there's a very famous experiment in

which rats were engineered to have no

dopamine and the scientists discovered

that if they put food in the rat's mouth

the rat would eat but if you put the

food even a body length away the rat

will starve to death which tells us that

dopamine is fundamental to get the

things that we need for our basic

survival now every time we're doing

something that's pleasurable from sugar

to video games work pornography social

media that will affect dopamine and the

more dopamine that's released the more

likely that drug or behavior is to be

addictive but also the genetic risk of

addiction is about 50 to 60% so if you

have a biological parent or grandparent

with addiction you are more likely to

develop that addiction we have to keep

it in balance in order to stay healthy

Dr Anna lmy is Professor of Psychiatry

at Stanford chief of the Stanford

addiction clinic and a world leading

expert on the subject of doping she will

tell you how this one powerful chemical

is controlling your life and what to do

about it one of the most important

findings in Neuroscience in the past 75

years is that the same parts of the

brain that process pleasure also process

pain and the balance wants to remain

level the problem is that we

automatically seek out pleasure and

avoid pain and we're exposed to all

kinds of Pleasures that we have in the

modern world and our brains are reeling

in response to try to compensate now I

need more of my drug and more potent

forms to get the same effect which then

leads to addiction and that's what

happened to me when I got addicted to

romance novels take me into that phase

of your life I was out of control and I

needed to restore a level balance and

take the advice I give my patients and

what is that advice

the Diary of a CEO is independently fact

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the

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this

episode Dr Anna

lmy you wrote one of the most iconic

well-known books about dopamine which

propelled the subject matter of dopamine

into the public

Consciousness but I guess the most

important question I should ask you

is why does dopamine matter ah good

question good good place to start I mean

dopamine matters because it

fundamental to our survival right so

it's the chemical that we make in our

brain that tells us this is something we

should approach explore investigate so

it's it's really almost the survival

chemical so what is dopamine if you had

to explain it to a 10-year-old how would

you go about explaining it so dopamine

is a chemical that we make in our brain

um it has many different functions but

one of its most important functions is

that it helps us experience pleasure

reward and

motivation um it may be even more

important for the motivation to do

things than it is for the pleasure

itself so for example there's a very

famous experiment in which rats were

engineered to have no dopamine in the

brain's reward pathway and the

scientists discovered that if they put

food in the rat's mouth the rat would

eat the food would seem to get some

pleasure from the food if you can deter

that from watching a rat eat which I

think they felt like they could uh but

if you put the food even a body length

away the rat will starve to death the

idea being that without dopamine we're

not motivated to seek out the things

that we need for our basic survival

that's crazy so you get a rat you put

the food an inch from its mouth and it

will starve to death because it doesn't

have dopamine the dopamine required to

just reach out and eat yeah essentially

maybe it's not an inch maybe it's a

little more than an inch but the idea

being that dopamine is necessary to be

motivated to do the work to get the

thing that we need and having an

understanding of dopamine how might that

improve my life having a basic

understanding of how dopamine Works how

we process Pleasure and Pain and also

what happens with dopamine as we go from

adaptive recreational use to Mal

adaptive addictive use is something that

is really useful especially for those of

us living in the modern world where now

we're exposed to so many reinforcing

substances and behaviors that we've all

become vulnerable to the problem of

addiction and what are the biggest

misconceptions of on the subject of

dopamine because it's kind of thrown

around in society I see it in my group

chats people saying I need more dopamine

or whatever or you know that person just

craves dopamine what what are the

biggest misconceptions you've come

across the main miscon conception is

that somehow we can get addicted to

dopamine we're not getting addicted to

dopamine itself dopamine is neither good

nor bad it's a signal to tell us whether

or not something that we're doing is

potentially useful for our survival and

also it's related to what we predicted

about how rewarding or pleasurable

something would be and so it's really um

you know I sort of sometimes I joke it's

like the um reward theory of relativity

DOP mean is in the sense that Pleasure

and Pain really are truly relative to

one another and so dopamine gives us

information about where we are in that

relativity scale between Pleasure and

Pain and when you say relative you mean

I mean it's it's quite fitting for

anyone that can't see we have a a set of

scales on the table and scales are

relative to each other because if you

pour in one end the other end goes up

and if you pour in the other end the

other end goes up and this end goes down

and when you say relative that's what

you're describing right yes that's what

that's what I'm describing yes okay and

what activities that I do every day have

an impact on my

dopamine well probably almost everything

you know in some ways um I mean every

time we are doing something that's

pleasurable reinforcing rewarding that

will affect dope mean it's it's really

the primary signal that lets us know

that this thing is potentially important

for our survival as I mentioned um but

you know even um aversive stimuli can

trigger dopamine what's oh something

that's painful or not pleasurable

dopamine gets involved in in that um

equation anything that's novel or new is

something that triggers our dopamine in

in our reward pathway dopamine is

fundamental for movement so not just

pleasure and reward but also movement so

for example Parkinson's disease which is

a disease related to stiffness and

Tremor is caused by a depletion of

dopamine in a part of the brain called

the substantia and as dopamine

gets depleted in that part of the brain

people lose the ability to move their

bodies and it's probably no coincidence

that the same neurotransmitter that is

so important for pleasure reward

motivation is also really important for

movement because most organisms have to

to locomote toward the object of their

desire we want that thing we have to

exert effort right we have to put in the

work to go get it but in the world today

we really don't have to do that right we

can swipe right we can swipe left and

all of a sudden it magically appears at

the touch of a finger and that's very

confusing for our brains because that's

not how we evolved we really evolved for

for having to do quite a bit of upfront

work for a tiny little bit of reward

I just want to before we move on talk

about this point you said because I

think it's quite foundational to

everything we're going to talk about

about dopamine being relative to pain

and I have this set of scales in front

of me and here I have some chemicals

that are likely to produce dopamine in

my brain I believe right so alcohol I

have some rum I have some whiskey I have

some vodka and can you explain to me

using this rum whiskey and vodka how

dopamine is relative to pain and what

going on in my brain sure okay I'll

slide this over to you oh

okay so one of the most exciting

findings in Neuroscience in the past 75

years is that Pleasure and Pain are

collocated in the brain so the same

parts of the brain that process pleasure

also process pain and in a very simple

reductionist kind of way they work like

opposite sides of a balance so imagine

that deep in your brain's reward pathway

which is is another exciting Discovery

right that there's this dedicated reward

pathway of the brain that consists

broadly speaking of the prefrontal CeX

which is this large gray matter area

right behind our foreheads that's so

important for future planning for

delayed gratification for appreciating

future consequences you might think of

it as like the brakes on the car if

we're going to analogize to to a to an

engine and then deep you know in the

brain we've got what we call the limic

areas or the emotion brain and there you

have the nucleus accumbens and the

vental tegmental area that are rich in

dopamine releasing neurons right and

they act like the accelerator on the car

so when you've got a healthy functioning

brain you've got enough accelerator but

not too much right so enough dop Meine

being released but not too much and

youve got a healthy prefrontal cortex

putting the brakes on that dopamine

release when people um become addicted

there's either a problem with the brakes

the prefrontal cortex or the accelerator

the nucleus accumbens and vental

tegmental area or both right what we're

finding is that there's actually a

disconnect so there are large neuronal

circuits and Pathways between those deep

lyic structures and the prefrontal

cortex that literally get severed or

disconnected when people become addicted

as we think about Pleasure and Pain

being collocated in the same parts of

the brain working like opposite sides of

the

balance in order to understand what

happens in the addicted brain is to

appreciate that there are fundamental

rules governing this balance and one of

the most important rules is is that the

balance wants to remain level it does

not want to be tilted very long to the

side of either pleasure or pain and in

fact what our brain does is first tilt

an equal and opposite amount to whatever

the initial stimulus is so I'm going to

try to illustrate that here so let's say

our

initial stimulus is alcohol now alcohol

Works through its own chemical pathway

it works on our endogenous opioid system

the opioids that we make we have

receptors for opioids in our brains it

works on our endogenous Gaba system

which is our calming

neurotransmitter and at the end of the

day it releases dopamine in the reward

pathway so any potentially addictive

substance will release dopamine in the

reward pathway the more that's released

and the faster that's released in a

given individual the more likely that

substance is to be

addictive now another important concept

here is what we call drug of choice

which is to say what releases a lot of

dopamine in your brain may not release a

lot of dopamine in my brain and vice

versa right which is this idea that

people have predictions to different

kinds of drugs and by the way people can

get addicted to behaviors too I should

emphasize that when you say drug of

choice you mean the brain has a

particular sensitivity to that drug in

terms of dopamine yes okay the more

dopamine that's released the faster that

it's released the more likely that drug

is to be addictive for a given

individual so you're holding some

whiskey there I'm holding some whiskey

there could be a brain that is very

sensitive to Whiskey and there could be

a different brain that you could pull

all the whiskey and you like and the

dopamine response is sort of limited

exactly okay and for many of my patients

who become addicted to alcohol they will

tell you that from the first moment they

had alcohol they knew they were either

in trouble or had met their best friend

or some combination it was a very potent

experience for them all right so let's

let's go ahead and put this on the

pleasure side of the

balance dopamine is being released but

no sooner has that happened then my

brain will work very hard to restore a

level balance and by the way a level

balance is what neuroscientists call

homeostasis okay and one of the

overarching physiologic drives for all

living organisms is to return to

homeostasis homeostasis is that

parameter of what's often called called

affordances or states of being that are

adaptive and healthy for the organism

for example like we have a certain

homeostasis of body temperature and if

we go much too much beyond that either

too high or too low we will disintegrate

and die right so homeostasis is that

that states of being that are compatible

with existence

and and potentially advantageous too

sort of Baseline level that's right yeah

Baseline level and by the way we're

always releasing dopamine at a kind of

tonic Baseline level in our brains I

sometimes think of it as the heartbeat

of the brain so what's happened here for

people that can't see is you've poured a

little bit of whiskey into one end of

the scale the pleasure side of the scale

and the other side of the scale has

risen because now there's whiskey um in

the the pleasure side which I guess is

released dopamine exactly so now now we'

released dopamine in the reward pathway

okay because the pain side went up does

that mean there's now less pain in the

brain well I think you know again this

is a metaphor it's an oversimplification

the idea here is just when we press on

the pleasure side we're releasing

dopamine in the reward pathway and

experiencing pleasure okay okay but no

sooner has that happened then our brain

will try to compensate or adapt to

increased dopamine firing by down

regulating dopamine transmission for

example by involuting post synaptic

dopamine receptors that mean okay okay

so our brain is a bunch of wires you

know um that conduct these electrical

signals and and these long spindly cells

are called neurons and the thing about

neurons is that they don't actually

touch end to end there's a little Gap or

space between them and that Gap is

called the synapse and that Gap or

synapse is bridged by what we call

neurotransmitters and dopamine is one of

those neurotransmitters okay and when

the pre synaptic neuron pulses and

releases dopamine it crosses the synapse

and binds to a receptor on the post

synaptic neuron which either continues

or aborts that electrical signal does

that make sense yes okay so one of the

ways that our brain can decrease the

effects of dopamine decrease dopamine

transmission is by involuting or taking

inside the neuron the post synaptic

receptor that way when dopamine is

released it has nowhere to bind oh okay

so it's like removing the docking

station exactly very good it's removing

the docking station so essentially

getting back to our scale we've we've

you know ingested alcohol we've

increased dopamine firing in the reward

pathway but remember our pleasure pain

balance wants to return to the level

position level with the ground

homeostasis so it's going to decrease

dopamine transmission by for example

involuting those post synaptic dopamine

receptors but one thing about the brain

in its process of trying to get back to

homeostasis and again I like to think of

this neuro adaptation process as these

Gremlins hopping on the pain side of the

balance to bring it level again you

don't have Gremlins here you have these

little rocks but let's go ahead and put

a rock on the pain side of the balance

and the these rocks are are friends

right their job is to level the balance

because remember we got to go back to

homeostasis I'm going to put a rock on

and you're going to see oh my gosh it

overshot right it now I've got it

pressed down on the the pain side of the

balance but that's exactly what happens

in our brains in this process of neuro

adaptation those Gremlins hopping on the

pain side of the balance don't get off

as soon as the balance is level they

stay on until we're tilted and equal an

opposite amount so is that what a

hangover is or a cown as they would say

when people take drugs they say I have a

come down exactly that's exactly what it

is that's the hangover the come down the

Blue Monday or on a much smaller scale

just that moment of craving right that

moment of wanting to have one more shot

right why does it overshoot why can't it

just perfectly hit homeostasis such a

great question because then we'd feel

fine yeah why did Mother Nature do that

to us so cruel right yeah okay I'm going

to tell you an evolutionary just so

story what we mean by that is we don't

really know why you know this mechanism

exists but from an evolutionary

perspective if you're living in a world

of scarcity and everpresent danger this

is the perfect mechanism to make sure

that we're never satisfied with what we

have that we're always wanting more it's

made us the ultimate

Seekers okay because immediately after

getting something I'm now feeling a lack

of pleasure and I'm at a deficit you

know on the pain side of the scale which

means that I'm going to go seeking out

more dopamine and in a world where

everything is quite scarce that could

mean going on another 4-Hour hunt the

next day to go killer gazelle or

something perfect you got yeah you got

it interesting yeah okay so that's going

to motivate me because this get so Jesus

people that have hangovers don't seem

very

motivated right so now that's a so why

is that right it's because alcohol is a

product of human

engineering that releases so much

dopamine all at once in the reward

pathway that our brains are reeling to

compensate right we we really weren't

evolved for this much pleasure with this

much easy access as you said yourself we

were really evolved for to have to do

quite a lot of work upfront and to be

hungry and to be lonely and to be tired

and then get a little bit of reward that

would then bring us back up to

homostasis so really we were evolved to

be pressing on the pain side of the

balance in our effort to find pleasure

and then when we find it that little bit

of food or clothing or shelter or a mate

would bring us back to the level

position does that makes sense yeah so

you're you're telling me essentially

that we're all wired to be addicted

because if this is how our brain works

in a world it's designed to seek out

more dopamine but the problem we have

now is we have all the synthetic

dopamine effectively like this so

synthetic chemicals and synthetic things

and you know an Internet that is wiring

us to give us so much dopamine so easily

that that means that our brains are

effectively like mismatched to the world

that we live in and therefore wired to

be addicted yeah I think you actually

said that I found a quote you said in an

interview where you said we all wired to

be addicted and if you're not addicted

yet it's right around the corner right

coming to a website near you yes I I

guess I would I would qualify that a

little bit by saying we're wired for

survival in a world of scarcity that's

not the world live in now we live in a

world of overwhelming overabundance and

so there is a mismatch between this

ancient wiring that has us relentlessly

pursuing pleasure in order to survive

and a world that's so infused with

pleasure and so many rewarding stimuli

that now we're overwhelming our reward

system and our brains are reeling in

response to try to compensate so what

happens to this scale then in such a

world where I can get a big hit of

dopamine all the time using some of

these synthetic things or the internet

or pornography or whatever else what's

going on with this scale over and over

again okay great so let me get there let

me first say though that remember after

we do something that's highly

pleasurable our brain compensates with

neuro adaptation tilting an equal and

opposite amount to the side of pain and

then restoring our balance back to the

level position right or what we call

homeostasis so this doesn't last forever

right it's to pleasure then it's to pain

then it's back to the level position but

if we continue to consume our drug of

choice over days to weeks to months to

years and we add in a whole bunch of

other drugs and now we're consuming you

know pornography and smoking pot and

eating um donuts and you know you name

it all at the same time then essentially

what happens is those Gremlins on the

pain side of the balance end up camped

out there for anyone that see she put

all of the Rocks into the pain side to

represent All Of The Addictive behaviors

that this individual has now taken on

right and now we've entered addicted

brain by which I mean that we've changed

our honic or Joy set point to the side

of pain now we need more and more of our

drug in more potent forms not to get

high and feel good but just to level the

balance feel normal and this is not

going to be enough to level the balance

I would have to like keep filling this

much more than this container can hold

and that would be in Pursuit really of

just trying to level that balance so

that we can feel normal and when we're

not using we're walking around with a

balance tilted toward the side of pain

experiencing the universal symptoms of

withdrawal from any addictive substance

or behavior which are anxiety

irritability insomnia depression and

crav

so if I managed to get enough vodka

whiskey rum and pour it into the

pleasure side of the scale now that all

the rocks are in the pain side of the

scale I managed to outweigh

it it would it would what would then

happen more rocks more rocks would be

added yes more so momentarily yeah I

would maybe be in a little bit of

pleasure yes but then my brain would

remove those docking stations again

remove more of them and more rocks would

go in and I'd slam

down on the pain side again which means

I need more alcohol to try and get up to

pleasure SL okay so really you want to

you want to like dopamine fast you need

you need to just balance this and this

is so difficult because of the world we

live in it's almost it's it's it's funny

enough because this little scales

experiment um analogy here has given me

a huge amount of empathy for people that

are addicts oh gosh I'm so glad you said

that because I think that is the key to

empathy for the disease of addiction as

well as for people with the disease

having empathy for themselves is

recognizing that on some level it it's

it's out of their control right because

when we are tilted to the side of pain

the overwhelming drive to restore a

level balance or restore homeostasis as

quickly as possible overwhelms any other

rational thought about the consequences

of my drug use right it's just like get

back to the level position because if I

do that I'll at least feel temporarily

better

one of the things this analogy also

highlights for me is that people who are

addicted aren't trying to self harm

right and this is kind of the prevailing

narrative that if you're like why would

you do that to yourself right whereas

when I look at this analogy I go

actually what they're trying to do is

to deal with pain and we're all trying

to find ways to deal with our pain and

but in this analogy what ultimately

happens and I guess is what's happening

with addicts is the way they're choosing

to deal with their pain is becoming

self-destructive and that's creating

more pain right and it's this vicious

downward cycle yes and I think that sort

of reframing of what's going on there is

really critical because again it begets

more empathy absolutely I agree with you

and and I think you know we this this

metaphor it makes an assumption that we

all start with a pleasure pain balance

that's level with the ground but

actually that's probably not true right

some people at Baseline may actually be

more depressed or more anxious or may

have had life experiences that sets them

up for a kind of chronic stress reaction

and we know that people with

co-occurring psychiatric disorders for

example are at increased risk of

developing addiction probably because

they're reaching for that substance to

self medicate their psychiatric problem

the the issue with that is that it's not

medicinal right it's not healing

although in the short term substances

can help with those kinds of feelings

feelings of psychological and physical

pain over time because of the way the

brain adapts as we've

discussed substances and other addictive

behaviors just make psychiatric problems

worse right as we drive ourselves

further into the the kind of uh you know

the pain side of the balance so is this

why trauma often leads to addictive

behaviors because the trauma has caused

a a pain a stress and we're searching

for ways to

medicate that pain or stress yeah to

numb ourselves to not be present in our

reality and have to deal with what's

going on there is dopamine what role is

dopamine playing in it's all the same

dopamine

originally was to help us find those

things that we need to survive food

clothing shelter a mate we call those

Natural Rewards but

today that same reward pathway that

relies on dopamine has been hijacked by

all of these

artificial rewards that our brain

confuses as necessary for survival which

is why people with severe addiction will

be willing to lose you know not

consciously but unconsciously their

loved ones their homes their jobs

everything they have in pursuit of their

drug of choice it's because their brain

has been hijacked and they now confuse

the drug as necessary for survival the

other thing about drugs is that they're

incredibly potent they release a lot of

dopamine all at once which again is

confusing for our brain Natural Rewards

require upfront effort where we do a lot

of work and then we get a little bit of

dopamine and that's what our brains

evolved for I mean I can that makes

sense in my own life when I'm most

stressed or most challenged by something

professionally is when I I immediately

notice that my diet goes out the window

I start eating things that are bad I

actually stop going to the gym as much

um and it's it be can form a bit of a

downward spiral can't it I guess as

we've kind of seen from the dopamine

scale um can I can I get back to that

your question though about trauma and

stress so um there's a very series

there's a very interesting series of

experiments in rodents mice and rats

where they first of all rodents very

easily get addicted to cocaine they will

press a lever for cocaine until

exhaustion or death but if that cocaine

is then taken away that behavior will

extinguish which means that the mice

will eventually just stop pressing the

lever right because they're not getting

any cocaine totally makes sense and then

they'll go off and do something else in

the cage but if they're then exposed to

a very painful foot shock right so a

very extreme physical pain which you

could equate to a serious life stressor

the first thing the rat will do is run

over to the lever and start pressing for

cocaine which tells us that once our

brain has discovered a drug that

releases a lot of dopamine in our reward

pathway even after we stop using that

drug if we are exposed to an extreme

stressor our brain will tell us

immediately go and do that thing that

gives us a lot of dopamine because you

are under stress and I need to be

relieved of stress does that make sense

makes perfect sense yeah so if you

especially so if you discover your drug

of choice when you're younger and it's

food or it's pornography or if it's I

don't know anything that really made you

feel good for a moment a moment of

pleasure that will always become in the

case of these rodent

experiments the thing you run back to

when life gets hard right and we see

that again and again in people in

sustained recovery from addtion that

when they are under stress that is a

trigger potentially for them to relapse

so they have to be really thoughtful in

their lives for number one trying to

avoid stressful situations and and by

the way stress can come in many

different forms there's a great acronym

in in alcoholic synonymous called halt

hungry angry lonely tired those kinds of

stressors everyday stressors which we

all experience hungry angry lonely tired

can trigger us to want to use so people

in recovery have to be really thoughtful

about not getting too hungry not getting

too angry not getting too lonely and not

getting too tired at the end of this

conversation I want to go through all of

the sort of practical solutions that

someone struggling with an addiction to

social media pornography food whatever

it might be um Can Implement to try and

shift that cycle that they might be

going through especially when they're

halting hungry angry lonely or tired how

often have you worked with addicts have

you spent much time working with addicts

directly oh my gosh yeah so that's the

bulk of my career is working uh with

people with all different kinds of

addictions me an example of the most

obscure the most I had a patient who was

addicted to

water I know hard hard to imagine you

have to though understand her narrative

so she had a very severe alcohol

addiction she got into recovery from

that addiction and gave up alcohol but

she discovered that by drinking copious

amounts of water she could become

hyponic meaning that she could lower the

sodium levels in her bloodstream which

would then lead her to become delirious

and so in her desire to just be checked

out she would do that she would she

would drink a large amounts of water

she's doing okay no sadly she's not um

she she ended up taking her own life so

that was very sad

gosh in that situation was there was

there a root cause of that behavior

pattern further Upstream some kind of

trauma or experience that had set this

sort of cascade cascading set of issues

off yeah you know I'm just speaking

broadly um for for some patients with

severe addiction trauma is a huge Factor

um especially severe Early Childhood

trauma but there are also many folks we

see

who have kind of great parents and have

had happy childhoods and have great

social networks and and work that they

enjoy and yet they still become addicted

and that's because we again we are wired

to consume as much as possible of

whatever releases dopamine in our brains

to have survived Evolution to this date

and yet we're living in this world where

we have access to so many drug aied

substances and behaviors that we've all

become vulnerable to this problem and

the reason I highlight this is because

one of the things that I think has

happened in the field of addiction

medicine that maybe isn't the best is

that often times patients themselves as

well as their providers are digging

really deep to find the trauma or the

reason that someone has become addicted

and I think that that's important to do

in some cases but in in other other

cases it can lead to kind of

manufacturing trauma where there really

isn't any furthermore I would say that

when a person is in the throws of their

addiction they're not going to be able

to really do the complex emotional

processing of their trauma while they're

still using their drug of choice that

they really need to get out of that

Vortex of addiction and get into some

degree of recovery before you would even

want to go tackle some of those early

traumatic experiences how many people do

you think are struggling with some form

of

addiction well if you think of addiction

as a spectrum disorder right there's

mild moderate and severe um and there's

I would even say a kind of a pre-

addiction state where we're all sort of

dabbling in compulsive overc consumption

I would say the vast majority of us like

90 probably

95% have some degree of compulsive over

consumption and you know if and when it

tips over into what we would call

addiction there's not a brain scan or a

blood test to assess that it's not like

you know switching a light a light

switch and it's like oh yeah now you

have addiction um it's not like that

it's you know it's a gradual often a

gradual and Insidious thing and we don't

in fact have a biological measurement of

addiction we Bas it on what we call

phenomenology which is patterns of

behavior that re repeat themselves

across time and broadly speaking the

definition of addiction is the continued

compulsive use of a substance or a

behavior despite harm to self and or

others and so you know that harm can be

very subtle um or not right and it can

be a judgment call interesting because

we do throw the word Addiction around a

lot in society but but really the most

important part of that is to understand

if it's harming yourself or someone else

the behavior pattern yes that's right

and to also recognize that we're not

very good judges of that when we're

chasing dopamine okay so we sometimes

justify behaviors we have as being not

harmful and it's fine and it's not

impacting me at all and what do you mean

exactly and we don't we're not very good

at seeing true cause and effect honestly

when it comes to these behaviors which

is why often times people won't really

see the harm until they've stopped using

for a period of time in your book

dopamine Nation you talk about an

addiction that you had yes and it was

really surprising to me because I would

never have thought that being obsessed

with erotic

novels could be classified as an

addiction

what happened what was the behavior take

me into that that phase of your life so

I was in my early 40s um my kids were no

longer little um I got a lot of my

self-worth and identity from being a mom

and my kids were sort of entering

adolescence they were doing fine but

they didn't need me as much um so I had

kind of a grief reaction you know in

response to that was trying to figure

out you know how to navigate this next

phase of my life I'd always been a

reader and in particular a reader of

novels um in my own way that was how as

a child I self soothed was to escape

into uh the Fantasy Life of novels um

but I never had what what I would call a

problem with it and then one day I heard

another mother at school said that she

was reading this great book it was

called Twilight it was about these

vampires and she was going on and on

about it and I read it and I I can't

tell you what it was but it was just

like the the the key in my particular it

was completely

transporting it just released a lot of

dope mean is all I can imagine in my

brains reward pathway and so I read the

whole series and then I read the series

again and I read it again and of course

by the third or fourth time it wasn't as

you know reinforcing and I thought to

myself I wonder if there are any more

vampire romance novels and then for me

the real Tipping Point was I got an

e-reader I got a Kindle because what

happened was I I even before I got the

Kindle I started reading you know novels

that I would say I would be slightly

embarrassed to admit that I was reading

like kind of bodice Ripper novels as

time went on I I needed more and more

like graphic kinds of descriptions in

order to find it pleasurable and and by

the way that's classic for the addiction

narrative right where you start out with

a little bit and it goes a long way and

then over time you build up tolerance

that's neuro adaptation the Gremlins

pressing down on the pain side of

balance now I need more of my drug in

more potent forms to get the same effect

gradually over time I started um reading

you know more and more sort of graphic

erotic sexualized versions of this novel

and I would I was embarrassed so I would

hide that I was reading them and that

gets into the whole double life of

addiction where now we're lying about

our use we're we're using our drug over

here but pretending like we're not so my

kids or my husband would walk in the

room and I would be you know hiding

behind another book one book behind

another book so it looked like I was

reading something you know I don't know

more

sophisticated and then the Tipping Point

for me came really when I got a Kindle

or an e-reader and then my reading was

totally Anonymous I could read these

books anywhere any time no one knew what

I was reading and as soon as I finished

one um I could read another one and I

almost overnight became a chain reader

like literally when I was n doing

something else that I had to do I was

reading romance novels one after another

after another um which meant I was you

know less present for my kids less

present for my husband I would often

stay up till 2: 3 4 in the morning on a

week night reading romance novels have

to get up two hours later go to work

exhausted not able to be present for my

patience not enjoying my work gradually

getting more depressed more irritable

more anxious more insomnia we went on on

a a family vacation with an family

friends of ours everybody together at

this beach house all the kids playing I

was like hiding in a room reading

romance novels so and this is exactly

what happens with addiction is that our

Focus Narrows and the things that we

used to enjoy are no longer pleasurable

only this one thing has salience for us

we plan our whole whole day around

getting it using it hiding our use um

and that's what happened to me

it's so interesting because I was as you

were talking about that I was thinking

about all the behaviors that I have that

are maybe isolating me or you know I

just even things like spending a lot of

time on the internet just watching video

after video after video on YouTube or um

those kinds of things or just like

spending tons of time in my WhatsApp

group chat talking like roasting my

friends about nothing right how do you

know if like this is it's cuz on end of

the spectrum I could say okay well

that's harming my relationship with

people in the real world but

it's helping making me feel good and

it's you know maybe helping me in

another department because I'm learning

more about vampires or you know like so

like you know because there's there

might be net harm somewhere else but

then an upside over here which and then

I start rationalizing this Behavior like

how' you just distinguish between these

behaviors and know what's bad and what's

good you know what it's really hard um

these digital devices are powerful tools

but also very potent drugs there's no

doubt that digital media lights up the

same reward pathway as drugs and alcohol

these devices and platforms were

designed to be addictive that is to keep

us scrolling and tapping long beyond

what we plan for or what we want or even

what's pleasurable I think we can all

relate to using this

medium to a point where we don't even

like it anymore and yet have difficulty

getting ourselves off of it that really

speaks to the inherently reinforcing and

cognitively adherent nature of this

medium it is a drug and so you know if

and when and how we're crossing into

addictive

use I think we need to be very Vig

about whether that's happened in our

lives and one of the ways to do that is

actually to try cutting out that

particular digital medium that website

or that behavior for a period of time

long enough to experience withdrawal

potentially reset reward Pathways and

then re-evaluate because when we're in

the behavior as you yourself noted it's

very easy to rationalize oh I need to do

this for work oh I need need to do this

to stay in touch with my friends oh I'm

learning so much from this right and all

of that may have been true initially but

may not be that true anymore and what I

often point to is the subtler signs of

addiction which are things like

depression anxiety in attention insomnia

restlessness these can be early signals

for our consumption entering into that

addiction range but us not realizing it

because again we don't see cause and

effect which is why doing an experiment

like I did with my romance novels you

know following in the footsteps of my

patients and taking the advice I give

them and I gave my romance novels up for

30 days right just to see like okay I

think this is a problematic Behavior can

I give it up how will I feel and the

very first day that I the very first 24

hours hours that I did not read any

romance novel any novel at all I was

astounded at my level of anxiety

restlessness and utter insomnia I had

completely unlearned the art of putting

myself to sleep without this digital

narrative and that lasted a good 10 to

14 days completely mapping on with the

amount of time it takes typically to get

out of acute withdrawal that is to say

for those neuro adapt PA Gremlins to hop

off the pain side of the balance and for

homeostasis to to begin to be re

restored um but by the time I got to

weeks three and four I felt not just

better than I had in the first two weeks

but actually better than I had felt in a

really long time I enjoyed my kids more

I was more present for them I enjoyed my

husband more my work seemed salian again

I had started to think oh maybe I should

do something else you know maybe maybe I

you know this work I've been doing it a

long long time I don't it's not that

interesting anymore all of a sudden it

was interesting again right so you see

the relativity of that honic pathway and

how when we're doing that behavior or

substance that's so reinforcing that

everything else loses its salience we

can really

misidentify what is causing our

irritability anxiety insomnia until we

stop that substance for long enough to

see its impact on our lives how is it

making you feel because I think a lot of

a lot of people can't understand how you

could get addicted to a book I'm sure

some people understand that but but for

me it's not something I've ever become

addicted to so how how did it feel was

it like exciting is it arousing is it

somewhere in

between I mean I think that romance

novels are essentially socially

sanctioned pornography for women okay

and the medium is narrative and if

you're a person for whom narrative is a

powerful drug as it is for me a story a

narrative a fiction um very potent since

I was a child then you know it was a

natural that that that would be the

thing that I would get addicted to and

basically just like we've hacked and

bioengineered everything to make it more

potent I mean people there's a formula

for writing romance novels like if you

take a physical copy if you go to a

store and you pick up a romance novel

and you literally physically open it to

2third of the way through you will get

to the climactic scene pun intended

right it's it's like it's

engineered I mean I got to a point where

I wouldn't even read it read after I

wouldn't finish the book I would go on

to the next book just to get to the

climax part and then you'd move yeah and

I wouldn't even read the danum ma or

like what happens to the characters I

didn't care you didn't care about no and

also I didn't I got to point where I

didn't care about the quality of the

writing or the depth of the car it

didn't matter it was it was the drug it

was that moment I was looking for and

you know there are a lot of free books

on Amazon some some of which are high

quality and some of which are not but

like you know any good drug dealer knows

free samples that's the way you hook

people I would search for these free

samples and that's part of it too like

the searching for the drug so the

Working The Upfront work you do for the

drug is part of the drug right it's all

that you know the machinations and the

hiding and the this and the that that

gets to be part of like all of the

rituals surrounding it as you were

talking as well I thought about work and

work addiction yes because you earlier

used the term excessive consumption and

when I think about work even my work I

Think Jesus I excessively consume work I

start so many bloody businesses and

invest in so many things and if you look

to that behavior objectively if you're

like an alien looking down at me you'd

go this guy's got a problem do

you know what I mean you think you think

that's funny joking you

know I feel for you and it's funny cuz

in society we then those people are

reinforced we clap that's right we clap

we got this guy's not sleeping he's

working 18 hours a day clap clap clap

give him a trophy an award name a thing

after him or her or right you know um

and it's just really interesting that

that that addiction of work and you tell

me if it is it can be an addiction it's

certainly in the scale of one end being

sort of consumption excessive

consumption in the other hand being

addiction it's on there somewhere people

can get addicted to work

and part of the reason is that we've

drug aied work right when when I say

drug aied what do I mean we've made it

more potent and this is true for all all

these drugs we've made them more potent

more novel more Bountiful meaning

there's more of it and more accessible

so if we if we break that down with work

how is work more potent well certain

types of work are more reinforcing not

all types of work so for example Works

work White Collar work is often now

associated with stock options and

bonuses right um there's often like a

social media aspect to it or maybe even

a Fame aspect or as you point out those

are our cultural Heroes right so you get

all this you know agulation for being a

workaholic and that also because we're

such social creatures right and human

connection stimulates dope mean that

that also makes work more of a potent

drug personal brand right so you're

LinkedIn oh my God this person got a

promotion we all clap we the likes the

comments you're amazing the agulation

the a as you said the awards the

trophies and then you've got um the fact

the fact of novelty so once we've

exposed our brains enough times to a

certain drug as I said we develop

tolerance right and then we need more

potent forms or novel forms one of the

ways we overcome tolerance is by taking

our drug and then changing it slightly

like adding a little new molecule on

this chemical right or on the Internet

you know when we're searching videos we

want something similar to what we liked

before but just a little bit different

and that's what the algorithm does

automatically right it offers oh you

should check this out oh how about this

oh check that out right and that engages

our treasure seeking function we're

looking for that that novel thing but

that's not too novel right it has to be

in our category of things we like and I

think for work we have that too like

there are so many ways now that people

can engage in their work and it's not

all bad that it's novel but you know

certain types of work it makes it very

enticing then you have quantity

right I mean work never ends there's

like no natural stopping point for work

you know you do a line of cocaine you

run out of money you run out of cocaine

you're done right but that's not true

for work everywhere anytime and then

that gets to

accessibility one of the biggest risk

factors for addiction to any drug or

behavior is simple access we know that

if you grow up in a neighborhood where

drugs are sold on a street corner you're

more likely to try them more likely to

get addicted if you live in a world

where you have access to work

24/7 you're more likely to expose your

brain to more work and more likely to

get addicted to work again especially if

it's got all those other reinforcing

qualities this is probably in part why

people quit their

jobs you mean if they just get

overwhelmed or it's it's partially why

people can never quit but I think it's

important to make a distinction between

work that's reinforcing in those ways

and then work that's completely not

reinforcing yeah

alienating mind-numbing work in which

the the actual task is separated from

the meaning of a task I mean they quit

their jobs either in search of more

dopamine so if I'm working in a job

where I don't know maybe it once gave me

dopamine and now it's become monotonous

and the same right I I need to quit to

go find but there's novelty for you

that's right yeah and that's true people

many people change jobs every two to

three years I I recently read that the

the average life of a business now is

like 15 years whereas you know 50 years

ago it was 50 years and there's all this

turnover all this churn chasing novelty

also you know I I do want to emphasize

that people who are in work that's not

like intrinsically rewarding but is the

opposite kind of soul sucking that's

also a risk factor for addiction because

people just wait till the end of the day

till they can go home and then use a

drug to numb themselves from the stress

of work so it's it's plausible that

people who are in lower pleasure jobs

are more likely to be overweight or

addicted or dependent on alcohol yeah or

simply opt out of the workforce as many

young men are doing now in the United

States and what we know from data that's

been collected is many of them are

playing video games right they've just

completely opted out of the workforce I

guess this in part explains why there's

a drinking culture that's associated

with people who are potentially lower

class um because they're doing um

potentially

less pleasurable work

and they're therefore they if we think

about the scale that they would then end

up in the pub after work you know maybe

that's partially true but even people

doing like doctors and lawyers they're

are oh okay yeah equal rates of

alcoholism among those groups I think

what's happening there though is that

the nature of the work is just so

stressful whether it's white collar or

blue collar that there's this kind of

work hard play hard right I'm going to

work all day and at the end of the day

I'm going to reward myself so now you've

got a pleasure pain balance that's going

pleasure pain pleasure pain and and

remember the biological definition of

stress is any deviation from

neutrality so that every time our brain

has to work to restore a level balance

we're actually triggering our stress

response triggering our own adrenaline

it's stressful to have to restore the

balance from those extremes of Pleasure

and Pain I read in um your book you were

talking about how different behaviors

and sort of chemicals and substances

have different impacts and I was on page

50 of dopamin nation in a study of mice

sex increases the release of dopamine by

100% And amphetamines which is like

drugs right hardcore drugs increases it

by 1,000% by this accounting one hit of

a meth pipe is equal to 10 orgasms yes

it's interesting to think about that the

different behaviors we have and how

they'll have a bigger impact on our

dopamine is there like any in an in in

typical order of things that are like

extremely dopamine inducing and things

that aren't what's it like the top and

bottom of the list but in your view you

know I really think that it depends on

the person and we've got to look at drug

of choice right I mean potent drugs like

methamphetamine like opioids like

alcohol like nicotine like cannabis um

are are going to be very reinforcing for

many people but not for all people and

most people do have their one drug that

they sort of prefer above all others so

although generally speaking intoxicants

release a lot of dopamine in the reward

pathway um I think every person is going

to be different and also we we don't

really have good ways of measuring

absolute values of dopamine in human

beings right we can do that in rats but

we can't really do that in humans it's

it's relative values I've got this um

picture here which shows what looks like

brain scans in uh normal person but then

in someone who's addicted to different

substances I'll put this on the screen

and I'll link it below in the

description for anyone that needs it and

wants to see it but it effectively shows

the impact that like cocaine has on the

brain meth um alcohol and heroin what is

what is going on here so the red in this

image represents dopamine transmission

okay so how much dope mean is being

released from the pr synaptic neuron

Crossing that synapse binding to

receptors on the Sy aptic neuron how

much dopamine is kind of swirling around

in the reward pathway part of the brain

and what this image shows is that on the

left hand side in healthy control

subjects who do not have addiction

there's plenty of red right so there's

plenty of dopamine Transmission in the

reward pathway specifically here in the

nucleus accumbens but if you look at the

right hand column you'll see that in

these individuals who have been using

cocaine meth amphetamine alcohol and

heroin in addictive ways there's almost

no red which means there's decreased or

below normal levels of dopamine

transmission they are in a chronic

dopamine deficit

State this is evidence of the brain

trying to

compensate for too much dopamine being

triggered by down regulating its own

dopamine production and transmission not

just to Baseline but below

Baseline and importantly these

individuals who are addicted to these

substances these brain scans were done

two weeks after they stopped

using oh wow yeah which tells us that

this dop dopamine deficit State persists

for some period of Time how long well it

depends on the person but we know at

least from this experiment that the

first two weeks are this persistent

dopamine deficit state which is

consistent with acute withdrawal right

people feel when they first stop their

drug of choice they feel terrible right

they experience all of the symptoms of

physical withdrawal that correspond with

that particular drug they were using

usually the opposite of what the drug

did plus the universal symptoms of

withdrawal from any addictive substance

or behavior anxiety irritability

insomnia depression and craving now if

they can get through the first 10 to 14

days what we see clinically is those

acute withdrawal symptoms slowly start

to get better and we think that that is

mapping on to regenerating dopamine

Transmission in the reward pathway and

if they can make it to a month that's

usually the point for for on average in

based on clinical experience when people

really can start to get out of that

constant state of craving for their drug

of choice and begin to see some light at

the end of the tunnel for what their

lives might look like if they can

maintain abstinence from their drug and

we can't just inject or drink dopamine I

mean I guess that would be like drinking

alcohol we can't just artificially mess

with the the balances to try and restore

the dopamine levels in an addict can we

can't just add a little bit of dopamine

yeah it's it's a great question because

we have some natural experiments that

suggest what what might happen if we do

that so as I mentioned before people

with Parkinson's have depletion of DOP

mean in the substan That's What

Causes That that motor disease the

treatment for it is to give L Doopa

which is a dopamine precursor if I were

to give you a spoonful of dopamine it

would do absolutely nothing because it

doesn't cross into the bra the brain it

doesn't cross the blood brain barrier

but I could give you lopa which is a

precursor chemical that would cross your

blood brain barrier and get turned into

dopamine and then diffusely bind

dopamine receptors in your brain in the

reward pathway but also in the movement

Pathways when we give patients with

Parkinson's dopamine in this form that

can temporarily improve their movements

but in about one in four Parkinson's

patients they will develop a denovo

addictive disorder shopping addiction

sex addiction other types of addiction

because we have the same problem we are

stimulating

the reward pathway with dopamine that is

ingested exogenously from the

outside and our brain reads that as oh

boy got to compensate by downregulating

dopamine transmission to below Baseline

which then puts us in that addiction

Vortex does that make sense it does so

we have to I mean it tells me that we

have to live lives in a certain sense of

we have to live our lives in a certain

sort of

homeostasis and

it's so easy not to in the world we live

in it's like it's like impossible to

live in a perfect homeostasis balance in

the world we live in right even more

than having to try to live within this

sort of narrow range of homeostasis in

the world we live in today we probably

have to intentionally do things that are

painful do things that are hard pleasure

pain balance like we learn that when we

press on the pleasure side of the

balance like with alcohol or pornography

or romance novels or cannabis or

whatever it is right no sooner does that

happen than our brain adapts by those

neuro adaptation Gremlins hopping on the

pain side of the balance to bring it

level again but they like it on the

balance so they don't get off right when

it's level they stay on until we're

tilted an equal an opposite amount to

the side of pain that's the come down

the hangover Etc but it turns out the

opposite is also true if we

intentionally press on the pain side of

the balance for example with exercise or

an ice cold water bath or intermittent

fasting those Gremlins will hop on the

pleasure side of the balance and we will

get our dopamine indirectly by paying

for it up front and there are studies in

humans showing that when humans expose

themselves to exercise for

example dopamine levels gradually rise

over the latter half of the exercise and

then when the exercise stops dopamine

levels will remain elevated for hours

after afterwards before going back down

to the Baseline level position without

ever going into that dopamine deficit

state so it's a great way to get our

dopamine in directly because it's much

less vulnerable to that compulsive

craving phenomenon of overuse so you're

not going to get an exercise come down

you can butc and people can get addicted

to exercise right but typically it's

it's very unusual because The Upfront

cost

to to do the work and endure the pain of

exercise in the first place mitigates

our vulnerability to an exercise

addiction and in general H okay CU it's

so hard to do that it's going to be it's

not like pulling a lever on a slot

machine or clicking on a porn website is

difficult yes okay so fighting for the

dopamine

is insulates us against the chance of an

addiction having to really fight hard

for it okay yeah and this kind of

explains I guess in part why

I pulled out some stats ahead of our

conversation today that from 1996 to

2008 participation in ultramarathons has

increased by

1,676 the ice bath Market is expected to

rise from 350 million in 2024 to to

nearly half a billion by 2030 the number

of people taking part in obstacle course

races like tough mut or hrock etc etc

has increased by almost 7x from 2010 to

2017 it seems like in society there's

this counter movement towards people

seeking out hard dopamine chasing pain

yeah those are amazing I didn't know

that those are amazing numbers um you

know in general there's a part of me

that wants to say well that's a good

thing um but there there's another part

of me that's wary also because we're so

good at drug aying everything that we do

that there's a way in which these types

of behaviors can also be drug aied right

made more potent with all of the

technology the way that we count

ourselves the leaderboards the social

comparisons all of that takes this thing

which is really in its natural state

kind of impervious to addiction like you

just typically wouldn't get addicted to

these types of painful physical

activities you would do what you needed

to do for survival but we've managed to

make them addictive in all these

different ways I still think it's a

better way to get your dopamine like I

really encourage exercise we always talk

about movement as medicine and in

general our our life is so convenient so

easy so passive so sedentary that I'm

telling patients all the time you know

get up off the couch move your body walk

around the block I think that's the

bigger obstacle right now is just

getting people to move but I do think we

need to be wary of not going too far in

the direction of like the ultra Ultra

Ultra whatever it is so what is a better

way to live if we're trying to optimize

happiness and to keep our dopamine in

balance and not have the crashes Etc and

come downs and hangover what is a

optimal way to live our lives do we have

to look back at our caveman ancestors

and live like them I think that part of

the problem is that we've

organized Our Lives now around

rewards almost everything that we do is

predicated on the Feelgood moment we'll

have at the end of it and because of

that that we

are missing out on the

process we're projecting our psyche

forward into the future toward the

reward and not able to really be here in

the moment okay this is going to be

sound weird I'm going to give you a

weird example so driving over here today

I found I was nervous for this interview

and in a way looking forward to it but

in a way wanting it to be over right and

and in seeing that in myself I thought

that's so sad like that's that's so sad

that we live our lives that way myself

included always this weird blend of

wanting whatever we're doing to be over

so that in a way we can just go hide and

do whatever that self- steem thing is

that we do where we're safe and we're

like you know stimulating ourselves in

some way and then I thought well what if

I knew that I was going to die right

after this going come off really weird

now but what if I knew that I was

actually going to die right after our

conversation today

that totally changes my perspective

doesn't it because this time you and I

have that's all I got it's over for me

when this so this this conversation is

it I really better be right here right

now and really taking joy in whatever

you and I can find together and and I

think the more we can do that the better

what's happening there you're removing

the thought of the outcome the rewards

the potential you know failure or

whatever and you're focusing on just

being present and in doing so what is

happening it's a great question and I've

actually given this quite a lot of

thought because I remember when I was in

college and I you know met some like Zen

people and they were like be here now be

here now and I thought well whenever I'm

here now I'm miserable like I I I don't

like me and I don't like being in the

world I I don't want to be here now I

want to be somewhere else so I didn't

really understand what they were getting

at

it really took me you know till I had

lived quite a lot of life and had some

you know some significant experiences

and given it some thought that I

realized oh be here now means be here

now and be

uncomfortable and be okay with being

uncomfortable and being okay with not

being able to

control my pleasure or my pain or my

comfort level but just being open to

whatever comes and I think that's a

really a key shift

that I'm not trying to control my

experience in the moment and that it's

okay to be unhappy or Restless or

uncomfortable and not trying to run away

from that but just really turn and face

it and embrace the discomfort which I

also think is quite Universal I don't

think I'm I'm alone in that and then the

key piece about not not anticipating the

reward is helps me be in the moment

right because I'm not just waiting for

the good thing to come after I'm saying

to myself imagine there's nothing good

coming after nothing at all right

there's just there aren't rewards this

is it and then also being able to say

and it's okay if in the moment like it's

not great like I I can Embrace that you

know I can be unhappy or Restless or

anxious or whatever it is and then when

I do that you know I feel like there's a

funny funny thing that happens and all

the sudden I I'm not as anxious right

and I am present and it there is some

Joy there interesting so when you allow

yourself to deal with being

uncomfortable in the moment it turns out

you it removes the thing that was making

you uncomfortable in the moment which is

like the avoidance or the worry or

overthinking whatever else yeah I I

think we have this and it's fed by

modern culture this kind of expectancy

that really we should be happy all the

time and if you know if we've arranged

things appropriately for our lives and

if we've done our work and you know

aimed true then we should just be like

life is great and I don't believe that

anymore I think that you know I mean

like Buddha said life is suffering but I

really think that

fundamentally like it's uncomfortable to

be

alive and that it's a kind of a constant

state of restlessness and discomfort if

we're being really honest and and tuning

in when I really let myself see that and

feel that all of a sudden I'm I'm freed

from from some of

that what has caused your anxiety

throughout your life in the moment you

you referenced earlier that some things

have happened that have led you to

understand this better and understand

yourself better what is what am I

missing from this jsaw puzzle yeah well

you're you're good you could have been a

psychiatrist oh really yeah it's always

time this doesn't work out there's still

time right it's not too late you get a

new profession yay um I think you know

for me the the big Turning Point um was

that we lost our we lost a child and um

in the immediate aftermath of our

child's death I was just determined to

like sort of undo the experience

and um you know get enough Psychotherapy

and enough whatever whatever it took to

sort of not feel that pain and it wasn't

until I really just said oh like I'm

going to feel this pain for the rest of

my life it's never going away that

suddenly I felt some relief from that

pain and that was a real window for

me so interesting that the

it's

acceptance yeah and and you know and and

I think you know one of the reasons I

love treating patients with addiction is

because I really relate to that hitting

bottom moment you know that moment when

it's like you just have the feeling that

like everything I try to do to manage

this Behavior or to make my life better

only makes it worse I felt like I had a

very similar

experience um and that it was only when

I kind of realized oh I yeah I I can't

run from this I cannot run this pain uh

that I I begin to have some the

beginnings of relief from that

experience I can't outrun this

pain it's all natural sort of

disposition to try and outrun pain isn't

it that's the irony right we're really

wired to outrun the pain we are like we

reflexively seek out pleasure and avoid

pain and yet that's the very thing thing

that doesn't get us to where we want to

go but we do now live in a world where

it's very easy to outrun the pain yes

this is a lion that's chasing me this

could be a bad email and then I open up

a tab and start Doom scrolling or open

up a tab and start watching video

playing video games or pornography or

whatever yeah that's exactly right there

are so many ways that we can now

distract ourselves from you know our own

suffering or our own

awareness and where do you find yourself

now with dealing with that grief and the

pain as we sit here yeah I mean I I feel

like in many ways it's been a real gift

in my life you know it's really informed

my life in in ways that um I mean I I've

learned things from that experience that

I think it would have been almost

impossible for me to learn otherwise you

deal with a lot of people that are in a

state of

suffering

I imagine that's a

weight because I um even hearing the

story of the lady that passed away after

that water addiction it was like a it

was like a weight on my shoulders just

to hear it

so if your profession puts you right at

the heart of this type of suffering how

do

you manage that to to hold that

weight a couple things um first of all a

lot of people get better and when people

with addiction get better

it's so much better that it's incredibly

rewarding to see and they're amazing

people Absolut like the most tenacious

talented people you'll ever meet and

when they get better it impacts so many

other people right their friends their

family the people they work with so it's

very rewarding work and and not at all

burdensome of course you know for

patients who don't don't get better or

patients who die it's a terrible feeling

and there is a sense of um

responsibility and and guilt even when I

feel like there was nothing that I could

have done otherwise um you know I carry

those losses with me so it's hard is

there any particular cases that have

stayed with you the most I mean every

patient I've had who's died while under

my care those are incredibly painful um

and I will never you know those are sort

of a those people will be with me as a

part of me for all of my life young and

old yeah young and old yeah it's

especially tragic to you to lose young

people and it always feels like their

second gu ing like oh if only I had done

that or if only we had intervened here

but I just think that's the nature of

death we we can't get away from the

feelings of guilt around it no matter

who we are and no matter the

circumstances how young can addiction

and the consequences of

addiction ruin someone's life like how

young can someone be when their life is

ruined from from the work you've done

and the the patients you've worked with

and what are those addictions typically

that seem to be most um susceptible to

those that are young

well I mean you know some some kids

start with drugs and alcohol you know

five six seven eight five six yeah I

mean it's you know some some some kids

use with their parents or their

caregivers they're exposed very early if

we seriously conceptualize digital media

as a drug I mean then we've got you know

even younger cohorts starting with that

and we do know that kids can get

addicted to digital media

and as a result um die from that I mean

there was just this tragic case of a

young man who essentially got addicted

to a chat box I think he was 14 not my

patient it was written up um in the New

York Times in the Wall Street Journal

and he fell in love with this chat box

started to isolate wasn't spending time

with his family or friends and then

eventually took his own life purportedly

so he could join this imaginary person

what's the youngest patient you've ever

seen the youngest I've seen is probably

around 15 14 15 and they had an

addiction yeah usually cannabis alcohol

nicotine can you get addicted to

cannabis oh yeah oh my gosh cannabis is

very addictive really oh yeah

yeah harmful very harmful the target

organ that it damages the most is the

brain um it's harmful in many ways I

mean it number one it demotivates people

often and so they can have the feeling

that they're getting stuff done or that

they're creative when in fact they're

not doing

anything um it most people smoke it and

so it can be damaging to the lungs and

and other other organs um a lot of

people say that well cannabis isn't

addictive because I don't have this

standard withdrawal phenomenon when I

stop like I don't have the shakes or

anything like that but keep in mind the

universal symptoms of addiction are

psychological symptoms anxiety

irritability depression insomnia craving

and people have that in Spades when they

try to stop using cannabis plus we often

see something called the hyperemesis

syndrome so cannabis can help with

nausea and vomiting it can help decrease

the feeling of wanting to vomit but

again as the brain continues to be

exposed to it there's this process of

neuro adaptation it stops working and it

can even turn on them and do the

opposite So eventually people can

actually have a cyclical vomiting

syndrome as a result of cannabis so

they'll show up in the emergency room

and say I can't stop I can't stop

vomiting and the reason is because of

the Cannabis that they maybe initially

started uh to stop feelings of

nausea on page 40 of dopamine Nation you

say we've lost the ability to tolerate

even minor forms of discomfort yeah and

as I was reading through this section of

your book I was thinking it sounds like

we've gone a little bit soft in society

um we've reset our pleasure pain

threshold to the side of pain that even

the slightest thing feels like trauma to