From mobile phones to opioids to sex, and even shopping, it seems practically everyone is addicted to something. Dr Anna Lembke’s book, Dopamine Nation: Finding Balance in the Age of Indulgence, a New York Times best seller, sheds a unique light on how to deal with addiction.
Dr Lembke is the medical director of Stanford Addiction Medicine, Palo Alto, California, program director for the Stanford Addiction Medical Fellowship, and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic.
We spoke with Dr Lembke about her unique research and her book.
You have a long history of conducting research to inform areas like addiction medicine, pain, and the misuse of drugs, as well as teaching a multitude of courses at Stanford University over the last 25 years. Was there a specific moment when you decided to write the book, Dopamine Nation?
Dr Lembke: The ideas in Dopamine Nation are ideas that I had been cogitating on for many years, but there was a specific moment, a specific patient, who I met, who all of a sudden made me see a way that I could communicate these ideas, namely through his particular story. And that is the patient’s story that I open with in the book. The patient, Jacob, has a very severe sex addiction and goes on to make a masturbation machine. And I literally did have a visceral reaction of horror to that in the same moment that I saw myself in him: I could really relate my own compulsive romance reading and my Kindle [use] to a form of masturbation. So that was the moment when I thought, “oh, this is the patient who, if he’s willing, could help me communicate these ideas.” And he was willing, which was so wonderful and generous of him.
Was there anything new that you learned in writing this book or something that challenged your previous beliefs?
Dr Lembke: I guess 1 of the things that stands out was when I learned that even running wheels can be addictive for mice and rats. I, like most people, had always thought that running wheels was just a way to measure physical activity or even a healthy alternative to drugs for a rat trapped in a cage. I had seen lots of reports that if you put a running wheel in a cage where a rat has access to cocaine, for example, they will use less cocaine when the running wheel is there than if the running wheel is not there. So, I was very surprised to learn that some rats, unfortunately, can get addicted to running on the wheel, and can run themselves to death or run so much that their tails get permanently curved in the shape of the wheel. The smaller the wheel, the more their tails curve.
And then I think the real kicker for me was the study that took a running wheel and put it in nature and found that rodents and other animals will voluntarily go onto the running wheel in nature just because they find it reinforcing. There’s no other secondary gain for them.
What are some changes clinicians can begin making today to provide holistic care for patients with addiction, depression, anxiety, chronic pain, etc?
Dr Lembke: The first most important change is to recognize that too much stimulation with too many reinforcing substances and/or behaviors can actually reset the brain and put it into a dopamine deficit state, which is akin to a clinical depression or a clinical anxiety. [Given] that, the first point of intervention is not necessarily to prescribe a medication or even do any particular type of psychotherapy, but rather to ask the patient to experiment with a dopamine fast, a period of 4 weeks in which they don’t play video games or use cannabis or drink alcohol or watch pornography or whatever it is, and to see if that dopamine fast alone will get them out of that depression and that anxiety. In my clinical experience, about 80% of people will be improved or even completely freed of their symptoms of depression and anxiety, simply by engaging in a dopamine fast.
What is dopamine fasting? Can it help with someone who is addicted to “digital” drugs?
Dr Lembke: I’ve been doing this work for 2 decades but it’s become trendy now in Silicon Valley to talk about dopamine fasting, which is similar but not exactly the same as what I’m recommending. What some Silicon Valley CEOs are doing is going and hiding in a cave for a week and so depriving themselves of all sensory experiences and then coming out and being mesmerized by a light on a green leaf. And that’s the same exact idea but not exactly what I’m proposing. I’m proposing instead…[that we] identify what is that “digital” drug or that constellation of “digital” drugs that has you clicking and swiping in a way that’s out of control, compulsive, causing you problems, or not consistent with your goals and values.
And once you’ve identified that, to set a specific quit date and let people know so you prepare for it and people are able to reach you in other ways. Put self-binding strategies in place, that is barriers between yourself and your drug of choice, maybe getting rid of the device itself, maybe deleting apps, maybe getting 2 devices. And then just really going cold turkey from that particular digital drug for long enough to reset reward pathways, recognizing that initially you’ll feel worse before you feel better. I recommend [going cold turkey for] 4 weeks, because in my clinical experience and in some of the scientific studies today, they suggest that it takes that long to reset dopamine firing back to healthy baseline thresholds.
Is dopamine fasting something that most clinicians are familiar with, or is this new knowledge for most clinicians?
Dr Lembke: I would say this is new knowledge, something that I landed on in over 20 years of practice, but it’s well supported by the science, especially the neuroscience of pleasure and pain and how we process pleasure and pain and what happens as we get addicted. I would say I’m the first person, though, to probably extrapolate this science to the rising rates of addiction, but more importantly, the rising rates of depression, anxiety, and suicide all over the world, especially in rich nations. This might be attributable to the stress of oversupply and the problem of a dopamine-rich world. There are many reasons why we’re seeing higher rates of depression and suicide, especially in wealthy nations. There’s a socioeconomic divide. There are all kinds of trauma that people experience. But I’m the first to put forward the idea that abundance itself is a serious stressor and that almost every aspect of our modern lives has become “drugified” in some way…[T]he constant stimulation of our brains with these highly reinforcing drugs and behaviors, from our smartphone first thing in the morning to our Netflix binge at the end of the day, are all things that are, hypothetically, driving our dopamine levels down as a way to compensate for too much stimulation, and leaving us all depressed and anxious as a result. And I think it’s an important contribution because it points to a very different intervention.
The intervention that you speak of, that would be dopamine fasting?
Dr Lembke: Yes. The intervention is basically, very simplified, and threefold.
- Abstaining for a period of time from our drug of choice.
- Learning to sit with discomfort, which is, of course, something that many different traditions teach.
- Intentionally doing things that are painful: things that are physically hard and mentally hard.
This is the science of hormesis, [which is a Greek word meaning] “just set in motion.” There’s a growing body of literature showing that when an organism is exposed to mild to moderate doses of toxic stimuli, that actually sets into motion the organism’s own healing mechanisms and leads to upregulation of our feel-good hormones and neurotransmitters, like oxytocin, opioids, endocannabinoids, serotonin, norepinephrine, and dopamine.
[The idea here] is that we can actually take action by doing things that are painful and hard in order to get our dopamine indirectly by paying for it up front. Of course, the huge caveat here is you don’t want to start cutting on yourself. That’s not hormesis. That’s too much pleasure or that’s too much injury that basically then causes a huge release of endogenous opioids and dopamine, which ultimately exhausts the system and breaks the balance. That’s what we’re talking about.
What institutional and/or cultural changes are needed to allow clinicians to pursue the course you outline in your book?
Dr Lembke: I think there should be universal screening for quantity and frequency of substance use, as well as for potential behavioral addictions. So as part of general preventive holistic medicine, I think every patient in pediatric clinics, emergency rooms, [women’s health] settings, and psychiatry offices should be asked about their substance use: how much and how often. And also asked about potential behavioral or process addictions. Are they playing video games? How much and how often are they looking at pornography? Are they looking at social media? Are they just generally on their phones? How much and how often? Cryptocurrency, online shopping, I mean you name it, all of that is a part of it.
And if the individual is endorsing daily use in particular, and also use that’s interfering with their goals and values or otherwise causing problems, then there should be a more in-depth screening for a possible addiction. Because if we try to intervene, especially from the mental health perspective, without also paying attention to what’s happening to the dopamine system, then our interventions are unlikely to be successful. We really need to integrate an understanding of the dopamine system and treatment for a potential addiction with our other interventions for depression, anxiety, schizophrenia, whatever it is.
What would you like clinicians to take away from your book?
Dr Lembke: So, in my book I do have this acronym, “DOPAMINE,” where I go through a kind of a step-by-step framework for approaching these problems with patients.
- “D” stands for data. That’s where we just ask patients to tell us what they use, how much, and how often. It’s very important to ask again about process addictions as well…[H]aving patients do that not only gives us the information but also gives them that kind of “a-ha” moment where they can see how much they’re using in a way that’s very difficult to see until you relate it in narrative form to another human being. I’ve had patients actually say, “Oh wow, I hadn’t realized it was that much.”
- The “O” is objective. It’s where we ask patients to reflect on why they use.
- The “P” stands for problems. Putting it in that order is intentional so that you finish up with problems. Because a lot of times patients will endorse, for example, that they’re self-medicating with their drug of choice. That may have been true initially, so that objective is valid initially, but very often the drug ends up being the source of the anxiety and depression after neuroadaptation has changed the brain so that it becomes a problem.
- “A” stands for abstinence. That’s the dopamine fast we’ve been talking about. The “A” can also stand for asceticism, this idea of intentionally inviting pain back into our lives.
- “M” is mindfulness. The dopamine fast requires patients to practice the skill of mindfulness so they can observe what they’re feeling without judgment and also without reaching for their drugs.
- “I” is for insight. It’s hard to get insight on true cause and effect until you get some distance from using your drug. That’s another reason for a dopamine fast.
- “N” stands for the next step. Folks will come back after a dopamine fast and then we just explore with them: what was good about that, what was bad about that, and what do you want to do next? And most people want to go back to using in moderation after they abstain, and that’s okay. We meet patients where they are. We may be thinking to ourselves, that’s not a good idea, but they have to go out and do the research. What’s key [here] is to come up with a very specific plan around what, for example, moderation would look like: how much, how often.
- “E” is for experiment. Because even if the ultimate goal is moderation, my clinical experience and data show that people are going to be more successful with moderation if they do a fast first and reset reward pathways.
And then just work with patients. Some patients, after trying to moderate for a while and not being able to, might say, “Hey, abstinence is obviously a better choice for me.” Or patients may be able to moderate but find that it’s just too exhausting and not worth it and may choose abstinence. Other people may relapse instantly, a signal to them that they’re more addicted than they thought they were. So, it’s just a really nice intervention. As 1 of my colleagues, a neuroscientist, will say, if you really want to understand how a system works, change 1 variable in it and then observe what happens.
Lembke A. Dopamine Nation. New York: Dutton