Human beings are programmed to approach pleasure and avoid pain. It's an instinct that dates back millions of years, to a time when people needed to actively seek food, clothing and shelter every day, or risk death.
But psychiatrist Anna Lembke says that in today's world, such basic needs are often readily available — which changes the equation.
"Living in this modern age is very challenging. ... We're now having to cope with: How do I live in a world in which everything is provided?" Lembke says. "And if I consume too much of it — which my reflexes compel me to do — I'm going to be even more unhappy."
Lembke is the medical director of addiction medicine at Stanford University and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. Her new book, Dopamine Nation, explores the interconnection of pleasure and pain in the brain and helps explain addictive behaviors — not just to drugs and alcohol, but also to food, sex and smart phones.
Lembke says that her patients who are struggling with substance abuse often believe their addictions are fueled by depression, anxiety and insomnia. But she maintains that the reverse is often true: Addictions can become the cause of pain — not the relief from it. That's because the behavior triggers, among other things, an initial response of the neurotransmitter dopamine, which floods the brain with pleasure. But once the dopamine wears off, a person is often left feeling worse than before.
"They start out using the drug in order to feel good or in order to experience less pain," Lembke says. "Over time, with repeated exposure, that drug works less and less well. But they find themselves unable to stop, because when they're not using, then they're in a state of a dopamine deficit."
On the role dopamine plays in addiction
Dopamine is a neurotransmitter that sends signals from one neuron to another, and it's probably the most important neurotransmitter in our experience of pleasure, motivation and reward. ... Dopamine is the final common pathway for all pleasurable, intoxicating, rewarding experiences. ...
[An] experiment has been done in rats, for example, putting a probe in their brain, measuring the amount of dopamine released in response to different types of substances. Now, remember, we all have a baseline release of dopamine that's sort of always there. And then when we ingest certain substances or engage in certain behaviors, our dopamine either goes up or down in response to that substance or behavior. So, for example, chocolate increases dopamine above baseline about 50%. Sex is about a 100%. Nicotine is about 150%. And amphetamines is about 1,000%.
On how pleasure and pain processing overlaps in the brain
One of the most fascinating findings in neuroscience in the last 75 years is that the same areas of the brain that process pleasure also process pain and that pleasure and pain work like a balance. So if you imagine that in your brain, there's a teeter-totter, like something you would find in a kid's playground, and when that teeter-totter is at its resting baseline, it is level with the ground. When we do something that's pleasurable — for example, when I eat a piece of chocolate — then my pleasure/pain balance tilts just a little bit to the side of pleasure, and I experience a release of dopamine in my brain's reward pathway.
But one of the governing principles regulating this balance is that it wants to remain level, which is what neuroscientists call homeostasis. It doesn't want to be deviated for very long, either to the side of pleasure or pain. So that when I eat a piece of chocolate, immediately what my brain will do is adapt to the presence of that pleasurable stimulus by tipping my balance an equal and opposite amount to the side of pain. And that's the aftereffects or the comedown or, in my case, that moment of wanting a second piece of chocolate. Now, if I wait long enough, that feeling passes — and homeostasis is restored.
On the comedown — when pleasure quickly becomes pain or discomfort
When that pleasure/pain balance tilts to the side of pain after the experience of pleasure, that pain is subjectively experienced as a number of different things. One of [them] is a subjective feeling of being uncomfortable, restless, irritable, unhappy and wanting to re-create the feeling of pleasure. But that's also in many ways what craving is: wanting to have the pleasure, again, being preoccupied with eliminating the experience of pain that we feel in the aftermath. And I will say, too, it's very reflexive. It's not like I'm even consciously aware of that aftereffect or the comedown. It can be very subtle, but I'm just sort of aware of wanting to have another piece of chocolate.
On poverty being a risk factor for addiction
If you look at all of these different risk factors for addiction, [they] include poverty, unemployment, multigenerational trauma. So those are a priori risk factors for addiction. And then you superimpose on top of that easy access to cheap rewards that are themselves reinforcing [and] what you find is that, in the United States, the people who are most vulnerable to addiction are people who are socioeconomically disadvantaged, because not only are they living in poverty, but they also have access to cheap feel-good drugs.
On whether we can be addicted to social media and our phones
It's important to recognize that addiction is a spectrum disorder, and it is possible to be a little bit addicted. Also, the same brain mechanisms that mediate severe addiction also mediate our minor addictions. ... I don't think that anybody is immune from this problem. And I do believe that smartphones are addictive. They've been engineered to be addictive and ... we don't really need more studies to show that that's true. All you need to do is go outside and look around.
On how the pandemic has affected various addictions
I think it's important for me to tell you that I've also had a lot of patients who have done better during quarantine. And what they tell me is that the world is kind of a hyperstimulated, triggering place for them. And quarantine forced them to slow down and also eliminated a lot of the types of interactions and stimuli that would typically trigger relapse or reuse for them. So I would say I've seen sort of a bimodal distribution in terms of the COVID response in my patient population. Again, for some people, it's been absolutely terrible. Of course, we've seen an uptick in overdose-related deaths, including some of my own patients. And that's absolutely tragic. ... I've also seen more people spend more time on their screens and really struggle and wonder about how to manage compulsive overconsumption of their digital devices. But again, I think it's important to say that some patients are doing much, much better — have found it easier not to drink alcohol, for example, because there aren't so many parties where people are consuming large amounts of alcohol. It's been an interesting mix.
Sam Briger and Kayla Lattimore produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the web.