We discuss flourishing with Dr. Anna Lembke, bestselling author and specialist in addiction medicine at Stanford University. Anna is Professor and Medical Director of Addiction Medicine at the Stanford University School of Medicine, Program Director of the Stanford Addiction Medicine Fellowship and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic.
Anna is author of a bestselling book on the prescription drug epidemic, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop (Johns Hopkins University Press, 2016), which was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic. Her latest book, Dopamine Nation: Finding Balance in the Age of Indulgence (2021) was an instant New York Times and LA Times bestseller, and explores how to moderate compulsive overconsumption in a dopamine-overloaded world.
Our conversation focuses on the relation between flourishing and dopamine addition – the focus of Dopamine Nation. We discuss the role of dopamine in pleasure and motivation; why it’s dangerous to conflate happiness with pleasure; and how to flourish while navigating addiction.
Anna offers us a picture of today’s world you may find shocking, but she also offers us much practical advice on how to escape the addictive world we’ve created for ourselves. In particular, to overcome dopamine addiction, Anna recommends we cultivate a lifestyle of being comfortable with the uncomfortable: to challenge ourselves physically, cognitively and emotionally.
“I am convinced that the leading cause of unhappiness in the modern world today is that we have way too much dopamine. To compensate for this firehose of dopamine, our brains have had to physiologically readjust and put us in a dopamine-deficit state akin to a depression to try, wildly, to restore homeostasis.”
What is addiction?
Anna defines addiction more broadly than we typically define it. The common definition is the continued compulsive use of a substance or behavior despite harm to oneself and/or others. Anna’s work on the neuroscience behind addiction has led to her to construct a broader definition: anything we ingest or any behavior we use is addictive if it affects our dopamine reward pathways in a way that makes us vulnerable to compulsive over-consumption. We can become addicted to anything that affects us in this way: alcohol, drugs, video games, gambling, shopping, sugar, social media or – something Anna recalls she was once addicted to – romance novels. All these are examples of a what Anna describes as a person’s possible “drug of choice.”
Dopamine is a chemical compound present in the body as a neurotransmitter and made in the brain. It contributes towards various bodily functions, processes and feelings, but it’s often described as the “feel good” neurotransmitter because it’s strongly associated with pleasure and is released when you’re expecting a reward.
Consider an activity you enjoy, such as drinking coffee or watching your favorite TV show. The smell of fresh ground coffee or the sound of the theme tune from the TV show may stimulate your brain to increase dopamine secretion. This may increase further as you sip coffee or sit down to watch the show. When you drink coffee or watch the show, dopamine reinforces your enjoyment of the experience, building your desire to have the experience again. Such experiences can become cravings, with dopamine reinforcing these cravings and building our desire to continue satisfying them in the future. As Ann Pietrangelo describes the process in Healthline, it’s a “cycle of motivation, reward and reinforcement.”
Anna argues that most people battle with addiction on some level in the broader sense in which she defines it. A key point in Dopamine Nation, emphasized in this episode, is that all of us are vulnerable to addiction, given its neurological roots deriving from dopamine overstimulation and the way in which we’ve become desensitized to dopamine in today’s world.
Anna on the world we’ve created for ourselves
Anna argues that we’ve created a world in which almost all human experience is “drugified,” by which she means that almost all activities in which we engage have been made addictive. Much of our conversation orients around a pessimistic analogy Anna describes of how sees our lives today, in a world where we’re overstimulated by dopamine. She uses the ancient Greek myth of Sisyphus as an analogy to describe our relationship with activities that cause us to become addicted to dopamine stimulation.
In the myth, Zeus condemns Sisyphus to the eternal punishment of repeatedly pushing a boulder up a hill in Hades only to watch it roll back down. As Homer describes the myth:
Sisyphus … wrestled with a huge rock with both hands. Bracing himself and thrusting with hands and feet he pushed the boulder uphill to the top. But every time, as he was about to send it toppling over the crest, its sheer weight turned it back, and once again towards the plain the pitiless rock rolled down. So once more he had to wrestle with the thing and push it up, while the sweat poured from his limbs and the dust rose high above his head. (Odyssey, Book 11: 593)
Anna says Sisyphus is a great example of a person who “really got life wrong,” yet in today’s world “we are all like Sisyphus” in our relationship with activities that overstimulate us and make us addicted to the dopamine stimulation they bring about.
Anna describes the connection as follows. We have a baseline level of dopamine stimulation for any given activity. We gain pleasure from doing the thing – for example, drinking coffee or watching our favorite TV show – then the pleasure subsides but we desire it again later. As we engage in the activity more, our baseline for dopamine stimulation is raised and we need greater stimulation to experience the same level of pleasure. If we feel we aren’t getting enough pleasure, we need more – such as stronger cups of coffee or several successive episodes of our favorite TV show.
Titian, Sisyphus (1548-49) (image from Brittanica)
To adapt the myth of Sisyphus, imagine that Sisyphus actually enjoys pushing the boulder up the hill the first few times. But as he continues trying to find a shred of enjoyment in his torment, his baseline is raised because he no longer experiences the same level of pleasure. He has to push the boulder higher or faster up the hill, or get creative with it in other ways to gain any sense of pleasure. Similarly, as we continue to gain pleasure from some activity more and more, our baseline for dopamine raises and we have to do the activity in additional or different ways to get a similar level of pleasure from it.
As we become addicted to a behavior or something we ingest, our general mood lowers. Our dopamine baseline increases as we become less sensitized to dopamine stimulation, resulting in us needing greater stimulation to experience pleasure (just like you need more caffeine to feel alert if you regularly consume caffeine). Since dopamine is strongly connected with pleasure, our baseline for experiencing pleasure is also affected by dopamine addiction. So if we become addicted to a behavior or something we ingest, it becomes more difficult to experience pleasure from that thing. This is one of the processes referred to by “neuroadaptation”.
Today, many things aim to stimulate dopamine. From advertising to social media to films and music, many areas of modern life are designed to grab and hold our attention as much as possible, which often involves trying to give us a quick experience of pleasure. For example, in recent years the “Spotify Effect” has been coined, referring to the phenomenon of songs becoming shorter and getting to the chorus quicker to grab and hold the listener’s attention. Some data suggests this is due to a reduction in consumers’ attention spans. Connecting this with Anna’s research, we could infer that this may be due to a raise in many consumers’ baseline level for experiencing pleasure from songs, wanting a quicker or stronger sensation of pleasure.
Sisyphus also comes up in our episode with Emily Esfahani-Smith. In her book The Power of Meaning, Emily recommends texts we should read to learn more about how to find meaning in life. Some books, she argues, “function as manuals about how to live.” These include novels, works of philosophy and religious texts, such as the philosopher Albert Camus’ The Myth of Sisyphus (Le Mythe de Sisyphe, 1942), in which Camus draws upon the plight of Sisyphus to argue that life is ultimately meaningless, but we cannot help but search for meaning in our lives, and that even Sisyphus could find meaning in his eternal punishment, by adopting a certain stance or “mindset,” as Emily describes it, towards his life.
Homeostasis and the balance between pleasure and pain
The points above about dopamine stimulation are connected with homeostasis: the self-regulating process of organisms to maintain a stable equilibrium and internal conditions for survival. For example, our bodies typically naturally maintain a steady temperature for us to survive, and adapt to external changes to temperature accordingly (making us sweat to cool us down when it’s hot, for example); when we’re ill, our body sometimes doesn’t maintain a steady temperature (hence having a high temperature when you have a fever). Homeostasis means that after dopamine secretion increases, the body naturally returns to its baseline level of dopamine. But with greater dopamine stimulation, our baseline for homeostasis changes.
Anna points out that “one of the most important discoveries in neuroscience is that the same parts of the brain that process pleasure also process pain.” Homeostasis causes our bodies to generally maintain a steady balance between pain and pleasure, just like our bodies typically maintain a steady temperature. Following any deviation from neutrality, our brain works hard to restore homeostasis.
To restore homeostasis after dopamine stimulation, the brain moves towards the other side of the balance, to a stronger degree in relation to the strength of the experience on the other side. So, for example, the short-term pleasure we experience from a strong sugar hit often results in a crash where we have a negative experience afterwards, and we experience greater sugar cravings later, to give us a similar experience of pleasure as before. The experience of pain is often the comedown after experiencing pleasure, where our bodies move into a state of dopamine deficit. As Anna says,
“The way that the brain restores a level balance is first by tipping an equal and opposite amount to whatever the initial stimulus was. It doesn’t just go back to baseline. It can go to pain before it returns to the initial balance.”
Homeostasis doesn’t, however, always restore us to the original baseline. “With repeated exposure,” Anna explains, “that initial deviation to the side of pleasure gets weaker and shorter in duration, and that after response to pain gets stronger and longer in duration.” This is an example of neuroadaptation.
Happiness, pleasure and flourishing
Anna describes the pursuit of pleasure for its own sake as a cycle of negative reinforcement: “hedonism – the pursuit of pleasure for its own sake – can actually lead to anhedonia: the inability to enjoy pleasure of any kind.” We often pursue pleasure because we think it’ll bring us happiness, and while it can to some degree, the pursuit of pleasure as an end in itself can in fact make it more difficult to become happy, since pleasure relies on dopamine stimulation. If we want genuine, long-term happiness, we need to be careful to avoid conflating short-term pleasure with happiness. Pleasure supports the pursuit of happiness, but it’s not definitive of it.
Anna argues that our conception of happiness today has been “adulterated” by our consumption of pleasure. She holds that people tend to pursue happiness by pursuing pleasure, but this is problematic because “pleasure is certainly not happiness.” In Dopamine Nation, she summarizes evidence that suggests that pursuing pleasure for its own sake makes it more difficult for us to become happy.
Anna suggests that the view that pursuing pleasure is a pathway to happiness is therefore confused, but it’s easy to fall into this confusion since pleasure makes us feel good. To illustrate, she compares this pursuit with the ways it can be difficult to form close relationships due to technology. Social media can give us the impression we’re forming close relationships with others we engage with online, although the relationship may in fact be merely one of acquaintance rather than friendship.
How to avoid anhedonia
During the comedown from an experience of pleasure, we often strive to gain more pleasure, but what we need to do is endure the comedown, and by so doing gradually resensitize ourselves to dopamine. Anna recommends that we increase our knowledge and understanding of what’s going on in our brains when we feel the urge to satisfy our cravings, such as when we finish an episode of our favorite TV show and feel the urge to watch another. Ask yourself, “Do I really want to watch this episode?”, and take into consideration how this experience fits with your overall happiness and enjoyment of life. It may be that we want to watch it, but if we’re honest with ourselves, we’d actually prefer not to. (On the related conflation between liking and wanting something, see Kent Berridge’s research.)
While the pleasure may feel good in the moment, it might not further down the road. These may take place over short or long time spans: consider, for example, the short-term enjoyment of caffeine but disruption of sleep later that day, or being in a relationship fueled by passion in its early stages but not being enjoyable long-term (on research on the latter, see Arthur Brooks’ recent book From Strength to Strength, pp. 125-132).
Anna says “this is the key I want to communicate to people”: doing the thing that you crave may put you in a dopamine deficit state, such that you might end up anxious, depressed, sleep deprived, having suicidal thoughts, experience difficulty concentrating, and so on. She used to prescribe drugs to people with such symptoms. Now she asks them, “What are you consuming, how much and how often?” With this question, she aims to figure out what a person has done to their baseline dopamine level and find out what their “drug of choice” is, so the first thing she can do to intervene is stop a person using their drug of choice for long enough to restore a baseline level of homeostasis.
On this point, Anna says:
“I am convinced that the leading cause of unhappiness in the modern world today is that we have way too much dopamine. To compensate for this firehose of dopamine, our brains have had to physiologically readjust and put us in a dopamine-deficit state akin to a depression to try, wildly, to restore homeostasis.”
How to overcome dopamine addiction
A key point emerging from Anna’s research is that a life of trying to experience as much pleasure as possible in our lives can, paradoxically, lead to a life of greater pain. Excessive pursuit of pleasure is therefore more likely to lead to languishing than flourishing.
As a pathway towards improving our well-being and ultimately flourishing, Anna recommends that we need to get used to enduring pain and other negative feelings, physically and mentally. She recommends we embrace doing things that are physically, emotionally, or cognitively difficult. She encourages us to cultivate a life of comfortability with discomfort, and abstain from activities that give us quick and easy paths to pleasure before they risk becoming activities to which we become addicted. (On the beneficial role of negative emotions in our lives, see our episode with Todd Kashdan.)
An example of training ourselves to become comfortable with being uncomfortable is avoiding distraction. Anna recommends that we cultivate the practice of avoiding distractions, such as avoiding the temptation to check our emails or social media when we need to focus more on a more important task. This connects with getting comfortable with being uncomfortable because when we’re distracted, the mind often wants to move towards the thing distracting us.
In her work with patients, Anna has observed that when people abstained from their drug of choice, “they experienced flourishing”: “a palpable improvement in their mood, levels of anxiety, sleep, levels of concentration, cognitive abilities, and abilities to be present and live in accordance with their goals and values.” This led Anna to hypothesize that this process of overcoming addiction would be more successful than prescribing drugs or therapy – that if her patients abstained from their drug of choice for long enough, dopamine homeostasis could be restored.
Anna reports that through this process, many of her patients were “reborn” and “flourished.” She’s found this approach to be so powerful that she’s used it with patients experiencing depression, anxiety, feelings of alienation, and chronic pain.
Dopamine detoxing and fasting
The above experiences led Anna to recommend a practice she calls “dopamine detoxing” or “dopamine fasting”. This kind of abstinence involves reframing how we see pleasure and pain, which ultimately requires “a major cultural reframe because we have this notion in modern life that pain is bad and we should avoid pain at all costs.” Anna recommends that we “befriend pain,” by “intentionally do things that are physically and emotionally painful.”
This connects with homeostasis: “by doing hard things, we tell our bodies they need to make more dopamine to restore homeostasis.” Doing hard things creates a “friction that allows us to get a dopamine rush indirectly, which leaves us less vulnerable to the problem of tolerance dependence, withdrawal and addiction.” Enduring difficult experiences trains our bodies to produce dopamine in response, to restore homeostasis. We discuss examples, such as studies of humans that immerse themselves in ice-cold water baths and gradually experience an increase in dopamine levels sustained for hours before returning to baseline.
The painful stimulus doesn’t have to be physically challenging – it can be emotionally or cognitively challenging. Many people are aware that doing physically challenging tasks is good for our physical health and an increasing number of people embrace this – consider the rise in popularity of competitive physical activities like marathon running and activities requiring significant skills of tolerance such as cold water swimming. People tend to be less aware of the benefits of cognitively challenging tasks for learning – that learning is most beneficial when it involves greater cognitive effort. Few of us are aware of the benefits of emotionally challenging moments for our well-being. Anna recommends we embrace all these levels of challenge to flourish.
For building emotional endurance, Anna recommends we cultivate “a kind of patient acceptance.” Most importantly, we need to develop restraint in relation to the things to which we risk becoming addicted, such that we become normalized into a restrained practice that reduces our risk of addiction to a particular source of dopamine. For example, rather than watching another episode of our favorite TV show and potentially clicking “watch next” again, we need to try to cultivate what Anna calls a “patient endurance” of avoidance. She also says she’s received lots of emails from listeners about martial arts as a means of reframing beliefs about pain such that we see it as something that can play a positive and important role in our lives.
The Flourishing Question
We ask all our guests “the flourishing question”: What’s the one lesson on flourishing you want our listeners to walk away with, and what might be a practical step for putting that lesson into action?
Anna recommends that we take a counterintuitive approach when we experience negative emotions: that when we experience negative emotions, rather than doing what occurs to us most intuitively – to find a quick means of relieving the negative emotion – that we in fact do the opposite:
“‘If you find yourself in a moment of feeling anxious, low, or unhappy, and you instinctually want to reach for something to relieve that feeling, what I suggest you try is to do the opposite: something really hard in that moment which you really don’t want to do.”
The aim of this is to restore homeostasis, or what Anna calls “emotional relativity”:
“This is to see whether, by embracing doing something that’s physically or mentally very challenging, you can, through the theory of ‘emotional relativity’, find yourself feeling better afterwards.”
Examples of this could be doing strenuous physical exercise when we feel low, taking an ice bath, trying to solve a difficult puzzle, or making a phone call to initiate that difficult conversation we’ve been putting off with a friend or member of our family.
About our guest
Dr. Anna Lembke received her undergraduate degree in Humanities from Yale University and her medical degree from Stanford University. She is currently Professor and Medical Director of Addiction Medicine, Stanford University School of Medicine. She is also Program Director of the Stanford Addiction Medicine Fellowship, and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. She is a diplomate of the American Board of Psychiatry and Neurology, and a diplomate of the American Board of Addiction Medicine.
Lembke was one of the first in the medical community to sound the alarm regarding opioid overprescribing and the opioid epidemic. In 2016, she published her bestselling book on the prescription drug epidemic, Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop. Her book was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic.
Drug Dealer, MD combines case studies with public policy, cultural anthropology, and neuroscience, to explore the complex relationship between doctors and patients around prescribing controlled drugs. It has had an impact on policy makers and legislators across the nation. Lembke has testified before Congress and consulted with governors and senators from Kentucky to Missouri to Nevada. She has been a featured guest on Fresh Air with Terry Gross, MSNBC with Chris Hayes, and numerous other media broadcasts.
Using her public platform and her faculty position at Stanford University School of Medicine, Lembke has developed multiple teaching programs on addiction and safe prescribing, as well as opioid tapering. She has held multiple leadership and mentorship positions and received the Stanford’s Chairman’s Award for Clinical Innovation, and the Stanford Departmental Award for Outstanding Teaching. Dr. Lembke continues to educate policymakers and the public about causes of and solutions for the problem of addiction.
Her latest book, Dopamine Nation: Finding Balance in the Age of Indulgence (2021), was an instant New York Times and LA Times bestseller, and explores how to moderate compulsive overconsumption in a dopamine-overloaded world.
Anna’s website and recent work
· Anna’s website
· Stanford webpage
· Stanford profile and bio
· The Social Dilemma (Netflix) IMDB page
· NYT Review of The Social Dilemma
· TEDx talk on the opioid epidemic
· Selected publications
· Anna on Finding Mastery
· Anna on Huberman Lab
· Anna on Feel Better Live More
· Anna on Modern Wisdom
· Anna on Under the Skin
· Anna on Rich Roll