EP. 21: PAIN, PLEASURE, AND FINDING THE BALANCE

WITH ANNA LEMBKE

Jul 26

WITH ANNA LEMBKE, MD

The Director of Stanford’s Addiction Medicine Service discusses how we can renew meaning and connectedness in our lives by moderating overconsumption in a dopamine-overloaded world.

Listen Now

Episode Summary

Our modern world grants us unprecedented access to high-reward, high-dopamine stimuli—not just drugs, but also food, news, shopping, sex, gaming, social media, gambling, and more. But psychiatrist Dr. Anna Lembke argues that this society-wide overindulgence in pleasure threatens to lead us to deeper pain. Dr. Lembke is the director of the Addiction Medicine Service at Stanford Medicine and is the author of two bestselling books, Dopamine Nation and Drug Dealer, MD. As one of the first doctors to sound the alarm on the opioid epidemic in America, she's an expert on the issue and has advised policymakers at the highest levels of government. In this episode, Dr. Lembke describes her work treating all kinds of addiction, discusses her deep concern with the overconsumption of pleasure in our culture, and shares what we can all do to renew meaning and connectedness in our lives through balancing pain and pleasure.

Anna Lembke, MD is a professor of psychiatry at Stanford University School of Medicine and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar, she has published more than a hundred peer-reviewed papers, book chapters, and commentaries. 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.
In 2016, she published Drug Dealer, MD – How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop, which was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic. Dr. Lembke recently appeared on the Netflix documentary The Social Dilemma, an unvarnished look at the impact of social media on our lives.
Dopamine Nation: Finding Balance in the Age of Indulgence, an instant New York Times Bestseller, explores how to moderate compulsive overconsumption in a dopamine-overloaded world.
In this episode, you will hear about:
• What first drew Dr. Lembke to a medical career and how she initially discovered psychiatry - 2:13
• Why Dr. Lembke dedicates herself to addiction medicine, and how her philosophy can help others find meaningful work - 9:16
• The historical shift, with the advent of the opioid epidemic, to understanding addiction as a medical condition instead of a moral or personal failing - 12:53
• Reframing addiction as a medical diagnosis and approaching patients facing addictive disorders with compassion - 17:58
• How flaws in contemporary medical practice and misaligned incentives for doctors contributed to the opioid crisis - 24:15
• A discussion of Dr. Lemke’s book Dopamine Nation, including how easy access to pleasure causes addictagenic responses in nearly every aspect of our lives - 29:32
• How humans can reconnect with meaning in a culture that often substitutes meaning with cheap pleasure - 34:15
• Dr. Lembke’s advice to all clinicians for how to better connect with patients - 45:20
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:02] Our brains are wired to seek pleasure and avoid pain. For most of humanity's existence, this has helped us survive and thrive. But addiction medicine specialist Dr. Anna Lembke argues that today's world is oversaturated with all kinds of pleasure not just drugs, but also food, news, social media, gambling, sex, shopping, gaming and much more. And that this easy overindulgence in pleasure, perhaps paradoxically, threatens to lead us to deeper pain. Dr. Lembke is the director of the Addiction Medicine Service at Stanford and is the author of two bestselling books, Dopamine Nation and Drug Dealer, MD. As one of the first doctors to sound the alarm regarding the opioid epidemic and the problem of opioid overprescription in America, she's an expert on the issue and has advised policymakers at the highest levels of government. In this episode, Dr. Lembke shares stories of patients suffering and redemption and offers a hopeful roadmap to how all of us can renew meaning and connectedness in our lives through balancing the pursuits of pain and pleasure. Dr. Lembke, thank you very much for being with us here today, and welcome to the show.

Anna Lembke: [00:02:10] Well, thank you for inviting me. I'm really happy to be here.

Henry Bair: [00:02:13] To kick us off, can you bring us all the way to the start and tell us what first drew you to medicine and then to psychiatry in particular?

Anna Lembke: [00:02:22] Well, I think psychiatry was something that was calling me very early. But what I resisted for a variety of reasons, some of them the usual reasons I'm having to do with people feeling like including myself, I guess on some level that psychiatry is not real medicine. Why go do all that medical school just to become a psychiatrist? And then when I was at medical school, I went to Stanford Medical School. My sister, who was an undergraduate at the time, had a major manic episode and became psychotic and ended up in the locked unit here at Stanford. And that actually pushed me away from psychiatry. I just felt like, Wow, that's too close to home. I'm not going be able to help people with serious mental illness if it's in my own family. So I originally went into pathology thinking, Well, that's safe and I really like teaching. So I thought, Well, I'll be teaching other doctors. But a couple of years into my pathology residency, when I found myself reading pap smears over and over again, I thought, You know, this really isn't for me. I'm really somebody who wants to be interacting with people. And by that time, my my sister was doing much better. And so it wasn't as raw for me. And then I then I decided, you know, I think I really do want to go into psychiatry. So that's sort of the the early bobbing and weaving, so to speak, that occurred.

Henry Bair: [00:03:44] Mm hmm. So now you are one of the leaders in addiction medicine. You lead the division here at Stanford. Can you tell us how you got started in that work?

Anna Lembke: [00:03:54] Oh, gosh, it's always a little embarrassing because these are always the stories of how I didn't know what I was doing. So this is another example of it. I went to psychiatry and I remember I did a fellowship. So I was here in the residency program. I did a fellowship in mood disorders. And then I remember when I was finally joined the faculty as an instructor and I went to intake and I said, I'll see any kind of patient, just don't give me anybody with addiction. And whoops, and the reason for that, so again, I just this is sort of ridiculous, but first of all, I didn't learn anything in medical school and I learned very little in my psychiatry residency. So I didn't really have any tools for addiction. So I didn't want to see those people because I didn't have any idea what to do. And then also I had some negative counter transference. That's a term that we use in psychiatry to talk about, just like some unconscious negative feelings I wasn't really able to look at because my dad, who was a surgeon, had been a very high functioning alcoholic. And so it was also just like not wanting to deal with that problem because it was also close to home. So you're seeing a pattern here, a kind of avoidant pattern that then sort of sends me in the wrong direction, but then ultimately I kind of get my bearings.

Anna Lembke: [00:05:06] So what happened to me clinically was that I was seeing this woman for severe depression and I was seeing her weekly doing psychotherapy, prescribing Paxil. And she was incredibly sedated when she would come to these sessions. And I thought twice and I kind of asked her about it. She was like, Yeah, I don't I don't know what it is. And I thought, well, maybe you're a slow Paxil metabolize. You know, I had this fancy education from Stanford. I knew about 2d6 enzymes. So I was like, I'm going to research slow, two rd six Paxil metabolizes. Anyway, not very long thereafter. Her brother calls me and he says she's been in a rollover car accident. I said, Oh, that's terrible. You know what happened? And they said, Well, she's been using again. And I literally said to him, I kid you not. I said, Using what? And there was this pause and he goes using heroin. Isn't that what you've been treating her for? And it was absolutely mortifying because I had not once in all our times together asked her a single question about drug and alcohol use. And of course, you could argue, well, it was her responsibility to tell me about it, but it really wasn't. I'm the doctor. I'm the one that needs to get that information. And we had talked about every conversation she'd ever had with her mother, but we had never once talked about drugs and alcohol.

Anna Lembke: [00:06:26] And her care was being paid for by her family, who just simply assumed that I was competent, which I wasn't. And when I was talking to her about her heroin use, which I wasn't. So that was really a very important turning point in my career because I realized, oh, wow, Ana, you're actually a bad psychiatrist. And then it was like, okay, I better I better learn about addiction because I'm I'm hurting people out of ignorance. And then that began this was in the early 2000, like 2001 or so. And then that began like a major reeducation where I just talked to colleagues who treated addiction medicine. Many of them in recovery themselves, started asking patients about drug and alcohol use. And it turns out when you ask patients about these problems, we are more than happy to talk about them. They're eager to have somebody to talk about it with. And then over over the course of that time just eventually became kind of like the go to person in the department, in part because nobody else wanted to see these patients. And what I've discovered is that they're wonderful when they get into recovery, not only do they get better, but so many people in their lives have better lives because of it. So it's been it's a great population to treat. I love it. They're fantastic. And I'm glad that I sort of realized that early on.

Henry Bair: [00:07:44] Why is it you think that especially early on there were few psychiatrists interested in helping these patients?

Anna Lembke: [00:07:53] Well, there is a long legacy in medicine of addiction not being recognized as a medical illness or as a disease process. And you can go back 200 years and see that there are doctors who are advocating for it to be recognized as an illness, for it to be treated in the house of medicine. And yet enormous, enormous resistance to that idea because of the fundamental stigma surrounding addiction. There is an element of choice, at least initially. We do choose to use and not use with those first few attempts. But what I think is really underappreciated is the extent to which we really lose agency and autonomy as we get into our addiction, how drugs and addictive behaviors change the brain so that it really is a disease and people have real neuroscientifically-validated brain changes such that they become really the victim of these neurological loops and also the ways in which our environment now is so addictagenic. And we're all vulnerable to this problem. In my career, it was really the opioid epidemic that changed things that where doctors had to look at their complicity in creating the opioid epidemic and then couldn't just step away and say, Oh, that's somebody else's problem over there. We had to say, okay, this is also our problem and I've seen a lot of change because of that. I guess that's a silver lining.

Tyler Johnson: [00:09:16] I want to get back to more of the societal and philosophical questions that are involved in some of your your research and expertise in a minute. But before we do that, I just wanted to step back for a moment. One of the points of the podcast is to talk about finding meaning in medicine. And I believe that you are the first psychiatrist that we have had on the program. And I just wanted to ask you if you could explore a little bit what making meaning in medicine looks like for a psychiatrist. Right. Because I feel like psychiatrists. I mean, if we're honest about it, psychiatrists sort of delve into the parts of being human that most other doctors run away from. Right. So for most other doctors, if a patient starts to bring up, I don't know, their relationships and their innermost feelings and whatever, most doctors are like, okay, next appointment, let's here's your money, here's your here's your metoprolol and let's let's move on to something else. Right? So I guess I'm curious sort of what that looks like for you and how that how that functions for you.

Anna Lembke: [00:10:27] Okay, great. What drew me to psychiatry was the opportunity to have meaningful relationships through time with patients. I realized I was a slow medicine person, not a fast medicine person, and that I wanted to have these relationships and that I also ultimately cared more about quality of life than quantity of life, and that I would rather figure out how to help somebody make the days they have as good as possible rather than give them just give them more days. So those were the things that originally drew me to psychiatry. I mean, one of the pivotal things in that whole transition to treating patients with addiction was also part of the meaning making for me, where my early career had been, like where I projected a plan onto my patients and onto my career, as opposed to being awake and open and receptive to what my patients needed from me and my embracing addiction medicine and the need for doctors to treat. That was really a pivotal moment for me because it was not something I would have chosen, and it certainly wasn't. It's not like a classy section of medicine like right now because of the opioid epidemic. People are talking about addiction more, but it's not like saying like, I'm going to be a neurosurgeon.

Anna Lembke: [00:11:47] Right? They'll stand up and applaud for you just just because it's like I treat addiction. People are like, ooh, that's creepy. Part of my embracing meaning was like, Well, what do my patients who are coming into my office actually need and can I give it to them? So I think that's one of the messages in my in my book Dopamine Nation. And one of the things I really try to encourage young people around is that we're trying to figure out, well, what's my passion? Or How can I make my life meaningful? And sometimes the best way to do that is to just really look around you and say, What is the work that needs to be done here and now that I am qualified to do? And it doesn't need to be glamorous or sexy or prestigious, you've got to make a living. But are you really interested in money or are you more interested in in meaning? And not that those things are mutually exclusive, but really being thoughtful about that and then just like embracing kind of what God gave you in terms of what you were called. Do.

Tyler Johnson: [00:12:53] Thank you so much for that. I think there has been an obviously you can speak to this more than we can, but my own observations, you know, even when I was in medical school, which was I graduated 13 years ago, I feel like there was still sort of a thought, maybe not always articulated, but there was sort of a sense that addiction was, at worst, a personal failing and at best, a personal problem. Right. There was an individual who is addicted to a substance because they had chosen to get involved in that substance for whatever complicated reasons. And I feel like over the last ten years, there has really been a shift to where there is much more of an appreciation. You mentioned specifically the opiate epidemic, right, that it is an epidemic and that that clearly has been a societal problem that has and now there are all kinds of societal responses, some probably more effective than others. But that also there has been and you mentioned this a little bit briefly, this sense that addiction itself writ large, has become a societal issue, right? Where you have people who arguably are addicted to everything from pornography to cell phone use to gambling, whatever, as you discuss to some degree in your in your Dopamine Nation book. But I guess, as one of the nation's experts about this, could you talk a little bit about that sort of big picture understanding or that big picture shift in how we think about addiction and sort of its its roots and causes?

Anna Lembke: [00:14:30] Sure. I think one of the big contributors to that shift is the neuroscience and the recognition that continued exposure to potent and reinforcing drugs and behaviors literally changes the brain in a way that is not the same as changing your brain when you learn to play the piano, which is an analogy that sometimes people use to debunk the disease model of addiction. And the reason it's not the same is because playing the piano is something effortful that you have to do. And of course there's probably dopamine involved in gratification in a variety of different ways. But addiction is something that really robs, robs us on some level of our our agency and our ability to choose to do the thing that's really key. So these brain changes that we see affect a very specific circuit in the reward pathway of the brain and essentially make us blind to some extent to the negative consequences of our use and pull us into this compulsive vortex by hijacking these reward pathways. And I just think the animal models, the human studies, the brain studies, they're all really quite convincing, by the way. They also very much dovetail with my clinical experience, which is that people with severe addiction really have lost agency. I'll never forget the patient of mine who called me up and said, You need to help me. I'm surrounded by empty bottles, I can't stop drinking. And I said to her, You need to go. This is a patient of mine. Longstanding. She had relapsed and I said, You need to go to the emergency room and you need to tell them that you're suicidal so that they'll admit you to psychiatry and you can get some help stopping. And she said, But I'm not suicidal.

Anna Lembke: [00:16:16] I want to live. That's why I'm calling you. I said, I know that. I know you're not suicidal, but they're not going to do anything for you if you just come in and say, I'm addicted to alcohol, will you help me? There's no infrastructure. There's no way to pay for it. There's no knowledge, there's no algorithm. So you've got to say you're suicidal. So, you know, it's kind of terrible, right, to have a system like that that does so little to acknowledge her total loss of volitional ability in that moment to save herself. The other thing that I would say about addiction as a disease and the disease model of addiction is that it's just the right model for our times. So you and I could have a reasonable philosophical and even scientific conversation about whether addiction really is a disease and how it's the same or similar or not to a disease like cancer or heart disease or asthma or whatever. But I really think all of those discussions are moot in the sense that we live in a time in which we medicalized a lot of different types of problems in order to solve them. And we can't leave addiction out of that. We need to metabolize that. That creates an infrastructure to treat it. We know that when we treat addiction within the medical infrastructure, people get better at the same rates, that they get better to diseases like depression, asthma, cardiac disease, diabetes, type two. So the medical model works and it also garners resources and a destigmatize. And when we destigmatize, potentially, we allow more people to get access to treatment, which is what we want. So it's a it's a solution oriented model for our time.

Henry Bair: [00:17:58] Dr. Lembke, I remember the first time I encountered a patient with an addiction to opioids on the inpatient service. I was on internal medicine, and there was this patient who had a history of Crohn's disease. And so the reason for his hospitalization was for flare up. But at some point in the past and the story is very unclear, like he had been given access to opioid medications and he has been dependent on them for a very long time. And even prior to the hospitalization during which I took care of him, he had exhibited a lot of opioid seeking behavior coming to the emergency room, complaining of pain, being aggressive to the care providers when they would not give him his opioids. So during his hospitalization, the team was discussing how to address this problem. And I think that might have been my first time hearing about the addiction medicine service. Like I had known, I guess I had known it existed, but I hadn't really encountered them or talked to anyone on them. So it was the first time I was calling a consult on addiction medicine and I wanted to shadow them just to see the kinds of conversations they were having.

Henry Bair: [00:19:12] I went with the addiction medicine team and I shadowed them as they met with this patient. We were in there for about an hour, an hour and a half, and we basically got nowhere. The patient got very aggressive. He was using pointed attacks at us. It was just just establishing that rapport was a huge challenge. The interaction started off extremely antagonistic, I think, because the patient saw us as the barrier to him getting what he wanted, what he felt he needed. And all that is just to say that I think for a lot of people helping patients with substance use disorders, opioid or otherwise, can seem like a very frustrating thing. It can take a very long time. Progress can be very slow, patients can relapse. And I'm just wondering, given all these challenges, given the very delicate patient encounters and conversations you need to have, how do you navigate that? How do you how do you see the challenges there and overcome it? And in spite of it, feel that you're able to help patients get to a better place.

Anna Lembke: [00:20:24] Well, first hand, we thank you for shadowing our addiction medicine console service and spending an hour and a half with them with one patient. I love that you did that. That really shows your curiosity and desire to learn and help patients. So thank you. And I think this case exemplifies it's a great example of the very real complicated kinds of clinical cases that we see with patients who have serious illness that cause real pain. And that pain is horrible and we want to help them like it's our natural desire to want to heal and alleviate suffering. It comes instinctively. It's why we choose medicine. And yet sometimes the ways that we try to help people end up getting them into this other problem, which is opioid dependance and in some cases opioid addiction, where the opioids are not helping them anymore and can actually make pain worse. So these are tough, tough problems. I'm sorry that you didn't get get to hang around long enough to see that sometimes when we have these interactions that seem all negative, they have to marinate for a while in the patient's brain and then over the course of days, or sometimes it takes weeks or months of intermittent contact or maybe even no contact at all. But then they come back later and you know, patients will come around and they'll know that on some deep level they need help, not just with the pain, but but also with the opioid problem.

Anna Lembke: [00:21:46] I think some of that early defensiveness is because they're so frightened that if they embrace the treatment or the intervention for their opioid problem, that will forget about or ignore their pain or say their pain isn't real. And so there's a lot of front kind of educating. This is not saying your pain isn't real and this is not saying we're going to ignore your pain. This is saying that you have a couple of different problems and one of them is the opioid problem. And we can help your pain if you let us help help you with the opioid problem in terms of like, you know, I just sort of quote you back to yourself saying, oh, these are so complicated and they take a long time and progress is slow and patients relapse. I would say to you, there are so many diseases in medicine for which that's true. Cancer, too, can take a long time. The treatment's really painful. Progress can be slow, the cancer can recur. And yet we have entire buildings and blocks of buildings dedicated to cancer treatment and not one little shack dedicated to addiction treatment. So we do a lot of complicated things renal disease, kidney care, dialysis, that's complicated people, and they don't necessarily get better.

Anna Lembke: [00:23:01] Sometimes people are on dialysis and then eventually die on dialysis. And yet we're so eager to embrace like, oh, the electrolytes. And they went in and out and the machine did this and, you know, transplants. So it's really, really fascinating to look at the difference between our willingness to embrace a lot of complex chronic diseases that recur and have complicated, slow treatment and yet be so reluctant to do that with addiction. Because the truth of the matter is our target organ is the brain. It's a brain disease and we can treat it. People who engage in addiction treatment get better about 50% of the time, and that's pretty good. And that's comparable to a lot of our other treatment interventions for chronic relapsing and remitting medical disorders. So I think we just have to shift our perspective on that and say, hey, this is a disease. And I can tell you it's super rewarding. I mean, these people are great and when they get into recovery, they're absolutely amazing people. You would not recognize that patient you met in that who thought I probably you probably had to feel like I really don't want to have anything to do with this guy. But if he ever got into recovery, you would probably find him to be a remarkable person.

Tyler Johnson: [00:24:15] You mentioned this a little bit in your last comment, how when you see a patient like the patient Henry mentioned with Crohn's disease, who has this terrible pain that we have this sort of instinctive desire to relieve their pain. But as you have pointed out in one of your books, one of the things that is really troubling about the opiate epidemic is that if you trace the roots back, obviously the causes are complicated and multifaceted. But I know again, when I was in medical school 15 years ago, there was a very heavy emphasis on the tagline, used to be Pain is the fifth vital sign, right? But the implication of that was pain is the fifth vital sign. And just like you would never leave somebody's blood pressure low without trying to bring it up, or you would never leave their heart rate too high without trying to bring it down, or you would never not give somebody a Tylenol for a fever. You never leave someone's pain alone. Right. And there were a lot of very heavily prescriptive cases. I mean, I remember one of the sort of classic cases in medical school was talking about how, well, if you have all of these different patients and one of them is an African American patient with sickle cell disease. And they have terrible pain.

Tyler Johnson: [00:25:25] How can you deprive them of their opiates? Right. With the sort of idea being that if you do that, you are both callous and racist. Right now, of course, it is true that people who are in terrible pain, including African American people who are in the middle of a pain crisis, need pain control. But the point is that, like the subtext underneath all of this stuff was that if there's a person in pain and you don't give them opiates, you are a bad doctor. Right. And yet the, I think, unforseen consequence, at least in part of that entire movement, was that then we ended up in a place where, yes, of course, there were exceptional people who were just giving out opiates like it was candy, and they had built entire clinics around basically just giving out opiates. But forget about those exceptional bad sort of bad apples for a minute. It was just a subtext of medicine in general, right. That opiates were there to be used. And I guess I'm I'm curious from like as you have thought so much about our complicity, as you mentioned, in that problem, what do you think are the lessons that we as a medical community should be taking away from that? What should we be learning?

Anna Lembke: [00:26:34] Oh, gosh. So so many lessons. And this is really what my my book Drug Dealer MD explores. I think the main lesson is to really become much more aware of both the visible and invisible incentives inside of medicine when it comes to opioid prescribing. Some of those incentives are actual pressure on doctors to treat patients with opioids if they complain of any kind of pain in any setting, in any context to the disregard of any other data point. And that was real. And that that hugely inflated opioid prescribing and basically was the the seeds of the opioid epidemic, but also to recognize the invisible incentives in the sense that we as people who naturally want to alleviate suffering and have our patients express gratitude, there's a there's an element of narcissism that goes in there where we don't want to be the bad guy, even if being the bad guy is the right thing for the patient. We would much rather prescribe the opioids and get the love and be the compassionate one. Then we would to really take a long, hard look at, well, what's better for this person in the long run?

Anna Lembke: [00:27:45] I do want to go briefly interject about the racial aspects of the opioid epidemic, because I think it's important to point out that the racial component here is really complex in the sense that there's good evidence showing that health care providers generally under prescribe opioids to black people, to black and brown people, because they assume that black and brown people are addicted and are drug seeking.

Anna Lembke: [00:28:11] And that's something that we really need to combat and to make sure that we know we practice in a in a racist infrastructure. And we therefore all are vulnerable to being racist in our medical practice, not because we're racist individuals, but because the system is sort of wired that way. So I do think it's important to acknowledge that. And also, interestingly, in the beginning of the opioid epidemic, the highest rates of addiction to prescription opioids were among white, middle class people. Why? Because they had the access to, quote unquote, the best medical treatment. And in the early 2000s, if you had access to the best medical treatment, you were actually in greater danger of getting addicted to opioids. But as the opioid epidemic has worn on, that's changed. And now, in fact, the highest rates of opioid related addiction and death are in black and brown people. So I just it's interesting and I think important to sort of highlight some of the racial components. The other really big racial component here with the opioid epidemic is that, you know, when a bunch of middle class and upper class white people are getting addicted to opioids, people were more more willing to embrace the disease model of addiction. But when black people in the inner cities, for example, in the 1990s were getting addicted to crack cocaine, nobody was calling addiction a disease then. So these are these are important aspects to talk about.

Henry Bair: [00:29:32] I'd like to turn next to your most recent book, Dopamine Nation. The subtitle of the book is Finding Balance in the Age of Indulgence. Can you tell us more about the genesis of the book in the sense like what made you want to write it and what does balance refer to in this case?

Anna Lembke: [00:29:50] Yeah, well, I'll start with what does balance refer to. So to me, one of the most interesting findings in neuroscience in the past 100 years or so is that pain and pleasure co-located in the brain and they work like opposite sides of the balance. So when we do something pleasurable, the way that our brains restore a level balance or homeostasis is first by tipping an equal and opposite amount to the side of pain. And that underscores or underlies what happens in the brain as people get addicted. That is with repeated pleasure. That initial deviation to pleasure gets weaker and shorter, but that after response to pain gets stronger and longer. And essentially we end up in a dopamine deficit state, or now we need our drug not to get high, but just to feel normal. And when we're not using, we're experiencing the universal symptoms of withdrawal from any addictive substance which are anxiety or debility, insomnia, dysphoria and craving. So the book Dopamine Nation is really about marrying that neuroscience with. The sociological consequences of living in a world of overabundance, where we now have instant, infinite access to highly reinforcing drugs and behaviors, where almost every substance we ingest from food to alcohol to many different types of drugs, but also the behaviors that we engage in, especially with the Internet, have essentially become drug ified, release dopamine in our reward pathway, have the potential for addiction. And essentially, we've all become more vulnerable to that problem of addiction because the firehose of dopamine has put us into this dopamine deficit state. The other inference that I make from the neuroscience and my clinical experience is that the rising rates of anxiety, depression and suicide that are happening all over the world in the last 30 to 50 years, but especially in rich nations, are due to this problem of overabundance.

Anna Lembke: [00:31:34] And that essentially the reason that we're so much more unhappy is because we're working so hard to not be unhappy and it's trying to seek out pleasure for its own sake and avoid painful experiences that has actually put us all into a dopamine deficit state. And I know that's like kind of a big hypothesis, but I see more and more patients who have really good lives, good social networks, good friends, good education, no financial worries, good jobs, and yet are incredibly unhappy, including young, otherwise healthy young people, also otherwise healthy young people with full body pain in the absence of any disease pathology to explain that pain and I think what we're dealing with there is a real physiologic change in the reward pathways such that people are in a dopamine deficit state because of the chronic access to pleasurable goods and substances and the way that we're insulated from not just painful experiences, but even any discomfort or physical experiences at all, such that the intervention is not more antidepressants or more talk therapy or more identifying your trauma. But the intervention is really to avoid intoxicants and even to some extent to much of these sort of tech pleasures and to actually invite pain into your life a new form of asceticism in order to reset the balance.

Tyler Johnson: [00:33:03] You know, it's so interesting because when I hear you talk about that, I guess my mind goes in two directions. One is, it reminds me that I think we have come maybe not completely, but somewhat towards Aldous Huxley's Brave New World, right? Where we can just give ourselves Soma any time we want it sort of. And in a real way. I think that's what smartphones have become. They're like instant soma injectors, right? You just sort of hold it up to your eyes and boom, there, it's just dopamine, dopamine, dopamine, as you say. The other thing is that I often worry and you could make an argument that this podcast is sort of our little teeny way of trying to chip away at this problem that we also try to. I think it's pretty widely recognized that the last 50, and especially the last 20 years, have seen a loss of meaning in the world. Right. That there's this sort of disillusionment with everything from personal religious experience to institutional credence, and that we try to fill the void that's left when we don't have meaning anymore with dopamine hits. Right. And that can look more or less sophisticated.

Tyler Johnson: [00:34:15] But it just I mean, you're the neuroscientist, but I feel like dopamine doesn't give us meaning, right? It gives us reward. It gives us a little bit of pleasure, but it doesn't fill the void of trying to make life meaningful, I guess all of which is a way of saying if you had a patient who came to you and said, Doc, I feel like my my life is filled with the thick of thin things. It's like all of these hits, but it doesn't add up to anything, right? Like it's not it just there's no there there at the middle of it. So part of this, as you say, is is embracing and asceticism. Right. It's it's getting away from the hit mentality. But then what about the other side? Like, how do you then and I mean, I guess I'm I'm turning you into some sort of religious person or like a religious counselor here. But I think it's an important question. Like, so you get rid of the hit mentality, your esthetic about it, but then how do you how do people then find meaning once they've stripped the hits away?

Anna Lembke: [00:35:20] So I think at the heart of finding meaning is reconnecting with ourselves, with other people and with the universe, or however we define that. And we cannot do that when we're chasing dopamine, because when we're chasing dopamine, we're essentially distracting ourselves from ourselves. We're running away from ourselves. Ultimately, addiction is also completely about isolation. So. We are substituting human connection with our drug. So we're running away from other people and we also can't be present or experience healthy, transcendent kind of moments when we're engaging with drug use. At least I believe that. So what we need to do, the very first step is to abstain for long enough to be back in our bodies, to endure the pain of the present moment, the suffering that comes with being alive, to sit with the great quiet and reacquaint ourselves with ourselves, with other people, with our need for a transcendent power or a higher being. And we vary, humans vary in terms of that need, but some of us have a great need for that. And people have made the argument from Carl Jung on down that people who become severely addicted are actually people who have transferred their need for God onto the false worship of this substance, which for a while really works. I mean, the power of addiction and of intoxicants and substance, it's profound.

Anna Lembke: [00:36:55] It really does initially fill the vacuum. But the key is that because of our ancient wiring, it eventually stops working and then you're left in a much, much worse place than you were, because then you have you're in withdrawal. You know, your God turned out to be a false God. You don't have the tools or you don't feel you have the tools to live in the world without that. And so it becomes very complicated for you, but there's lots of hope and people get into recovery from all kinds of addictions, even minor addictions to our phones and I think feel much more tethered to themselves and the world, which is the first step in finding meaning. In the book, I talk about a Stanford student who was terrified to unplug because she just sort of was just like so afraid of being bored. And I encouraged her to try spending a day not listening to anything at all. Not music, not not watching shows, not listening to anything. And what she came back and said was that at first it really was boring. And then we acknowledged the ways in which boredom is not just boring, but also kind of terrifying, because when you're faced with boredom, you're faced with the bigger questions about why do why do I do anything that I do? But what she said, which was really poignant, was, yeah, I was walking to class and I started noticing the trees and like, you know, it's, it's like that.

Anna Lembke: [00:38:17] It's like, yeah, you started reconnecting with yourself and the world around you. And that's, that's we want to feel tethered. We need to have that feeling. And what's so insidious and dangerous about the Internet is that besides being addictive, it promotes this sense of realization, which is the sense that we're not real in the world, is not real. And this is a very, very scary feeling. You know, the sense that I'm in a movie, I'm in the Matrix, I'm floating in space, because when people start to have that hollowed out feeling, then the idea of suicide becomes very near and dear because it's like, "Well, if I'm not real, then really ending my life, or for that matter, ending somebody else's life doesn't really matter because none of it's real." So we have to get back to that place where we feel that things matter, where things in the world have a three dimensional quality, where we don't need to wait for Mark Zuckerberg's metaverse because we live in an amazing world.

Anna Lembke: [00:39:21] I do not like the metaverse. Why would we need to do that? We live in an amazing world that we're totally ignoring, and yet I have empathy for it because I can go down the rabbit hole myself and I know what it is to have that feeling of peak anxiety, that things aren't real and that I'm not real, and that this three dimensional thing has a two dimensional quality. So how do we get that back? We get that back, really. It's not it's there's a pretty prescriptive plan. You have to reacquaint yourself with your own suffering and you have to not try to run away from it. And you have to try to align your experience in your values that are tied to a higher meaning, which is often tied toward your meaning and purpose. And that doesn't mean like becoming Gandhi. That means, like, how can I make my world and the experience, the cards that I've been dealt, how can I live in my my life? How can I be in my life? It's a lot harder to do than it sounds. We can tolerate a lot of pain if we're doing it in the service of some kind of higher meaning and purpose.

Tyler Johnson: [00:40:34] Your description reminds me there is a really beautiful essay a number of years ago by Andrew Sullivan called I Used to Be a Human Being. It's this beautiful meditation about he comes to realize that he has become just this constant stream of photons from screens. And so he disconnects from everything and goes out in. It's like Thoreau or something goes out into the woods and it is torture. Like he just like that experience of coming back into his body or whatever you want to call it. Right? He just can't like the presence of the trees and the sounds of the forest and the feel of it. Like it's like he doesn't know how to do that anymore, right? Like he's forgotten how to process the reality of the world and the reality of being in his own skin. It is a it's weird because it's about going into the woods and it's a harrowing essay in its way. It's so visceral what that process is like. It also you're talking about three dimensional objects. Reminds me, I used to sort of be this sort of Apple fanboy who was like very excited about like the new resolution on the new computer or whatever. And then for a while, I realized that all of the Apple products were always advertising computers with pictures of Half Dome or Yosemite on them. And then at some point I was like, Why don't I just drive to Yosemite, all this? What is the point of having a whatever, however many megapixels, something, something when you can just go to the mountain.

Anna Lembke: [00:41:58] And these things are drugs and they really can usurp so many aspects of our well being. I love that description. I'm going to look for that essay. What I think is the most important message, just based on what you've told me of the essay, is that giving up our intoxicants in our drugs and all their various forms is hard and it's painful. And to be in the moment is to embrace the terror of being alive. And the reason I think that's important is I know when I was in college, I would like hear about Ram Dass and "Be Here Now," And I kept trying to be here now, and all I could think of was I must not be doing it right, because every time I hear now I'm unhappy. It's like, I don't like to be here now. I would rather be somewhere else later, you know. So but it took me a long time and a lot of aging and some hard life experiences. Oh, oh. Being here now means being uncomfortable, being uncomfortable and being okay with being uncomfortable and realizing I'm not alone. That all of us who are trying to be here now are like, it hurts, you know? But if you just tolerate it long enough, it gets better and then it gets something really quite amazing and glorious in moments of intermittent, unexpected grace. And I think that's really also the key that our greatest pleasures really are not the ones we plan for. They're the ones that come to us unbidden and unexpectedly. They're gifts, and we have to be open to see them when they arrive, but we don't really get to plan them.

Tyler Johnson: [00:43:37] Yeah, it really is sort of a frightening or at least sobering prospect that maybe true transcendence is only possible in a world that includes suffering. Right. And I think that's part of Aldous Huxley's point, is that you just can't you just can't summarize the world without losing what actually makes it meaningful.

Anna Lembke: [00:43:58] Yeah. And again, I think a really important message because I felt so alone in my suffering. Like it was really a revelation of, oh, like life is a terrifying and awe inspiring and spiritual and horrible experience all at once. And that is what life is. And if I'm experiencing life that way, then I'm living life. And that's what other people are experiencing, too, if they're allowing themselves to.

Henry Bair: [00:44:28] Dr. Lembke, thank you very much for for that conversation. I think it's been incredible how you're able to weave together really abstract ideas about what makes things meaningful and how we perceive our own place in the world and our existence, and then bring it down to really applicable chunks. And for our listeners, I really encourage you all to read Dr. Lembke's book, Dopamine Nation. One of the things that stood out to me was how, after understanding the way that the reward pathways work in our brain, you start seeing it everywhere, right? It's not just substance use. It is technology. It is your behaviors, it is your relationships. It is present in healthy and unhealthy ways everywhere. So in reading it, it really made me reflect on the way that I live my life.

Anna Lembke: [00:45:17] That's a that's very precious to me. Thank you.

Henry Bair: [00:45:20] Yeah. So I know our time is almost up, but I just wanted to ask one last question. Tyler early on made the point that for a lot of doctors, it's very uncomfortable to talk to patients about feelings, about emotions. And yet for patients, often this is this is the stuff that they really want to talk about. They want to know that a doctor isn't there just to give them medications, but that they care. And for patients, it's never really just chest pain. It's never really just difficulty breathing. They always contextualize what they're experiencing in the greater picture of what makes their life worth living, what they enjoy doing. It's always in a part of a grander narrative. And so I think that whether we like it or not, I think all clinicians should be equipped to interact with patients at that level. So I'm hoping you can share some ideas and advice. What can clinicians learn from you that can help them better connect with patients?

Anna Lembke: [00:46:16] I think the main thing is to remember that our relationship with patients, it's part of the healing process, that it's not all the other things that we do alone, that the relationship itself is a medium for healing, that we heal through relationships. And I know that sounds like maybe overly obvious or simplistic or Pollyannaish, but I just can't emphasize that that enough and that the way that we can create what we call in psychiatry, that therapeutic alliance, is the ways that people learn about. But often forget when you first go into the room, try and have what Martin Buber called an I Am Thou moment, written by a famous theologian and philosopher from the last century. And basically what that means is try to have that moment of recognition of our mutual humanity. It can happen in seconds. I mean, it really can. It's just where you see the person, you let them see you. You make that human connection. Maybe you're not even talking about the medicine or it doesn't matter really what it is. But that's so, so important. Of course, the competing interest is the to do list, right? All of the things we have to get through. So at some point we have to take off the hat of the eye in vow moment and go through our list, and that's okay. But then before you end the encounter, try to again end with that moment of recognition, of that connection of our mutual humanity. So I think about a time compressed encounter with patients where we have a lot to cover.

Anna Lembke: [00:47:52] Think about bookending it with an authentic moment of connection and then try to end it with an authentic moment of connection. And again, it doesn't have to necessarily be any particular words, but it's opening yourself up perceptively to being present for that person, acknowledging them. Maybe some open ended question, how are you doing? This is really, really important. Interestingly, I just went to the doctor yesterday and she was incredibly thorough and she had her checklist and she was really impressive in her knowledge. But not once did I feel she paused in her to do list, to just simply be present with me, and I felt really deprived because of that. It was interesting because in the course of the encounter she actually knocked the lamp over, which then hit the wall clock, which then hit her on the head, which I thought was like a prophetic moment of this clock hitting her on the head because she was clearly so focused. And I burst out laughing and I just I just thought it was sort of funny, you know, it was kind of a nervous, oh, whoops. Oh, gee, you know, she did not even crack a smile. Not even she didn't stop typing in the computer. She removed the clock from her head. It sort of perched on her head. She removed it and just kept going. And I thought, wow, I guess that's what we're doing now. You know what I mean?

Henry Bair: [00:49:15] Wow. That is that is quite, quite a symbolic moment there.

Anna Lembke: [00:49:20] Right? Yeah.

Henry Bair: [00:49:21] On that note, thank you very much, Dr. Lembke, for taking the time out of your very busy schedule to join us in. Conversation.

Tyler Johnson: [00:49:28] Thanks so.

Anna Lembke: [00:49:29] Much. Oh, my goodness. My pleasure. It was a pleasure talking to both of you. And thank you for inviting me and thank you for doing your podcast. It's great.

Henry Bair: [00:49:38] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctors art sitcom. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:49:57] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.

Henry Bair: [00:50:11] I'm Henry Bair.

Tyler Johnson: [00:50:12] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.