#321 – Dopamine and addiction: navigating pleasure, pain, and the path to recovery | Anna Lembke, M.D.

Attia and Lemke delve into the biochemistry and neurobiology of [restricted term], discussing how it plays a fundamental role in both the pleasure we derive from positive experiences and the potential for addiction development.

[restricted term] is a key neurotransmitter involved in the brain's reward and pleasure pathways, and its dysregulation is central to the development of addictive behaviors.

[restricted term] serves as a fine-tuner for neural circuits and acts as the common currency for pleasure, reward, and motivation. It is the final pathway for all reinforcing substances and behaviors. The brain maintains a baseline tonic level of [restricted term], which increases in response to positive stimuli. Anna Lembke describes how the brain processes pleasure and pain using a balance metaphor: substances that release [restricted term] tip the scale towards pleasure. She mentions that this increased [restricted term] release can change our hedonic set point, resulting in a worsened state of depression and anxiety over time.

[restricted term] also plays a crucial role in movement regulation, which is evident in conditions like Parkinson's disease. It's released as part of the brain's reward circuitry, which includes crucial areas like the prefrontal cortex and deeper limbic structures such as the nucleus accumbens and the ventral tegmental area.

The prefrontal cortex acts as the "brakes" on impulsive behaviors, while the nucleus accumbens and ventral tegmental area serve as the "accelerator", driving the pursuit of rewarding stimuli.

The prefrontal cortex, involved in [restricted term] release, is the control mechanism that curbs impulsive behaviors, promotes delayed gratification, and projects future consequences. It acts as the brakes in a vehicle analogy, while the nucleus accumbens, teeming with [restricted term]-releasing neurons, behaves like the accelerator, driving the pursuit of rewarding stimuli. Addiction can stem from a dysfunction in either too little braking from the prefrontal cortex, excessive acceleration from the nucleus accumbens, or a combination of both.

Addiction involves a complex interplay between inherited, environmental, and neurobiological factors that can predispose individuals to compulsive and destructive patterns of substance use or behavioral engagement.

Certain individuals possess inherent susceptibilities to addiction, which are compounded by environmental factors such as familial modeling, experiences of trauma, and how individuals are raised. Lemke expands on this by noting that inherited risk is significant, with family and twin studies suggesting a genetic predisposition around 50 to 60 percent. Moreover, addiction could be tied to a "neurobiological lock" where an individual's particular biology is ...

Anna Lembke, Peter Attia, and other experts discuss the complex nature of addiction, a clinical diagnosis characterized by observable behaviors and significant brain changes.

Addiction is characterized by the four C's: loss of control over use, compulsive use, cravings, and continued use despite consequences, as well as the development of tolerance and withdrawal symptoms.

Lembke identifies addiction as a form of psychopathology, diagnosed by patterns of behavior known as the four C's—control loss, compulsive use, cravings, and continued use despite consequences—plus tolerance and withdrawal. Tolerance is described as the need for more of the drug to achieve the same effect, or the alteration of the method of delivery or the chemical composition to overcome waning effects. Withdrawal manifests as a predictable set of symptoms opposite to those of the drug's effect when use is stopped or reduced, including anxiety, irritability, insomnia, dysphoria, and craving.

Addiction is a clinical diagnosis based on observable patterns of behavior, not on a single biological marker or brain scan.

Lembke explains that addiction diagnosis is reliant on the observable behaviors of the four C's rather than physiological tests such as a brain scan or blood test. Though addiction is associated with distinct brain changes, she does not directly address brain scans in confirming an addiction diagnosis in the provided content.

The severity of addiction can vary, and even individuals who have previously met criteria for addiction may be able to engage in moderated use under certain circumstances, though this is the exception rather than the norm.

While Attia and Lembke agree that it is rare for people who have been clinically diagnosed with addiction to return to moderated use of a substance, Lembke notes that it is possible in a small minority of cases, with the percentage of individuals who can successfully transition to moderated use after struggling with addiction being very low.

Addictive behaviors involve a complex interplay between the drive for pleasure/reward and the need to avoid pain/dysphoria, with the brain's homeostatic mechanisms often becoming dysregulated.

Lembke touches on the complexities of addiction, such as compulsive use characterized by a strong mental preoccupation with the behavior, the covering up of ...

Peter Attia and Anna Lembke discuss the multifaceted nature of addiction, covering both substance-related and behavioral addictions, and the various demographic trends and risk factors associated with these issues.

Addiction can manifest in the use of both substances (e.g., alcohol, drugs, nicotine) and behaviors (e.g., gambling, sex, social media, exercise), with distinct risk factors and patterns for each type.

Certain demographic groups, such as men, may be more prone to certain addictive behaviors, while others, like women, may be more vulnerable to others, likely due to a combination of biological, psychological, and sociocultural factors.

Attia discusses his own addictive behaviors with online shopping, a form of behavioral addiction. Similarly, Lembke mentions the "drugification" of everyday activities such as reading romance novels, expanding the scope of recognized addictive behaviors. Lembke and Attia explore various types of addictions, including to alcohol, gambling, cannabis, sex, social media, and exercise.

Lembke acknowledges the distinction between physiological dependence and subsequent addiction patterns, a distinction highlighted by Attia's experience with opioids following an injury. Lembke also notes the rise in compulsive pornography consumption and pathological gambling due to the availability of online platforms.

Men typically make up the majority of patients suffering from various forms of sex addiction, primarily involving pornography and compulsive masturbation. Likewise, gambling is presumed to have a predominantly male demographic. In contrast, women show higher addiction rates to benzodiazepines and are increasingly experiencing social media addiction.

Lembke talks about a case where a recovered addict substituted ice-cold showers for the high from drugs, exemplifying behavioral addiction. She also comments on the changing trends of addictions, like the equalization of alcohol use disorders among millennials of all genders, signaling a shift in demographic tendencies historically linked to addiction.

The availability and accessibility of potentially addictive substances and behaviors can significantly influence patterns of use and the development of addiction, as seen with the rise of online gambling, social media, and pornography.

One of the most significant risk factors for addiction is the easy access to drugs; individuals are more inclined to try and become addicted to substances that are readily availab ...

The pervasive growth of technology and digital media has led to an increase in addictive behaviors among young people. Anna Lembke and Peter Attia discuss the challenges presented by this rise in addiction, especially concerning, pornography addiction and social media use.

The proliferation of technology and digital media

Anna Lembke addresses the dangers the internet and social media pose to younger generations, leading to problematic behaviors such as excessive consumption of pornography and rampant use of social media. She highlights young men's addictive engagement with pornography and their retreat from engaging in real relationships. Lembke underscores that compulsive consumption of pornography among younger age groups is facilitated by the advent of the internet and smartphone technology.

The discussion extends to social media addiction, with empirical evidence showing that excessive time on social media correlates with negative mental health outcomes like anxiety and depression. Anna Lembke agrees that social media does cause harm but emphasizes implementing guardrails rather than complete elimination. Peter Attia suggests focusing on age-appropriate use of social media, while Lembke argues for the removal of smartphones from schools to prevent the hijacking of the reward system in children's brains.

The developing brains of children and adolescents

The lack of specific mention of the susceptibility of developing brains to digital stimuli in the provided transcript chunk is noted. However, the conversation hints at the vulnerability of young people’s developing brains, emphasizing the need for parents to discuss pornography's realities with their children.

Effective prevention strategies

Lembke promotes several strategies for preventing these addictive behaviors, such as limiting unsupervised internet access for children under the age of 13 and replacing smartphones with devices that do not have internet capabilities. She proposes directing federal and state funding toward schools that create tech-free spaces. When private schools eliminate smartphone usage, increased physical interactions amongst students are reported.

Parental involvement and education

The dialogue suggests that parents should take a proactive role in educating their children about healthy behaviors, s ...

Anna Lembke and colleagues discuss a comprehensive approach to addiction treatment and recovery that encompasses both pharmacological and non-pharmacological methods, tailored to individuals' needs.

A multifaceted, individualized approach to addiction treatment is often necessary, incorporating both pharmacological interventions and non-pharmacological therapies

The experts state that individuals with concerns about serious withdrawal symptoms from substances like alcohol, benzodiazepines, or opioids should consult a medical specialist. They suggest that as an early intervention, attempting to stop can help users gauge their level of dependence, acting as a personal experiment in behavior change. Lembke explains that giving up any habit-forming activity and observing one's withdrawal can be enlightening for understanding addiction, while Peter Attia highlights the importance of changing one’s environment as part of the recovery process.

Lembke discusses using a range of pharmacological interventions, such as [restricted term] for alcohol withdrawal, though its use for maintenance is less often due to concerns about addiction. [restricted term] is used almost as first-line aid in reducing consumption and supporting moderation, and Lembke also touches on [restricted term] ([restricted term]), [restricted term], and off-label use of GLP-1 agonists like semaglutide for treatment-refractory cases. [restricted term] or [restricted term] are also prescribed for opioid use disorders.

The effectiveness of treatment can depend heavily on the individual's unique needs, the type of addiction, and the severity of the condition, highlighting the significance of a personalized approach.

12-step programs and other peer-support networks can provide valuable resources and a sense of community for individuals in recovery

12-step groups, although not professional treatment, provide free peer recovery support and are effective, especially when members are actively involved. These programs provide accountability, emotional support, and practical guidance through their narrative-based, shame-reducing, social elements, playing a crucial role in long-term behavior change a ...