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October 14, 2024 • 2hr 21min
#321 – Dopamine and addiction: navigating pleasure, pain, and the path to recovery | Anna Lembke, M.D.
The Peter Attia Drive
In this episode, Dr. Peter Attia interviews Dr. Anna Lembke, Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic and author of "Dopamine Nation". They discuss the neurobiology of addiction, diagnostic criteria, risk factors, treatment approaches, and emerging issues like social media addiction. Dr. Lembke shares insights from her clinical experience treating various addictions and her perspective on effective interventions.
#321 – Dopamine and addiction: navigating pleasure, pain, and the path to recovery | Anna Lembke, M.D.
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Key Takeaways
- Dopamine is the key neurotransmitter involved in pleasure, reward, and motivation. It is released in the brain's reward circuitry in response to reinforcing substances and behaviors.
- Addiction is characterized by the "4 C's": out of control use, compulsive use, cravings, and continued use despite consequences. Tolerance and withdrawal are also key features.
- Risk factors for addiction include genetics (50-60% heritable), early childhood experiences, and environmental access to addictive substances/behaviors.
- Abstinence from addictive behaviors for 4+ weeks can help reset reward pathways and reduce cravings in many cases. This "dopamine fast" is often used as an early intervention.
- Social media and smartphones are likely causing mental health harms in young people, though more research is needed on causality. Limiting access and creating tech-free spaces for youth is recommended.
- Cold exposure (e.g. ice baths) can provide mood-elevating effects and may be a healthier alternative to other addictive behaviors for some individuals.
- 12-step programs like AA can be highly effective for some people due to easy access, peer support, and allowing people to be vulnerable about their struggles.
- GLP-1 agonist drugs like semaglutide show promise for treating alcohol use disorder in addition to their approved uses for diabetes and obesity.
- Taking time to listen to a patient's life story and background is crucial for effective psychiatric care, rather than just focusing on symptoms and diagnoses.
Introduction
In this episode, Dr. Peter Attia interviews Dr. Anna Lembke, Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic and author of "Dopamine Nation". They discuss the neurobiology of addiction, diagnostic criteria, risk factors, treatment approaches, and emerging issues like social media addiction. Dr. Lembke shares insights from her clinical experience treating various addictions and her perspective on effective interventions.
Topics Discussed
The Neurobiology of Dopamine and Addiction (3:00)
Dr. Lembke explains that dopamine is a key neurotransmitter involved in pleasure, reward, and motivation. It is released in the brain's reward circuitry in response to reinforcing substances and behaviors. While other neurotransmitters are involved, dopamine is the "final common pathway" for all reinforcing stimuli.
The reward circuitry includes:
- Prefrontal cortex - involved in executive function and impulse control
- Nucleus accumbens - rich in dopamine-releasing neurons
- Ventral tegmental area
Dr. Lembke notes: "We're always releasing dopamine at a baseline tonic level. But when we do something that's pleasurable or reinforcing or that our brains consider salient or important for survival...we will increase dopamine firing above baseline."
Defining and Diagnosing Addiction (13:00)
Addiction is characterized by the "4 C's":
- Out of control use
- Compulsive use
- Cravings
- Continued use despite consequences
Additionally, tolerance and withdrawal are key features of addiction. Dr. Lembke emphasizes that addiction diagnosis is based on patterns of behavior, not brain scans or blood tests. It requires clinical judgment and patient self-reporting.
Assessing Alcohol Use and Addiction (17:15)
For alcohol use assessment, clinicians look at:
- Quantity and frequency of drinking
- Reasons for drinking (fun vs. problem-solving)
- Problems caused by drinking
- Binge patterns
Dr. Lembke notes epidemiological data shows increased health risks for men drinking >14 drinks/week or >4 drinks/day, and for women >7 drinks/week or >3 drinks/day.
Risk Factors for Addiction (25:15)
Dr. Lembke outlines three categories of risk factors:
- Nature (genetics) - 50-60% heritable based on family/twin studies
- Nurture - Early childhood experiences, parental modeling, trauma
- Neighborhood - Environmental access and exposure to addictive substances/behaviors
She explains that individuals may have different "drugs of choice" based on which substances/behaviors are most reinforcing for their unique neurobiology. Access intersects with this individual vulnerability to increase addiction risk.
Abstinence and Resetting Reward Pathways (41:15)
Dr. Lembke describes using a 4-week abstinence period as an early intervention for addiction. This "dopamine fast" aims to reset reward pathways and reduce cravings. She explains:
"If they are willing and able to do that, they feel so much better after that abstinence trial or dopamine fast that there's not even an indication after that to prescribe an antidepressant or an anxiolytic or necessarily do psychotherapy."
She uses the metaphor of a pleasure-pain balance to explain how the brain adapts to repeated substance use, leading to tolerance and withdrawal. Abstinence allows this balance to be restored.
Safely Abstaining and Transitioning to Recovery (51:30)
Dr. Lembke discusses considerations for safely abstaining from addictive substances:
- Alcohol and benzodiazepine withdrawal can be life-threatening in severe cases
- Medical monitoring may be needed for high-risk patients
- Past withdrawal experiences help predict future risk
- Opioid withdrawal, while extremely unpleasant, is generally not life-threatening
For long-term recovery, she emphasizes the importance of "self-binding strategies" - creating barriers between oneself and addictive substances/behaviors. This may include environmental changes, accountability systems, or medications like naltrexone for alcohol use disorder.
Behavioral Addictions and Gender Differences (1:08:30)
Dr. Lembke discusses the rise of behavioral addictions like pornography and compulsive masturbation, particularly in men. She notes that while historically men have had higher rates of most addictions, the gender gap is narrowing for some substances like alcohol.
Exceptions where women may have higher rates include benzodiazepine addiction and potentially social media addiction.
Social Media and Mental Health in Youth (1:34:45)
Dr. Lembke argues there is strong evidence that social media use is causing mental health harms in young people, citing:
- Dose-dependent relationship between use and mental health issues
- Improvement when social media use is reduced
- Biological plausibility
- Strength of association across many studies
- Temporal relationship in some cases
She recommends removing smartphones from schools and creating more tech-free spaces for youth socialization and learning.
Cold Exposure for Mood Regulation (1:47:15)
Dr. Lembke discusses how practices like cold showers or ice baths can provide mood-elevating effects for some individuals. While not a cure-all, she sees this as a potentially healthier coping mechanism compared to substance use for some patients in recovery.
GLP-1 Agonists for Addiction Treatment (1:58:30)
Dr. Lembke shares early clinical experiences using GLP-1 agonist drugs like semaglutide (typically used for diabetes/obesity) to treat alcohol use disorder in some patients who have not responded to other treatments. She notes dramatic reductions in alcohol cravings in some cases.
While more research is needed, she predicts these drugs may become an approved treatment for alcohol addiction in the future.
Benefits of 12-Step Programs (2:06:00)
Dr. Lembke discusses the strengths of 12-step programs like Alcoholics Anonymous:
- Free and widely accessible
- Peer support model
- Allow people to be vulnerable about struggles
- Sponsorship provides 24/7 support
While not for everyone, she argues they can be highly effective for many people struggling with addiction.
Importance of Patient Stories in Psychiatric Care (2:11:45)
Dr. Lembke emphasizes the value of taking time to listen to a patient's life story and background, rather than just focusing on symptoms and diagnoses. She trains psychiatry residents to start with open-ended questions about a patient's life history before moving to more structured assessments.
She states: "If we don't do that, we end up with a kind of a laundry list of symptoms that is not actually a person."
Conclusion
This wide-ranging discussion provides insights into the neurobiology of addiction, current treatment approaches, and emerging issues like social media addiction. Dr. Lembke emphasizes the importance of understanding individual risk factors, resetting reward pathways through abstinence when needed, and taking a holistic view of patients' life experiences in addiction treatment. While challenges remain, new treatment options like GLP-1 agonists show promise. Creating environments that support mental health, especially for youth, remains a crucial public health goal.