<Laugh>.

JD Kalmenson:

You know, they're getting ready to go to a wedding. And she just you know, spent a half hour getting dressed in makeup. And she'll be like, “How do I look?”  “You've looked better,” you know,

Anna Lembke:

<Laugh>. 

JD Kalmenson:

So I guess that's the only area where honesty might, you know you, you know, what do you, the ethical sort of component about how you make other people feel? And the truth is that it does have a lot of resonance for addiction, because a very common question that addicts will constantly have is, full disclosure whether, you know, the full disclosure will pain somebody to the point where is it, is it worth, is it worth it? Do they have the right to tell somebody you know, information that will just permanently ruin them emotionally for their own recovery?

Anna Lembke:

Yeah. So you make a good point. You know, is it, is it a good thing to tell the truth if in doing so, you're, you're harming another? And I think I think that's generally not a good thing. The problem is that we are very good and very quick to rationalize our lies as protecting other people, when really what we're doing is protecting ourselves. So it can be a very slippery slope. You know, and it's the lies that we tell that protect ourselves that, that really are the, the very pernicious lies that lead to a lot of harm to ourselves and also harm to others, both in the short and the long run, we're trying to stave off the consequences of our transgressions or our foibles, our mistakes, our selfishness. And in doing that, we almost always compound the misery going forward.

So I, and we, we lie so reflexively it's, it's really fascinating. I mean, if, if you wake up and say, I'm not going to tell a single why today, not, not about anything. I mean, I think what, what I find is that it's quite difficult. You know, I may be a few minutes late for a meeting, and I just would like to say that there was a lot of traffic when in fact, I just wanted a few more minutes to read the paper and drink my coffee. Right? Or I might come home and tell a story about how I was waiting for somebody else, and I was really only waiting about three minutes, but in the story, I'm waiting 10 minutes. Why? Because that's much more exciting story. And you know, it looks, it makes the burden on me seem much greater than if I had just impatiently been waiting three minutes.

So it's all these little fudgings and, you know I mean, I grew up in a home where you know, the adults in my home had a lot of difficulty telling the difference between what really happened and their version of events. You know, in other words, we become such prolific and proficient liars that we come to believe our massaged version of reality. And so I think, I think it's worth it to, you know, individually and collectively to be vigilant. Now, is there a role for stories? Of course, we need stories. And, you know, my kids get on my case all the time because I'll tell a story and I'll naturally dramatize it because it's sort of more interesting. Whereas my husband, who sort of alexithymic and deadpan, will recite the facts in something that's not interesting at all to listen to. He has no sense of a narrative arc. So, you know, we need drama and we need excitement, and we need stories, and stories have lessons. But I think it's, especially in this day and age of social media, fake news where we have politicians and, and world leaders who seem to, you know, continually misrepresent the truth, I think we have to be a little more vigilant even than we have been perhaps in, in previous generations.

JD Kalmenson:

And it's true, I think if we as individuals and as communities begin to elevate our standards of truth telling, and I think that it's the exaggerations which are more dangerous than the lies, because the lies can be exposed. But the exaggerations, you just fail to recognize, you know, the, the dishonesty inherent within it. But if we elevate our own standards, then, you know, we will demand that from our politicians. But the politicians sort of mirror what goes on in society in a way, because they can get away with it. 

I wanna just ask you a specific question about medication assisted treatment, which is for, for, you know, for those of our listeners who are not aware of it, it's, it's really the sustained use of a regulated form.

And obviously Anna, you can describe it better than I will, but it's, you know, whether it's Suboxone or whether it's methadone, it's, it's the, it's a, the, the drug allowing some form of the dopamine release to occur in a much more regulated way without necessarily the high of it. But I guess what's troubling me with that entire process, and that's becoming more and more popular, insurance companies are in fact mandating that you offer this as an option to your clients. And this is at great odds with the AA sort of philosophy, the pure AA philosophy. But like everything, you know even within the AA community, there's, you know, an increasing sort of receptiveness and openness to the medication assisted treatment objective and agenda. So first and foremost, I'd love to just get your take on where and when do you feel that medication assisted treatment is the most appropriate path and strategy, and where would you say total abstinence is the route to go? 

Anna Lembke:

 So basically what, what we're talking about here is specifically opioid agonist therapy. These are opioids that are used to treat opioid addiction or opioid use disorder. And there are two of them. One of them is Methadone, and the other one is Buprenorphine, commonly referred to as Suboxone. These are both opioids. They are FDA approved medications for opioid addiction. They have some of the most robust evidence to support them. If you look at all different treatments for addiction, then you look at opioid agonist therapy, they have been shown to be effective across geographic locations over decades. And if you think about it from, from the perspective of neurobiology, essentially what's happened is that hypothetically, there are some individuals who have a broken pleasure pain balance, that is to say, after repeated exposure to their drug of choice opioids, they end up with so many gremlins on the pain side of the balance, that they're kind of stuck in that dopamine deficit state.

And even with sustained abstinence, the gremlins don't hop off. So that means those individuals are walking around in a constant state of craving, withdrawal, anxiety, depression, irritability, unable to move forward in their lives or engaging other recovery work, because every moment of every waking day, they're struggling with withdrawal. So what do these opioid agonist treatments do? They essentially restore homeostasis or a level balance. It doesn't get these individuals high, it just allows them to be back at homeostasis so they can then engage in the rest of their lives. You ask a very good question, why is it that the gremlins don't just respond to those drugs and hop more gremlins on the pain side balance? Sometimes they do. So that's one of those sort of well-guarded secrets in addiction medicine that for a small subset of individuals, they actually do need higher doses of methadone and buprenorphine over time in order to get the same effect.

But for reasons that we don't fully understand, most people can have a stable dose. Most people with severe opioid addiction can have a stable dose of their methadone and buprenorphine and don't need to increase it over time. I think it probably has something to do with the very long half-life of methadone and buprenorphine, which is also why they're effective for opioid addiction. Because what's so pernicious about addiction is this constant fluctuation of intoxication with rising dopamine levels followed by plummeting dopamine levels, then withdrawal, the dopamine deficit state, then the craving and the drug seeking that takes all of our energy and time. But what happens with buprenorphine and methadone, they have these really long half-lives. So people get out of this constant cycle of intoxication and withdrawal, and they get a steady state in their bloodstream, which then allows them to not be focused on drug seeking and on opioids, and allows them to turn outward and engage more fully in their lives And that’s essentially how it works. 

JD Kalmenson: 

Fascinating. You reference in the book at tension that really exists in the behavioral health and addiction recovery community as a whole with neuroscientists, psychiatrists and professional clinicians you know, sort of looking at the efficacy and the power of the AA community, even though the principles they're in are not necessarily scientific and are not necessarily sanctioned or being advocated by the clinical scientific community. And I mean, at one point you even encouraged the client Jacob to pray because that, for him was gonna work. How, how do you sort of reconcile this fascinating phenomena where within behavioral health, the most prominent, or I shouldn't say the most prominent, but one of the most vocal and powerful movements, is this sort of spiritual set of principles that seems to have such an incredible impact on folks who struggle? 

Anna Lembke:

Well, I, I mean, I, I have seen in my professional life and also experienced in my own life the power of spirituality and the power of turning to a higher power for healing and succor and guidance in life. One of the things that attracted me to addiction medicine is it may be the only area left in medicine where it's okay to talk about spirituality. Yeah. And so that's very lovely that we get to do that. Spiritual transformation as you know, is a cornerstone of the AA philosophy. And, I've just seen so many times that it's the spiritual aspect that, that allows people to get into recovery. You know one of the founders of AA, Bill Wilson, actually wrote to Carl Jung, the famous psychoanalyst, to ask him what his view of addiction was.

And Carl Jung said, I think it's basically a yearning for God, and that when people are not in connection with God, however they define that, then they look for a kind of a replacement spirituality through drugs and alcohol. And Carl Jung’s famous saying was “Spiritus,” which is the, you know, the name of alcohol, “Contra Spiritum,” which is this idea that we're using spirits or alcohol to fill the emptiness that we experience because we are not living with any kind of connection to a higher power. So I think it's really important. It doesn't have to occur within the context of AA. I have people who you know, are attached to various faith organizations you know, specific religions and actually find that as a better spiritual source for their recovery. But I do think that ultimately neuroscience will also show us the level at which spirituality is really fundamental to a life well lived. I think we're eventually going to understand that.

JD Kalmenson:

Even within the broader mental health space, not necessarily this

Anna Lembke:

Addiction. Yes, yes, yes. I think so. I think so. I mean, I think this incorporation of eastern traditions and mindfulness, which has now become sort of like a, you know, a psychological practice rather than a spiritual practice, but as practice in the East, it's a religion. You know, and so it's interesting how we've sort of adopted it and fit it to, to be sort of a religious or somewhat, you know let's say scientific or, you know, to fit our comfort level in our, you know, growing secularization. But you know, and that's important. We have to make these things fit the age in which we live. But there's no doubt to me though that this is a key, key piece, not just to recovery, but to meaning and purpose and wellbeing.

JD Kalmenson:

No, I mean that we, we've actually the developed a spirituality assessment even in our primary mental health facilities and part of what we’re…

Anna Lembke:

Oh, that's great.

JD Kalmenson:

There. It's, it's fascinating. It's even folks who will come in and openly acknowledge that they're atheist or that they don't subscribe to any sort of spiritual values after taking the assessment, they invariably say things like, Wow, I never really thought of it like that. Cuz some of the questions are, for example, what would you like to be remembered as you know, at your funeral? And all of a sudden they're taking a bird's eye view of their entire life. And that elevated prism allows them to see past the temporal hedonistic here and now. I mean, you even reference something like that in the book where you're telling somebody, you know, think about your future and use that as a motivation to help you cut through the emotional fog and see the present for what it is and muster up the courage and the motivation to wanna engage in some type of abstinence. Talking about, you know, Carl Jung and addiction being a yearning to get closer to God. You really see this in the recovery community as a whole. The type of selflessness and acts of service that they will on a long-term basis be engaged in is something really unparalleled than any other segment of society. And it's no surprise, you know, these are people who it seems have a deep sort of perpetual need to engage in meaning and purpose 

would you say that that's the case in all of, you know, in all of the addiction population or, you know, definitely a significant portion of it 

Anna Lembke:

The spiritual pathway may be at the heart of recovery for somebody, and maybe not that important for somebody else. But I do think that if we think temperamentally, a lot of the patients that I've encountered over the years you know, who become profoundly addicted, they are seekers, they are people who from very early on, you know, experience you know, kind of a, let's say a yearning, a yearning, and a wanting to find answers to these larger existential questions. 

JD Kalmenson:

What happens really so often is, we say this a lot in the, in, in the treatment space, is people, they're in their head. And what it means that they're in their head is that there's sort of this emotional fog throughout the entire process. Even as I was telling you earlier, to I, you know, to look at a relapse and say that I'm gonna lose faith in the whole process is a lack of mindfulness. They're not really seeing the entire context and picture of what's going on. 

But that mindfulness, the ability to sort of be a third party for your own life. So, you know, that is something that is really not holistic. It's, it's a, it's clinical, it's, you know, do you see the effect of that in the brain?

Anna Lembke:

Yeah. I mean, interesting. So mindfulness meditation has been shown to increase dopamine levels as, as has prayer. So these are potential alternative healthy sources of dopamine to counteract the dopamine deficit state that people experience in, in withdrawal and early recovery.

JD Kalmenson:

That's incredible. And then you talk about the binding, self-binding, and that's really your solution to the dopamine nation, to all the problems that we're encountering. Could you give a brief synopsis of, I know that there are several steps, but somewhat of a brief synopsis to how we deal with this, this real crisis?

Anna Lembke:

Yeah. So I mean, self-binding acknowledges that we're living in a domine overloaded world where we're constantly being tempted to consume and, and also acknowledges that willpower is a limited human resource that our willpower you know, taxes are our brain muscle and, and eventually runs out. So we can't rely on willpower, and we're living in a world of incredible temptation. So we essentially have to create both literal and metacognitive barriers between ourselves and our drug of choice so that we're not constantly being triggered and tempted and having to rely on our willpower. Also, these triggers alone release a little bit of dopamine followed by a dopamine deficit state. So they're a little bit of that whole cycle of  the pleasure, pain balance and the gremlins on the pain side. And we don't wanna continually expose our brains to that kind of fluctuation. 

So we create barriers, and those barriers can take the form of using time as a construct. For example, say I'm not going to consume this drug until this point in time at my birthday, or it's a celebration, or after I finish my exam, or after I graduate, or after I get this work project done. That's one way to use time as a construct, or even just within a given week, if the goal is moderation, I'm only gonna use on these days of the week, I'm only gonna use for this amount of time or in this time window. I think with technology, this is really helpful. For example, saying, I'm not going to get onto my devices until after I've exercised, made my bed eaten breakfast, brushed my teeth, and then I'm gonna get on my device. So it's a way to use that kind of, sort of a future time or finish line construct.

We can use literal geographic barriers where we literally do not keep our drug in the house. So this is very common. No potato chips in the house, going to a hotel and calling the hotel in advance saying, please remove the mini bar, please remove the television. Disconnecting wifi from our house at certain times of literal barriers between ourselves and our drug of choice. 

And then there are categorical barriers. This is where we have sort of subcategories. So, for example, a patient of mine who got addicted to video games after a period of abstinence, when he was doing much better, he wanted to try to go back to using in moderation. But he knew, for example, that he could never play League of Legends because that was a category of video game that once he started, it was very difficult for him to stop. So he had two categories. He had no League of Legends and no playing with strangers. I'm only gonna play with my friends because that way it will strengthen social bonds and serve another purpose. So these are the types of barriers we need to put in place in order to be able to navigate the modern ecosystem. 

JD Kalmenson:

You know, it's counterintuitive and it's really sort of a principle's critique on today's society and today's culture in which the, the, the idea that is so pervasive is if it feels natural, then it must be right. And what self-binding is saying is you can curb what you naturally want, and that's actually a good thing for you. 

The idea of white knuckling for, for a while, the idea of creating an inorganic, so to speak, a non-natural solution, and that being a true solution, an authentic method of dealing with the problem is counterintuitive. And that's why it's so important to be that voice, to say that self-binding can be your solution. It could be as technical as that. It doesn't have to be, It's never gonna be you wake up one morning and gone, you have no desire.

Anna Lembke:

Yeah, that's right. And what I tell my patients since early recovery is for the time being you can't trust your brain. So, we have this idea that, you know, go, go with the flow or what, you know, go with your feelings. I'd say, you know, your feelings will not guide you to the right place. You have to do contrary to your feelings. You have an urge to do something, do the opposite. And that, that's again, you know, very counterintuitive. But the, the right way.

JD Kalmenson:

If there's one thing you can change in society, what would it be?

Anna Lembke:

I would create a lot more limits on internet access.  I think there should be etiquette, cultural etiquette. Also rules and laws so that we have some internet free spaces so people can be more fully present in the moment and reconnect with each other.

JD Kalmenson:

That's amazing. That's so special. I wanna really thank you for sharing your expertise and time with us, Anna. It was so inspiring to talk with you. Thank you for joining us on the podcast today

Anna Lembke:

Thank you. It was, it was my pleasure. Thank you for having me.

JD Kalmenson: 

Of course. And thank you audience for joining us too. If you haven't read Dr. Lembke's most recent book, Dopamine Nation, I highly recommend it. So accessible and filled with vivid stories that will really bring to life the challenges of living in today's society. I hope you enjoyed today's episode of Discover U as much as I did. At Montare we want you to know that you're not alone on your journey, and you can always find out about our innovative treatment programs at montarebh.com, and you can listen to our podcast on iTunes, Spotify, or wherever you get your podcasts. Wishing all of you radiant health in a safe and fulfilling day.