Are You a Dopamine Addict? | Dr. Anna Lembke  ## Metadata - Author: [[We Can Do Hard Things]] - Full Title: Are You a Dopamine Addict? | Dr. Anna Lembke - Category: #podcasts - URL: https://share.snipd.com/episode/95a2c7fd-ba5d-47ba-b709-2b55e6cbf9a1 ## Document Notes ## Highlights - **Quick Fix Culture Fuels Overconsumption** - Modern life supplies engineered, instant dopamine fixes that temporarily relieve discomfort but worsen baseline mood. - Recognizing that cultural mismatch explains why we chase short-term relief repeatedly. Transcript: Glennon Doyle By the end of this episode, you are going to understand why all of the things we're doing to make ourselves feel better are making us feel worse. And we're going to fix it, okay? In the next 50 minutes, we're going to fix that and tell you how to actually make yourself feel a little bit better and not get tricked. To do that is the only person who could really help us do that. And her name is Anna Lemke. And she is here with us. She is the medical director of Stanford Addiction Medicine, program director for the Stanford Addiction Medicine Fellowship, and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She is the recipient of numerous awards for outstanding research in mental illness, for excellence in teaching, and for clinical innovation in treatment. 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. ([Time 0:02:22](https://share.snipd.com/snip/b1508eb7-83e4-46b2-b5fd-dcf6fa87430f)) - **Pleasure-Pain Brain Teeter-Totter** - The brain processes pleasure and pain in the same circuits and constantly seeks homeostasis. - Dopamine pushes the balance toward reward while the brain counteracts to restore equilibrium. Transcript: Anna Lembke, MD Agree with what you said. For me, it really comes down to understanding how our brains process pleasure and pain, recognizing that pleasure and pain are co-located in the brain. The same parts of the brain that process pleasure also process pain, and they work like opposite sides of a balance. So imagine something like a teeter-totter in a kid's playground. When we're at rest, hypothetically, that teeter-totter is level with the ground. When we do something pleasurable, it tips one way. And when we do something painful, it tips the opposite way. Now that is a vast oversimplification. Let me just emphasize, I mean, we can experience pleasure and pain simultaneously during sex, when we're eating spicy foods, when we're watching a complex piece of art. Evolution to reflexively approach pleasure, avoid pain. And this pleasure-pain balance metaphor tells us something really important about how our brains get us to do that. So essentially, that level balance is what neuroscientists call homeostasis. So that is our baseline level of happiness. ([Time 0:04:58](https://share.snipd.com/snip/99ac463f-fc34-485d-9b6d-c26f16c49a50)) - **Neuroadaptation Gremlins Explain Cravings** - Repeated dopamine spikes trigger neuroadaptation that overshoots into a deficit below baseline. - Those adaptation "gremlins" sit on the pain side and drive craving, hangovers, and long-term withdrawal. Transcript: Anna Lembke, MD And dopamine is our reward neurotransmitter. It's not the only neurotransmitter that is to say brain chemical involved in that process, but it is the final common pathway for all reinforcing, rewarding, pleasurable substances And behaviors. So when we do something that is pleasurable, which we're all seeking, right, to approach pleasure and to avoid pain when we do something that's pleasurable, that releases dopamine In the brain's reward pathway. And that pleasure-pain balance tilts to the side of pleasure. Yay. The problem is that there are certain rules governing this balance. And the first and most important rule is that the balance wants to remain level. And that with any deviation from a level balance or homeostasis, our brains will work very hard to restore a level balance. That process is called neuroadaptation. Okay. And essentially when we have an increase in dopamine firing in response to something pleasurable, our brain will react by down-regulating dopamine transmission. For example, down-regulating dopamine production. But it doesn't just go to baseline, it goes below baseline into a dopamine deficit state. You might think of that as these little neuroadaptation 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 we're level, they stay on until we're tilted an equal and opposite amount to the side of pain. That's the come down, the hangover, the blue Monday, or just that moment of craving, right? Wanting to have one more glass of wine, smoke one more joint, watch one more Netflix episode, rerun one more chapter in my romance novel. Now, if we don't have more of whatever it is, which by the way, for most of human existence, we didn't have more of that stuff, then the gremlins get the message, hey, my work here is done. They hop off the pain side of the balance and homeostasis is restored. But if we continue to consume our drug of choice over days to weeks to months to years, those gremlins multiply. They get bigger. They get stronger. They call their friends. Pretty soon they are camped out on the pain side of the balance. ([Time 0:06:43](https://share.snipd.com/snip/1f616025-65a8-4caf-b10c-79bb7ddbe37b)) - **Addiction Becomes A Vortex** - Addiction shifts your hedonic set point so you need more substance just to feel normal. - That explains why people relapse despite knowing their lives improve when they stop using. Transcript: Anna Lembke, MD They get bigger. They get stronger. They call their friends. Pretty soon they are camped out on the pain side of the balance. And now we've entered into addicted brain, where we have essentially changed our hedonic or joy set point such that we need more of our drug in more potent forms, not to tilt to the side Of pleasure and feel good, but just to get out of pain and feel normal. And this is the vortex of addiction. It explains why people continue to use their drug of choice, even when they can objectively see that their lives are better when they're not using it. It's why people will relapse. And it's why people describe a state of kind of constant craving, particularly when they first try to give up their drug of choice, because when we first give it up, those gremlins that Have accumulated crash down to the side of pain. ([Time 0:08:57](https://share.snipd.com/snip/d1d6b9a6-0512-40a3-8390-b1c16cba0ae9)) - **Recovery Removes Shame** - Abby Wambach says learning dopamine science removed much of the shame she felt about addiction. - That reframing turned a moral failure story into a clearer, treatable brain process. Transcript: Abby Wambach Want to bring this into a personal reflection and what your work has really done to change my life. I'm almost 10 years sober. I lived a life as a professional athlete. And I didn't realize that dopamine was, in fact, the thing that I was chasing all along. It was covered up by booze and attention and, you know, winning gold medals, et cetera. And one of the things that I've found so fascinating and almost, it might be the most important thing that I've learned in my recovery is that learning about dopamine and the process Of what the brain is going through while seeking pleasure and also experiencing pain. It's like so many of us that live with addiction have and carry this incredible amount of shame with us because it feels like, why can't I do this? Like, what is wrong with me? There's some sort of moral or something wrong with me personally. And when I read your work and have been obsessed with it, and I've sent all of the podcasts I've listened to to all of my addicted friends, like, listen to this. Because it de-shamed me. It's like my brain, though it might be more susceptible to others for this search of dopamine. Yeah. It just took so much shame away. And I just think that your work is so important and made it feel more scientific than moral, than moral. ([Time 0:14:26](https://share.snipd.com/snip/16d376a0-ee62-4f41-909b-9e5914e970e9)) - **Baseline Happiness Is Both Trait and State** - Baseline happiness likely reflects both inherited traits and life states that change over time. - Family history plus environmental stressors together shape addiction vulnerability. Transcript: Anna Lembke, MD It's a great question. It gets to the kind of state or trait phenomenon. You know, are these inborn traits that people have, though they'll always go back to whatever their baseline level of dopamine firing is, or are these state phenomenon as a result of, You know, environmental stressors or other stressors? And again, this is speculation, but my sense is that it's both state and trait. So I do believe that some people are born with just kind of like lower levels of pleasure. And those people are often diagnosed as having mental illness. Sometimes it's episodic, right? They'll have an episode and then they'll go back. So I do think, and we do know that the risk of addiction, I mean, there are many risks of addiction, right? There are poverty, unemployment, co-occurring mental illness, access to your drug of choice. Those are all risks. But there is also very likely an inherited or biological risk of addiction that's complex and polygenic that probably is related to baseline levels of dopamine firing. We know, for example, if you have a biological parent or grandparent with addiction, you're more likely to develop addiction yourself, even if raised outside of that substance using Home. So when we're trying to differentiate nature versus nurture, that's one of the types of experiments or studies that people look at. ([Time 0:22:35](https://share.snipd.com/snip/69beb216-e872-42b2-bf5c-e1504298c47b)) - **Try A 30-Day Abstinence Trial** - Try abstaining from your main dopamine-triggering behavior for 30 days to let homeostasis begin to return. - Use that month to see whether cravings subside and life feels less driven by compulsion. Transcript: Anna Lembke, MD Yeah. Well, I mean, the long-term fix is actually to restore homeostasis. And the way to do that is to abstain from our drug of choice for long enough for those gremlins to hop off and for homeostasis to be restored. But if we've been accumulating those gremlins on the pain side of the balance for years, it can take a really long time for them to get off and for homeostasis to be restored. I will often present to patients, try abstaining from your drug of choice for 30 days. It's not that I think 30 days is a cure for addiction. That would be incredibly naive. But interestingly, on average, that is the amount of time it takes for folks to begin to get out of that vortex of craving and see the light at the end of the tunnel. ([Time 0:29:00](https://share.snipd.com/snip/940e300c-7616-41c4-9189-bfd0cdbfd8d2)) - **Check The Four C's** - Watch for the four C's: control loss, compulsion, craving, and consequences as signs of harmful overconsumption. - Notice tolerance, secretive use, and narrowing pleasure as red flags to act on. Transcript: Abby Wambach Great, great point. Anna Lembke, MD Let's start there. So we talk about the four C's, control, compulsion, craving, and consequences. Out of control use would be like, I planned to only have one drink and I had four. I planned to just watch one TikTok video and two hours later I was still watching. Okay. Compulsion is a lot of our mental real estate occupied with thinking about using the drug as well as a narrowing of our focus and our pleasure spectrum. So looking forward to it all day, planning on it. If we're doing it secretly, which commonly happens, then hiding our use. And that can also start to be part of the drug itself, the adrenaline that we get from the secret life and hiding our use. So that's the compulsion and also the automaticity. Craving is interesting. Craving can manifest in different ways. People can get sudden stomach aches and feel like the only solution to my stomach ache or my nausea or my dizziness is to use. But more often craving comes in the form of an elaborate narrative that our brains can manufacture in a nanosecond, telling us why we really should use after all, even though we committed To not using. And it's an elaborate, it can be like, this is a stupid thing. I'm not really addicted. I'm in pain. I deserve this. Nobody loves me. I need a reward. This is the only way to reward myself. And these are very, very convincing narratives that, you know, get a life of their own and are difficult to get away from. And then consequences is really like the heart of addiction. And often we don't see the consequences. It's harm to others, harm to ourselves, and really subtle decrements in mood and increases in anxiety that happen slowly and insidiously over time that we especially don't attribute To our drug of choice because when we use, we temporarily relieve those like we were talking about, right? ([Time 0:31:19](https://share.snipd.com/snip/4ae71f05-bfd2-422d-aeba-1e62299b3f42)) - **Expect To Feel Worse First** - Expect intense dysphoria, craving, and sleep disruption in the first 10–14 days of stopping. - By weeks three and four many people notice craving becomes intermittent and hope starts to return. Transcript: Anna Lembke, MD The most important thing that I tell my patients and barring nothing else, this is the most important thing I say, you will feel worse before you feel better, but that is not the way you're Going to feel for the rest of your life. Yes, that's it. When you take the pain off the pleasure side of the balance, the gremlins will crash down to the pain side. And it will take those gremlins a while to get the message that you're not using your drug of choice anymore. And then it's time for them to hop off of the pain side of the balance and for homeostasis to be restored, not through repetitive use, but through the gremlins hopping off and upregulation Of our brain's own production of our feel-good neurotransmitters like endogenous opioids, endogenous cannabinoids, endogenous GABA, serotonin, and dopamine. Amanda Doyle So how long does that usually take if we're working with 30 days? During what period of time in that 30 days do people typically stop feeling like shit and start to feel a little bit like, and what do they feel like? Like, what does that feeling feel like when it emerges? Because it's probably not been there for a very long time. How do people describe the new emerging feeling? Anna Lembke, MD So the first 10 to 14 days, people feel really, really lousy. And again, it's not necessarily primarily physical, although it can be if it's something like an opioids or alcohol, but there's just a lot of intense craving, intense dysphoria, Irritability, insomnia. And then if they're able to get through that part without using, which is really hard, but if they're able to do it by weeks, three and four people just begin to notice it's not 24 seven Craving, right? Or they start to notice some lightness or just some hopefulness about the future. Now I want to emphasize that on average, we see clinically that it takes 30 days to start to feel better. ([Time 0:34:28](https://share.snipd.com/snip/738add70-d686-404c-99ba-8c07a697962a)) - **Earned Reward: Pain First, Joy After** - Small, managed exposure to pain (exercise, cold water, meditation) triggers endogenous opioids and later dopamine. - Doing the hard thing first produces durable, healthier reward signals than quick artificial spikes. Transcript: Anna Lembke, MD And let me just say that, you know, those gremlins are agnostic to what the initial stimulus is. We know that when we press on the pleasure side, they will jump on the pain side. But it turns out that if we press on the pain side, not too hard and not too fast, but just the right amount, those gremlins will actually go on the pleasure side and we will get our dopamine Indirectly by paying for it up front. And this is things like the runner's high, which is, you know, sports are initially toxic to cells, but what happens is the body senses injury in response to exercise and then upregulates Feel-good neurotransmitters like serotonin, norepinephrine, endogenous opioids, dopamine. Same thing with ice cold water plunge. That's painful, but it causes the body to upregulate those feel-good neurotransmitters. ([Time 0:42:59](https://share.snipd.com/snip/87bd41a4-a670-4935-9caa-6305f16469ee)) - **Try Not Looking Forward Experiment** - Try going a day without looking forward to anything to force presence and reduce anticipatory craving. - That experiment often reveals richer, more immediate enjoyment and weakens engineered dopamine expectations. Transcript: Anna Lembke, MD And I think that's where we go astray. One of the good Duncan experiments that I sometimes do, and you might want to try it, is imagine going through your whole day not looking forward to anything. Oh my God. Right. Which is kind of weird, right? But stay, bear with me for a second. So, you know, like whatever it is, that morning cup of coffee or that, you know, that person you're going to see or whatever, imagine, okay, today I'm that, that, and all of a sudden everything Shifts because if I'm not projecting myself into the future towards some expectancy, I'm really forced to be right here and now. And then it takes on a qualitatively different feeling. Like, for example, like if I were now looking forward to like, you know, podcasts make me a little nervous. So I'm looking forward to this podcast, some part of my brain being over. So then I won't, you have to deal with the nerves anymore, but, but that's a terrible thing because the moment I shift away from that, I'm like, oh, here I am. I'm just with you all. And there's no other place to be. And then I'm fully present and it's a wonderful experience, right? ([Time 0:46:33](https://share.snipd.com/snip/852b2f41-a23e-4223-9ccb-a77ff588b05d)) - **Surviving Failure Builds Resilience** - Glennon Doyle describes her daughter's devastating loss followed by relief and strengthened resilience. - Surviving the "unsurvivable" teaches children they can fail and still be loved and whole. Transcript: Glennon Doyle It is a dopamine thing. Right. The more goals, the more people watching, the more the college thing, the whatever, the winning. And I can sense in my kids a deep fear of when it goes wrong, when people stop loving them because they are human, when people, when it all comes crashing down and they're like holding their Breath. But recently we had an experience where what happened to our kid on the field is what you just never want to happen. We'll just leave it that way. Just happened. Just didn't go well. And we watched her. Am just going to tell you that I thought I was going to die. Abby Wambach Like I. That Glennon, she herself thought that it was happening. I get it. I hear you as a mother. I totally hear you. Yeah. Glennon Doyle And then something really wild happened, which is that she was awesome. I mean, she was horribly sad and it was awful. And then several hours later, there was this strange relief or euphoria. And I'll just tell you this just happened yesterday. Okay. Anna Lembke, MD Very cool. Glennon Doyle And what I said to Abby this morning and said to Amanda, cause she was riding this wave with me last night was, I think she just discovered the invincibility of surviving the unsurvivable. ([Time 0:51:50](https://share.snipd.com/snip/e0b18cbd-a01f-4401-ac5b-c3cf6b5b1cbc)) - **Praise For Effort, Not Pride** - Say "I'm happy for you" rather than "I'm proud of you" to avoid tying worth to outcomes. - That phrasing helps decouple children’s identity from performance-triggered dopamine loops. Transcript: Abby Wambach Well, and one thing I would say to that, something that I was conscious and intentional about when our kids were getting into sports. I never wanted to say, I am proud of you. Uh-huh. Yep. I say, I am happy for you. Yeah. And I love watching you, but the pride thing really trips me up because this is like the insinuation that I'm only going to be proud of you or like, it's just a weird word that we, I love it. Anna Lembke, MD I love it. That's such a pearl. That is such, and I have, I have said, I am proud of you and I'm, I'm done. Yeah. Thank you. I am. Thank you. Abby Wambach So happy for you because it just puts the, I'm so happy for you. ([Time 0:54:40](https://share.snipd.com/snip/b52d60f2-8005-4d37-8863-fc786019378d))