Anne Lembke's book is a clearly-stated and compassionate explanation of addiction that makes you think a very powerful thought; To what and how am I addicted to pleasure?
Dopamine Nation Quotes
Introduction: The Problem
We’ve transformed the world from a place of scarcity to a place of overwhelming abundance.
The smartphone is the modern-day, hypodermic needle, delivering digital dopamine, 24/7 for a wired generation.
Scientists rely on dopamine as a kind of universal currency for measuring the addictive potential of any experience.
The moment of wanting is the brain’s pleasure balance tipped to the side of pain.
“Persons with severe addictions, are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are.” – Kent Dunnington
Part 1: The Pursuit of Pleasure
Chapter 1: Our Masturbation Machines
One of the biggest risk factors for getting addicted to any drug is easy access to that drug.
The risk of addiction increases if we have a biological parent or grandparent with addiction.
Trauma, social, upheaval, and poverty contribute to addiction risk, as drugs become a means of coping and lead to epigenetic changes – heritable changes to the strands of DNA outside of inherited base pairs.
In an attempt to find a less addictive opioid painkiller to replace morphine, chemists came up with a brand new compound, which they named “heroin” for heroisch, the German word for “courageous”. Heroin turned out to be 2 to 5 times more potent than morphine and gave way to the narco mania of the early 1900s.
The Internet promotes compulsive, overconsumption, not nearly by providing increased access to drugs, old and new, but also buy suggesting behaviors that otherwise may never have occurred to us.
Videos don’t just “go viral.” They are literally contagious.
When we see others behaving in a certain way online, those behaviors seem “normal” because other people are doing them.
We are like flocks of birds. No sooner has one of us raised a wing in flight than the entire flock of us is rising into the air.
We are all at risk of titillating ourselves to death.
Chapter 2: Running from Pain
“It sounds like the pills weren’t really helping.” David paused. “In the end, it came down to comfort. It was easier to take a pill than feel the pain.”
These brochures illustrate how the pursuit of personal happiness has become a modern maxim, crowding out other definitions of the “good life.” Even acts of kindness toward others are framed as a strategy for personal happiness. Altruism, no longer merely a good in itself, has become a vehicle for our own “well-being.”
“Religious man was born to be saved; psychological man is born to be pleased.” - Phillip Rieff
Perceiving children as psychologically fragile is a quintessentially modern concept.
The practice of medicine has likewise been transformed by our striving for a pain-free world.
“For certainty, a moderate degree of pain and inflammation in the extremities are the instruments which nature makes use of for the wisest purposes.” - Thomas Sydenham
Pain in any form is (now) considered dangerous, not just because it hurts but also because it’s thought to kindle the brain for future pain by leaving a neurological wound that never heals.
In 2012, enough opioids were prescribed for every American to have a bottle of pills, and opioid overdoses, killed more Americans than guns or car accidents.
It’s pretty exhausting avoiding yourself all the time.
They use drugs, prescribed her otherwise, to compensate for a basic lack of self care, then attribute the costs to a mental illness, that’s necessitating the need for more drugs. Hence poisons become vitamins.
We’ll do almost anything to distract ourselves from ourselves. Yet all this, trying to insulate ourselves from pain seems only to have made our pain worse.
Richer countries have higher rates of anxiety, than poor ones.
The number of new cases of depression worldwide increased by 50% between 1990 and 2017… Physical pain too is increasing… They found that Americans reported more pain than any other country.
The reason we’re all so miserable may be because we’re working so hard to avoid being miserable.
Chapter 3: The Pleasure-Pain Balance
For a rat in a box, chocolate increases the basal output of dopamine in the brain by 55%, sex by 100%, nicotine by 150%, and cocaine by 225%. Amphetamine, the active ingredient in the street drugs “speed,”“ice” and “shabu” as well as in medications like Adderall that are used to treat attention deficit disorder, increases the release of dopamine by 1000%. By this accounting, one hit off a meth pipe is equal to 10 orgasms.
Pleasure and pain are processed in overlapping brain regions and work via an opponent process mechanism. Another way to say this is that pleasure and pain work like a balance.
With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain, gets stronger and longer, a process scientists call neuroadaptation.
The paradox is that hedonism, the pursuit of pleasure, for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.
Craving translates into purposeful activity to obtain the drug.
“The measure of how addicted a laboratory animal is comes down to how hard that animal is willing to work to obtain its drug – by pressing a lever, navigating a maze, climbing up a chute.” - Rob Malenka
The entire cycle of anticipation and cravings can occur outside the threshold of conscious awareness.
An expected reward that fails to materialize is worse than a reward that was never anticipated in the first place.
The more gamblers lose, the stronger the urge to continue gambling, and the stronger the rush when they win – a phenomenon described as “loss chasing.”
The brain encodes long-term, memories of rewards and their associated cues by changing the shape and size of dopamine-producing neurons. For example, the dendrites, the branches of the neuron, become longer and more numerous in response to high dopamine rewards.
Learning also increases dopamine firing in the brain… the brain changes that occur in response to a stimulating and novel environment are similar to those seen with high dopamine (addictive) drugs.
Our sensory perception of pain (and pleasure) is heavily influenced by the meaning we ascribe to it.
Science teaches us that every pleasure exacts a surprise, and the pain that follows is longer lasting and more intense than the pleasure that gave rise to it.
With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases.
By raising our neural setpoint with repeated pleasures, we become endless strivers, never satisfied with what we have, always looking for more.
Our brains are not evolved for this world of plenty. As Dr. Tom Finucane said, “We are cacti in the rainforest.
Part 2: Self-Binding
Chapter 4: Dopamine Fasting
High-dopamine substances and behaviors cloud, our ability to accurately assess cause and effect.
Abstinence (from the addictive substance or behavior) is necessary to restore homeostasis, and with it, our ability to get pleasure from less potent rewards.
How long do people need to abstain in order to experience the brain benefits of stopping?… At two weeks, patients are usually still experiencing withdrawal. They are still in a dopamine deficit state. On the other hand, four weeks is often sufficient.
Mindfulness demands that we see our thoughts and emotions as separate from us, and yet, simultaneously, a part of us.
Mindfulness practices are especially important in the early days of abstinence. Many of us use high-dopamine substances and behaviors to distract ourselves from our own thoughts.
I have seen again and again in clinical care, and in my own life, how the simple exercise of abstaining from our drug of choice for at least four weeks gives clarifying insight into our behaviors. Insight that simply is not possible while we continue to use.
Evidence suggests that some people who have met criteria for addiction in the past, especially those with less severe forms of addiction, can return to using their drug of choice in a controlled way.
Rats who show a genetic propensity to become addicted, will, after a 2 to 4-week period of abstaining from alcohol, binge on alcohol as soon as they have access to it again.
The ultimate goal of the dopamine acronym is to restore a level of balance (homeostasis), and renew our capacity to experience pleasure in many different forms. D = data. O = objectives P = problems. A = abstinence. M = Mindfulness, I = insight. N = next steps. E = experiment.
Chapter 5: Space, Time, and Meaning
“I want to stop, but I can’t. What should I do?” “Pack up the machine, and any spare parts,” I told him, “and put it all in the garbage. Then take the garbage to the dump or somewhere else, where it is impossible for you to retrieve it.” He nodded understanding. “Then anytime you get the idea or urge, or craving to use, drop to your knees and pray. Just pray. Ask God to help you, but do it from your knees. That’s important.” I converged the mundane and the metaphysical. Nothing was too low or too high for my consideration. Telling him to pray was breaking unwritten rules, of course. Doctors don’t talk about God. But I believe in believing, and my instincts told me this would resonate for Jacob, raised Roman Catholic.
Telling him to drop to his knees was also a way to insert some physicality into it, anything to break the mental compulsion that was compelling him to use.
Self-binding is the term to describe the way we intentionally and willingly create barriers between ourselves and our drug of choice in order to mitigate compulsive overconsumption… Self-binding openly recognizes the limitations of well.
The key to creating an effective self–binding is first to acknowledge the loss of voluntariness we experience when under the spell of a powerful compulsion, and to bind ourselves while we still possess the capacity for voluntary choice.
If we wait until we feel the compulsion to use, the reflexive pull of seeking pleasure and/or avoiding pain is nearly impossible to resist. In the throes of desire, there’s no deciding.
Examples of physical self-binding strategies; “I unplugged my TV and put it in my closet.” “I call hotels beforehand, to ask them to remove the minibar.”
Pharmacotherapy alone, without insight, understanding, and the wheel to change behavior, is unlikely to be successful.
It turns out that willpower is not an infinite human resource. It’s more like exercising a muscle, and it can get tired the more we use it.
The fact that we must resort to removing and reshaping internal organs to accommodate our food supply (gastric bypass surgery) marks at turning point in the history of human consumption.
Another form of self-binding (chronological self-binding) is the use of time limits and finish lines. By restricting consumption to a certain time of the day, week, month, or year, we narrow our window of consumption and thereby limit our use.
High-dopamine goods mess with our ability to delay gratification, a phenomenon called delay discounting. Delay discounting refers to the fact that the value of a reward goes down the longer we have to wait for it.
In today’s dopamine-rich ecosystem, we’ve all become primed for immediate gratification… Samuel McClure and his colleagues examined what parts of the brain are involved in choosing immediate versus delayed rewards. They found that when participants choose immediate rewards, emotion and reward processing parts of the brain lit up. When participants delayed their reward, the prefrontal cortex - the part of the brain involved in planning and abstract thinking - became active. The implication here is that we are all now vulnerable to prefrontal cortical atrophy, as our reward pathway has become the dominant driver of our lives.
Another variable contributing to the problem of compulsive over consumption is the growing amount of leisure time we have today, and with it the ensuing boredom.
“I suspect, only half-jokingly – that addicts are bored or frustrated problem-solvers who instinctively contrive Houdini-like situations from which to disentangle themselves when no other challenge happens to present itself. The drug becomes the reward when they succeed and the consolation prize when they fail.” – Erik J. Iannelli
Once he started using cannabis, he wasn’t governed by reason; he was governed by the pleasure-pain balance. Even one joint created a state of wanting not easily influenced by logic. Under the influence, he could no longer objectively, evaluate the immediate rewards of smoking against their long-term counterparts. Delay discounting ruled his world.
“Not thinking about myself, and my problems was a good change.” – Jacob
Categorical self-binding limits consumption by sorting dopamine into different categories: those subtypes we allow ourselves to consume, and those we do not. This method helps us to avoid not only our drug of choice but also the triggers that lead to craving for our drug.
There’s something tragic and touching about having to ban yourself.
“When we realize that we are capable of this inner legislation, the (natural) man feels himself compelled to reference for the moral man in his own person.” – Immanuel Kant. Binding ourselves is a way to be free.
Chapter 6: A Broken Balance?
Any drug that presses on the pleasure side has the potential to be addictive.
Recent data showed that even antidepressants, previously thought not to be “habit forming,” may lead to tolerance and dependence, and possibly even make depression worse over the long haul, a phenomenon called tardrive dysphoria. Beyond the problem of addiction, and the question of whether or not these drugs help, I’ve been plagued by a deeper question: what, if taking psychotropic drugs is causing us to lose some essential aspect of our humanity?
One patient who seemed to be doing well on antidepressants told me she no longer cried at Olympics commercials… But when she couldn’t even cry at her own mother’s funeral, the balance for her had tipped. She went off antidepressants, and a short time later, experienced a wider, emotional amplitude, including more depression and anxiety. She decided the lows were worth it to feel human.
In my 20s, I started on Prozac for chronic low-grade irritability and anxiety diagnosed as “atypical depression.” I felt better right away. Mostly, I stopped asking the big questions: What is our purpose? Do we have free will? Why do we suffer? Is there a God? Instead, I just sort of got on with it.
In medicating ourselves to adapt to the world, what kind of world are we settling for?
Under the guise of treating pain and mental illness, are we rendering large segments of the population biochemically indifferent to intolerable circumstances?
Have psychotropic medication’s become a means of social control, especially for the poor, unemployed, and disenfranchised? Psychiatric drugs are prescribed more often and in large amounts to poor people, especially for children.
There is a cost to medicating away every type of human suffering, and, as we shall see, there is an alternative path that might work better: embracing pain.
Part III: The Pursuit of Pain
Chapter 7: Pressing on the Pain Side
Unlike pressing on the pleasure side of the pain-pleasure balance, the dopamine that comes from pain is indirect and potentially more enduring.
Pain leads to pleasure by triggering the body’s own regulating homeostatic mechanisms.
With intermittent exposure to pain, our natural hedonic setpoint gets waited to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time.
With repeated exposure to painful stimuli… the initial response (pain) got shorter and weaker. The after-response (pleasure) got longer and stronger. Pain morphed into hypervigilance morphed into a “fit of joy.”
Socrates mused on the relationship between pain and pleasure more than 2000 years ago: The two will never be found together in a man, and yet, if you seek the one and obtain it, you are almost bound always to get the other as well, just as though they were both attached to one and the same head.
Just as pain is the price we pay for pleasure, so too is pleasure our reward for pain.
Hormesis is a branch of science that studies the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli, such as cold, heat, gravitational changes, radiation, food, restriction, and exercise. Hormesis comes from the Ancient Greek hormáein: to set in motion, impel, urge on.
Worms exposed to temperatures above their preferred 20°Celsius lived 25% longer and were 25% more likely to survive subsequent high temperatures than non-exposed worms.
Fruit flies that were spun in a centrifuge for 2 to 4 weeks, not only outlived unspun flies, but were also more agile in their older age, able to climb higher, and longer than their non-exposed counterparts.
Exercise is immediately toxic to cells, leading to increased temperatures, noxious oxidants, and oxygen and glucose deprivation. Yet the evidence is overwhelming. That exercise is health–promoting, and the absence of exercise, especially combined with chronic sedentary feeding – eating too much all day long – is deadly.
When rats were given access to a running wheel six weeks prior to getting free access to cocaine, they self-administered the cocaine later, and less often than rats who had not had prior wheel training… When exercise is not voluntary, but rather forced on the animal, it still results in reduced voluntary drug consumption.
Dopamine’s ancient role in physical movement relates to its role in motivation: to obtain the objective we desire, we need to go get it.
Pursuing pain instead of pleasure is countercultural, going against all the field – good messages that pervade so many aspects of modern life. Buddha taught finding the middle way between pain and pleasure, but even The Middle Way has been adulterated by the “tyranny of convenience.”
We must seek out pain and invite it into our lives.
The history of medicine is replete with examples of using painful or noxious stimuli to treat painful disease states. Sometimes called “heroic therapies.”
Pain to treat pain. Anxiety to treat anxiety. This approach is counterintuitive and exactly opposite to what we’ve been taught over the last 150 years about how to manage disease, distress, and discomfort.
Chapter 8: Radical Honesty
Every major religion and code of ethics has included honesty as essential to its moral teachings.
Telling the truth is painful.
Children begin lying as early as age two. The smarter the kid, the more likely they are to lie, and the better they are at it.
Recounting our experiences gives us mastery over them… Our honest disclosure brings our behavior into relief, allowing us in some cases to see it for the first time.
Honesty can be strengthened by stimulating the prefrontal cortex… This led me to wonder if practicing honesty can stimulate prefrontal cortex activation… Consistent with the lived experience of people in recovery, truth-telling may change the brain, allowing us to be more aware of our pleasure-pain balance and the mental processes driving compulsive overconsumption, thereby change our behavior.
Telling the truth draws people in, especially when we are willing to expose our own vulnerabilities… People come closer. They see in our brokenness, their own vulnerability and humanity. They are reassured that they are not alone in their thoughts, fears, and weaknesses.
Intimacy is its own source of dopamine.
Wild truth-telling promotes human attachment, compulsive overconsumption of high-dopamine goods is the antithesis of human attachment. Consuming leads to isolation and indifference, as the drug comes to replace the reward obtain from being in a relationship with others.
Patients who tell stories in which they are frequently the victim, seldom bearing responsibility for bad outcomes, are often unwell and remain on well. They are too busy blaming others to get down to the business of their own recovery.
“We must suffer, suffer into truth.” – Aeschylus
If I am disciplined and diligent, I realize I too am responsible.
Donald Winnicott introduced the concept of “the false self” in the 1960s. According to Winnicott, the false self is a self-constructed persona in defense against intolerable, external demands and stressors.
When our lived experience diverges from our projected image, we are prone to feel detached and unreal, as fake as the false images we’ve created. Psychiatrists call this feeling derealization and depersonalization.
Honesty enhances awareness.
Chapter 9: Prosocial Shame
Shame can be the vehicle for perpetuating the behavior, as well as the impetus for stopping it.
Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self.
Studies show that people who are actively involved in religious organizations on average have lower rates of drug and alcohol misuse.
It is not our perfection but our willingness to work together to remedy our mistakes that create the intimacy we crave.
Conclusion: Lessons of the Balance
The rewards of finding and maintaining balance are neither immediate nor permanent.
The relentless pursuit of pleasure (and avoidance of pain) leads to pain.
Abstinence resets the brain’s reward pathway and with it our capacity to take joy in simple pleasures.
Prosocial shame affirms that we belong to the human tribe.