Modern Wisdom - #392 - Anna Lembke - How To Reset Your Brain's Dopamine Balance

Episode Date: November 1, 2021

Anna Lembke is a psychiatrist who is Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic at Stanford University and an author. Dopamine is a key neurotransmitter in our reward pathway. It tells us when to feel pleasure and pain, it can cause depression and anxiety, and it's being hijacked by the modern world. Phones, video games, porn, food, our world is filled with cheap dopamine, which in turn is making us miserable. Expect to learn how dopamine creates a see-saw balance of pleasure and pain, why cravings to use your phone are driven by dopamine, the truth about dopamine detoxing, how to reset your brain's dopamine balance, the most successful interventions for changing your relationship to dopamine long term and much more... Sponsors: Join the Modern Wisdom Community to connect with me & other listeners - https://modernwisdom.locals.com/ Get 50% discount on all products site-wide from MyProtein at https://bit.ly/proteinwisdom (use code: MODERNWISDOM) Get 20% discount on Reebok’s entire range including the amazing Nano X1 at https://geni.us/modernwisdom (use code MW20) Extra Stuff: Buy Dopamine Nation - https://amzn.to/3pL2Uw8 Get my free Reading List of 100 books to read before you die → https://chriswillx.com/books/ To support me on Patreon (thank you): https://www.patreon.com/modernwisdom - Get in touch. Join the discussion with me and other like minded listeners in the episode comments on the MW YouTube Channel or message me... Instagram: https://www.instagram.com/chriswillx Twitter: https://www.twitter.com/chriswillx YouTube: https://www.youtube.com/ModernWisdomPodcast Email: https://chriswillx.com/contact/  Learn more about your ad choices. Visit megaphone.fm/adchoices

Oh hello friends, welcome back to the show. My guest today is Annelemki. She's a psychiatrist who is chief of the Stanford Addiction Medicine Jewel Diagnosis Clinic at Stanford University and an author. Dopamine is a key neurotransmitter in our reward pathway. It tells us when to feel pleasure and pain, it can cause depression and anxiety, and it's being hijacked by the modern world. Fones, video games, porn, food, our world is filled with cheap dopamine, which in turn is making us miserable.

Expect to learn how dopamine creates a seesaw balance of pleasure and pain. Why cravings to use your phone are driven by dopamine, the truth about dopamine detoxing, how to reset your brain's balance, the most successful interventions for changing your relationship to dopamine long-term and much more. This is one of the most fundamental levels of understanding that I think everyone needs in the modern era. This is the chemical, which is being manipulated the most by the hyper-convenient, super-abundant world that we have about us. And it's a children in school need to be taught this. They need to understand

what dopamine is, how it plays a role in their lives, and how to control it. The excesses of pleasure end up causing us pain. And that paradox is something that I totally didn't realize. There is so much to take away from today. I really, really hope that you enjoy it. If you do, and you want to meet some other people who are also interested in the same things as you, like life hacks and productivity and optimization and culture and sense-making and learning new things, join the Modern Wisdom Locals community. Modernwistdom.locals.com. Over a thousand people have already joined and we're having some awesome conversations on there. There's discussion threads about every episode and you get to make new friends and also have conversations that

you don't need to worry about being cancelled for. ModernWizdom.locals.com. But now it's time to learn about dopamine with Annelambki. It's like one of those buzzwords at the moment. I've seen dopamine fasting and dopamine detoxes thrown around YouTube a lot and we're talking about imbalances in the brain, is it chemical, is it environmental? What's your favorite framework for explaining what dopamine is and how it affects us? Well, my framework for communicating the role

that dopamine has in our brain really has to do with the fact that pleasure and pain are processed in the same part of the brain. It's a part of the brain called the reward pathway. And pleasure and pain effectively work like opposite sides of a balance. So when we do something pleasurable, that balance tips to the side of pleasure. And we get a little release of dopamine in our brain's reward pathway, which is reinforcing and feels good.

But one of the overarching rules governing this balance is that it wants to remain level. It doesn't want to be tipped for very long to the side of pleasure or pain. And the brain will work very hard to restore a level balance or what's called homeostasis. But importantly, the way that the brain brings that balance back to a level resting state is first by tipping it and equal an opposite amount to the side of pain. And that's when our brain down regulates our own dopamine production and our own dopamine transmission, not just back to baseline levels, but actually below baseline levels to the dopamine deficit state. Now, if we wait long enough, you know, that's that feeling of wanting another piece of

chocolate, just one more video game, another drink, if we wait that passes and our balance is restored. But if we continue to repeatedly expose ourselves to highly reinforcing drugs and behaviors. Then, over time, that initial stimulus gets shorter and weaker, but that after-response gets stronger and longer, which is why typically we need more of a drug or more potent forms over time to get the same effect. Furthermore, what can end up happening is our balances can kind of get stuck on the pain side where we end up, I like to think of it as these neuroadaptation gremlins hopping

on the pain side of our balance, kind of camping out there. With we bum barred our brains with so much dopamine, that our brains have to compensate by way downregulating our own dopamine production and transmission. Then we end up in this chronic dopamine deficit state where nothing else is enjoyable. We're only focused on our drug of choice. We need to keep using not to feel good, but just to restore a level balance and feel normal. And when we're not using our drug,

we're experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and craving. What is the sensation of dopamine? How would you describe what it feels like for someone to have it and not have it? Well, dopamine fluctuates around this tonic baseline. So we're always releasing dopamine at sort of a constant steady rate. And it's really the way it fluctuates up and down below this

baseline level that affects the way we feel. Typically, when it rises above baseline level, then we have more dopamine in our reward pathway. We feel good. We can feel really, really good. We can feel even euphoric, or sometimes it's just a sense of calm well-being, or a sense of not being anxious. So it's all of those things wrapped into one. Whereas when dopamine goes below baseline, again, we feel restless, we feel anxious, we feel like something's missing in our life, and we have a lot of incentive and motivation to use that drug again in order to not just recreate that good feeling, but also just bring us back to a normal homie

stasis. Why do we have a dopamine balance? Is it adaptive? Well, it has been adaptive for most of human existence. If you think about it, our brains were evolved to approach pleasure and avoid pain. And that's been conserved over millions of years of evolution as we've lived in a world of scarcity and ever-present danger. But the problem is that now we no longer live in that world. We live in this world of overwhelming abundance, and we're very insulated from all kinds of painful experiences, such that what was once adaptive is no longer so. So I think that we really need to rethink the way that we live in this highly dopamine

overloaded world. Why is it? So if that's the case, if it's the case that we feel calm, sometimes at a moderate increase of dopamine and we feel comfortable, does that not mean that trying to feel calm and comfortable all of the time is inherently a wasted effort because you're going to go back to baseline eventually. Is that something that we can't chase? We can't be in that sort of calm, comfortable situation all the time? Yeah, I mean, you've really instituted what is essentially the bottom line of the way that pleasure and pain are processed in our brain. That really any kind of for any kind of reward

seeking, there is a cost and that cost is the come down and the pain, and that the harder we try to be in that place of comfort and reward, the larger the price that will pay, the greater the dopamine deficit state, such that ultimately there is futility in seeking out reward for its own sake. Is there a different dopamine set point for each person? Is that a tolerance or degrees and dopamine releases? Yeah, it's a great question. There is some science around this.

For example, this pleasure pain balance metaphor assumes that we all start off with the same level balance, but it's probably not true. There are probably people who, you know, metaphorically start off with a balance that's tilted slightly to the side of pain. That could be because of people who live with chronic pain. That could be people with depression. There are studies showing that people with depression probably have lower baseline dopamine levels or might be less

sensitive to typical rewards and might need more of certain types of rewards in order to get their dopamine to rise up above baseline levels, all of which potentially makes those people more vulnerable to the problem of addiction as they seek out rewards to just feel normal, not necessarily feel good. Why is it that people that are in chronic pain don't find pleasure superbly easily then? If you're saying that it's one side of the same seesaw, the people that are in chronic pain should be able to feel amazing off just a tiny little glimpse of something that's nice. Is that not the way it works? No, remember, one of the overarching rules governing this balance is that it wants to preserve

homeostasis. So it wants to go back to whatever that baseline is, and it will work very hard to do that. I mean, there are, you know, evolutionary just-so stories for why that is. But essentially a person with chronic pain, who starts out in pain, their physiologic system will want to return to that baseline. So for example, if they take an opioid to try to get out of pain, that will initially work.

But over time, they'll need more and more of that opioid to get the same effect. And ultimately, the initial response to the opioid will get weaker and shorter in duration and the after effect. And this is really probably the most fascinating aspect of this pleasure pain balance is that after effect gets stronger and longer. So with repeated exposure to the same or similar pleasure stimulus, we end up in a deeper dopamine deficit state. It lasts longer, it goes further down.

So a person with chronic pain has to experience that pain below, even beyond their baseline pain before returning to their baseline pain. So in other words, there's no free lunch, what goes up must come down. And if you start out in chronic pain, you're also subject to the same problems of tolerance, needing more and more to get the same effect, and the dependence and withdrawal, which are

essentially this dopamine deficit state. It's a vicious asymmetry, the fact that you need more and more to gain less and less pleasure, but the more and more will incur an even larger power-low return of depression and feeling bad on the other side. That's exactly right. I love your terminology of vicious asymmetry. When we think about why on earth would Mother Nature do that to us, it seems so cruel. But if you think about it from the perspective of millions of years of evolution, and that

for most of humanity, we've lived in this very dangerous world with very limited resources and we've had to work very hard to get those resources in order to survive, it makes perfect sense, right? If you have a pleasure pain balance, which with a single exposure will give you just a little bit of pleasure, but then afterwards will give you pain, then you're going to be very motivated to keep going and find that next oasis or find that next berry bush. It's what has turned us into these constant seekers, never happy with what we have, always wanting more, except that our ability to be constant seekers and always improve on our

lives and on our circumstance has essentially allowed us to transform the world. This is really, you know, we're living in the anthropocene in the sense that this is the first time in human history that we have used our brains and our technology to create more abundance than we could ever need or ever want. And not just abundance, these highly addictive, highly reinforcing, feel good drugs and behaviors, essentially making us all vulnerable to addiction, because our primitive wiring wasn't adapted for the modern ecosystem. Have you heard the quote, after copulation, the devil's laughter can be heard?

I haven't, but that's good. Because a lot of men report, how do you say, acute post-coital depression is something that after guys have sex, sometimes you feel a bit existentially. Once you've finished up, I can't remember, it's someone far too important and impressive, like Jung, Jung said, after population,

the devil's laughter can be heard. It sounds so apocalyptic. But that was something that I thought that was interesting. Why after something that's so enjoyable, does something occur afterward that is a bit unenjoyable? And it's because if you only ever had sex once, then you probably wouldn't have very many grandkids. And we are grand children optimizing machines.

So the sex just being a little bit more uncomfortable or dissatisfying than you thought, that meal just being a little bit more uncomfortable or dissatisfying than you thought, that meal just being a little bit more unfulfilling than you'd anticipated. Those things, they make you want to go again. Yes, although let's tease this apart a little bit because I think there might be, I would wonder when that quote, that quote was said because it does get to the issue of sex addiction and pornography in kind of a nice segue, I think it's important to talk about because I think it's a huge and growing problem and we don't talk about it enough. So as long as you're

comfortable going there. Take me that on it. Okay, all right. So I mean you know when we have an orgasm it releases a huge amount of neurotransmitters in our brain including dopamine. It is in and of itself a chemical reinforcement. You know, whether we're having sex with another person or sex with ourselves, the orgasm is reinforcing. And we do develop tolerance to that reinforcing effect. So if we repeatedly have orgasms over a short period of time, they will be less reinforcing

with each subsequent orgasm. And there's of course this natural refractory period too, where it becomes even impossible to have an orgasm if we're condensing so many orgasms in a short amount of time. So orgasms can very much work like a drug. And I think, you know, in the modern world where sex is almost the last bastion of physical things that we still do, where we are in our bodies and connecting with our bodies, it has become, become a really vulnerable place for sex addiction. So when I think about, you know, the devil's laughter after, after orgasm or intercourse, especially, and you say for men, but I guess this could include women.

I think where that's probably amplified is when sex is just an end in itself, and it's not an expression of intimacy and love between loving partners, but it's really a way to get an orgasm. And I think when sex becomes that and only purely that, especially in large quantities, then it really becomes all about the dopamine and it becomes about that release divorced from other meaning.

And then of course, we're going to go into that dopamine deficit state and it's going to be even more so. Then if we were, let's say having sex less frequently and only in a way that's kind of sacred or sanctified. So maybe that's a little bit too holier than now. But those are sort of my thoughts on it. I'd be curious to hear your thoughts. What I think is interesting is when thoughts on it. I'd be curious to hear your thoughts. What I think is interesting is when we've got two elements going on here. You have the experience and the subsequent physiological impact and the experience, the phenomenological experience of that impact. But after that event, you have the retrospective psychological way that you label the experience overall. That's the thing that I think's really, really interesting.

What does it mean to think back on a situation that you had and to frame that in a different way, to feel shame or guilt or envy or dissatisfaction? This interpretation, how does that slot in? Yeah, I mean, I think that's exactly right's exactly right that that's that's what I'm trying to get at but you said it even better. I mean, the meaning that we give to that sexual act has a huge impact on how we feel about it, how we feel about ourselves. You know, sex itself, I mean as you go through life, the more orgasms you have, it really is like a drug.

We inevitably build up tolerance. We need more and more potent forms to get the same effect. You know, the classic trajectory of my sex addicted patients is that they might start out masturbating to sort of, you know, vanilla, college girl pornography. And then 10 years later, you know, it's, it's something much more deviant than that some say to mass acoustic thing. And it's not really because they're, they're violent people or they have a preference for that. And nearly it's that they need some, something more to, you know, jazz it up because they become tolerant. And, you know, and that's, and we're living

longer now, you know, then we ever did before. Like when we died at 30, and that's, and we're living longer now, you know, than we ever did before, like when we died at 30, it was like, well, you only had a little bit in about a time to get enough sex in there. And now, why is it that everyone isn't addicted to sex then? If that's the case, if all the time, the moral gasms that you have, the more that you need to be able to get the same level of pleasure from them,

surely that just puts everybody on a path to sex edition, but not everyone has that. No, not everyone has that, because part of what makes somebody addicted is how hard they're willing to work for their drug. So, my neuroscience colleague, Rob Malenka, he once summarized that beautifully. He does a bunch of animal studies.

And he said, yeah, you know, basically, I can measure how addicted a rat is by how hard it's willing to work to get cocaine, how many times it's willing to press that lever, you know, to get a little scoosh of cocaine. And that's really what separates people who become addicted to a given drug from those who don't. At some point, most of us kind of tire out. They say, you know what, it's not worth it.

Like chasing that all around, I'm done. Oh, so there's a cost-benefit analysis that's going on along with the pleasure pain dynamic? Yes. Yes. Yes. Yes. And, and those people who are like relentlessly trying to oppose those Neurodaptation Gremlins and bring that balance, not just level, but tweak it down to the side of pleasure. And they'll just keep that until they can do that. Those are the people who become addicted. Plus, don't forget there's inter individual variability and drug of choice. So what works for one person is not going to work for another person.

I mean, as I talk about in the book, I got addicted to romance novels. I started with the twilight saga. And I eventually, you know, over time, graduated to socially sanctioned pornography for women, which is these erotic novels, not consistent with my values, really embarrassing to talk about. But, you know, I didn't really see it as it was happening. I sort of only once I sort of got to, you know, 50 shades of gray at two in the morning. I was like, why am I reading this? You know, and then I stopped and I went through withdrawal. I was really hard for me to stop. But I could really see that I had become addicted. But interestingly, I've never been tempted by alcohol.

It makes the tired and gives me a headache. Caffeine, I would love if caffeine woke me up. It doesn't do a thing for me. So you've got to take into account that we've got these different types of drugs that work and on a population level totally makes sense, right? You would want, you're tribe, you would want one guy to be out there chasing raspberries and you would want someone else looking for meat and somebody else rounding up, I don't know. So we have a small amount of variability in what are the things that get us going? What are the addictions, the small sorts of addictions that we have? And that's adaptive at a group level because it spreads the pursuits so that you have a hedge,

one person's getting fruit, one person's getting vegetable, one person having sex all day. I think so. I mean, I think so, you know. That makes a lot of sense. I have a confession to make with regards to the dark romance stuff. I'm on the cover of about 15 dark romance novels. So, depending on what era it was, you may have read a book that's got my face on it. I probably have. I've been through many of them.

Which would be at first. Which is super embarrassing. We're all friends here, Anna. All right, so what else is it? What about serotonin? Is there a role for serotonin to play? Are there any other chemicals that we need to understand embarrassing. Let's see. We're all friends here. All right. So what else is it? What about serotonin? Is there a role for serotonin to play? Are there any other chemicals that we need to understand to kind of give us a full picture?

Yeah. So serotonin is really interesting. I think it's really associated with feeling connected to other people, that feeling of belonging, being part of the tribe. If you look at drugs like LSD, basically what they do is they cause a huge surge of serotonin, you know, in these limbic structures in the brain. And people will often report this kind of connectivity, forgetting the cell, feeling, you know, this peace and this closeness, which is of course a really wonderful, wonderful feeling.

So again, you know, all these drugs work in a slightly different way, Norepinephrine, also a very potent monomy, neurotransmitter, which is really important not just to enhance mood, but also for paying attention. So stimulants often work on this Norepinephrine pathways, and on Norepinephrine, and they get our frontal lobe really, really focused and we get really good at sort of automatic kinds of wrote tasks. So all of these chemicals are involved,

but interestingly the final common pathway for all addictive substances and behaviors is dopamine. And you know, that essentially the currency that neuroscientists use to kind of measure the addictive potential of something. Is dopamine detoxing legit then? You know, I think so. I was doing it in my practice long before it became popular

in social media. I've been practicing psychiatry for 25 years. And it was something that I just sort of happened along early on. I would have patients come in, primarily seeking help for depression and anxiety. And early on, I would prescribe the man a depressant or do psychotherapy.

Many of them who were also actively using drugs and alcohol didn't really get much better. Then what I discovered, and this is also informed by the neuroscience, because some studies show this too, that if instead of trying to initially target their depression anxiety, I got them to stop their drug of choice, what happened was, and I asked them to do that for 30 days, so a 30-day absence trial, in the first 14 days they felt much worse because they were experiencing the universal symptoms of withdrawal, but by 30 days, they really almost universally endorsed feeling better than they had in a really

long time, less anxious, less depressed, better able to sleep. And when you look at that from the perspective of the neuroscience of addiction, it really makes sense because essentially what's happening is that the substance itself is driving the depression and anxiety. That huge release of dopamine, the reward pathway is invariably followed by a decrease in dopamine transmission below baseline. That dopamine deficit state, which is experienced as anxiety and depression, then we reach for our drug again because we're feeling bad.

And temporarily, it feels like it alleviates that. So it's like, oh, this is making me feel better. I should keep doing this. But in fact, the drug itself is what is driving that dopamine deficit state that makes us anxious and depressed in the first place. So the intervention is to stop using the drug, allow your own dopamine transmission and other feel good hormones to upregulate. And then if you go back to using your drug of choice, make sure that you use it in moderation and that you don't press too hard on that pleasure side of the balance so that you don't end up in that dopamine deficit state.

What else should people do? Let's say that someone wants to do a good dopamine detox other than abstaining from whatever the behavior or the drug is that they're currently addicted to. What else do you advise them to do during that period? Well, you have to also beware of triggers and also eliminate those triggers. So if you're somebody who's addicted to video games,

like a patient of mine, and you find that once you go on YouTube and you start watching other people play video games, you're more likely to play a video game yourself, then you should probably eliminate YouTube for that month. If you're somebody who's trying to quit smoking cigarettes, and you find if you have a casual drink with friends, you really want to smoke a cigarette,

you should probably eliminate alcohol for that month as well. And from the perspective of neuroscience, it makes a lot of sense because we don't just get a release of dopamine with our drug of choice. We also get a release of dopamine with any reminder of our drug of choice. So for example, my patient addicted to video games,

when he watches other people play video games, that actually releases a little bit of dopamine in his reward pathway. And he feels a dopamine surge. But right after that, it goes into a dopamine deficit state. He feels craving and that craving is the physiologic drive that sends him to want to go and play the video game, which is why you know, alcohol, synonymous often talks about avoiding people, places, and things in that time when you're

trying to avoid the drug as well. What's happening in the brain when we get a cue and a craving? What's going on? So when we get a cue for our drug of choice, that is a reminder, any kind of reminder of the drug, like an alert on our phone that someone texted us, we get dopamine released in our reward pathway. So that in itself is rewarding,

but that reward is followed by a dopamine deficit state. And that dopamine deficit state, remember, that is craving. That is what makes us then want to go out and get the drug. It's the deficit that drives the motivation, which is why people often talk about dopamine as not really being just about pleasure. It's also about motivation because it's that dopamine deficit state and that balance to the pain side that is an incredibly powerful physiologic drive that gets us to do the work to get our drug. What does social media and technology do to our dopamine levels? Have you looked at this?

Yeah, so social media essentially has drugified human connection. So social media essentially has drugified human connection. We are evolved over millions of years to want to connect with other people. We are tribal creatures, we're social animals. My colleague Rob Malenka recently showed that oxytocin, the love hormone, when it's released, binds to dopamine neurons in the reward pathway and causes a release of dopamine. It's not really a surprise to most of us.

We are motivated to connect and our brain gets us to do that by releasing dopamine, so it feels good to connect. That means that all of those meta-experiences that tell us we're making a connection also released dopamine. So we have a dopamine release when people like us, we have a dopamine release when people agree with us, we have a dopamine release when people enhance our reputation. We have a dopamine release when we're experiencing the same emotion at the same time as other people. So that's very powerful, which is why social media

can really be like this frenzy because when we are getting outraged at the same time as somebody else that releases dopamine when we're laughing at the same time as somebody else that releases dopamine when we watch somebody watching a video and we have the same reaction as they have to that video that releases dopamine which explains the mystery of why we would ever want to watch people watching other people, but it makes perfect intuitive sense. Reaction videos explain to you exactly. Yeah, right. But what social media has unfortunately, the potential to do is actually drugify human connection by contributing to all of the features that make something addictive, and that is access, quantity, potency, and novelty. So if we have easy access to our drug of choice, which we do with social media, then we're more likely to get addicted,

especially when you compare that to prior to social media, what you had to do to go out and meet people, right? First of all, you had to get off the couch, you had to go out and find the people. Most of them are gonna be average looking and average interesting, right? It's not like that now. You know, you can just stay on your couch and swipe right or swipe left, swipe left.

Quantity, right? So if you think about almost all traditional drugs and alcohol, I mean typically eventually you run out and you gotta go out and get more. TikTok never runs out. If you look at potency, how do we make things more potency? We combine, drugs together, and that's exactly what social media has done. It's combined beautiful images with sex, with gaming, with gambling, with music, with flashing lights to make it all the more potent. And then finally novelty. Dilkamine is very sensitive to anything that's new, especially if it's something that we liked before, but it's a slight variation on that.

And these AI algorithms are basically learning us, figuring out what we liked before, and then suggesting something that's similar but slightly different, which automatically triggers dopamine, automatically triggers our search and explore function, our treasure hunting function, you know, when we're often running looking for that next slightly better thing. And then finally, social media has enumerated things. It's given it numbers. And for reasons we don't fully understand, when we enumerate things or when we have rankings or number of likes, that's really reinforcing.

We tend to like that. Why is it that some people find certain things rewarding in terms of how we interpret them? So for instance, one person might really get g'd up by gaining followers on Instagram, but another one might be really interested in shooting people in a video game, and another one might be funny cat videos. Is this more of that genetic spread from the group, do you think, or is there something else going on? more of that genetic spread from the group do you think or is there something else going on?

I think it's mostly just natural drug of choice, you know, that some people are just going to enjoy certain drugs and not others and that there's variation in the human population, but some of it too has to do with our social networks. So addiction really does spread like a virus and we're more likely to try and use drugs that people in our social network are trying and using. So if you hang out, hang out with a bunch of video gamers, you're more likely to get online partially because it's socially enhancing and binds you to them, which is also important for people. Ah, behavioral interventions, the only solution then, a dopamine detox and you spend time away from your drug or your activity of choice, is it just down to behavioral interventions

or is the pharmacological solution for this? Can we pray the addiction away? What's going on? Yeah, so addiction really is the quintessential biopsychosocial disease, which means that we need biological interventions, psychological interventions, and social interventions, behavioral interventions, like a dopamine fast, sort of cross all of those because biologically,

what we're doing is allowing reward pathways to reset themselves, allowing ourselves to look back and see true cause and effect, but also in order to accomplish that, we often have to change our environment or change the people that we hang out with. So it's also psychological and social, but that's not the only intervention.

We can also use chemicals to help people stop using. So for example, now Trekzone is an opioid receptor blocker, which can be used to treat people, not just with opioid addiction, but also with alcohol addiction. Alcohol is mediated in part through our endogenous opioid system. So by blocking our opioid receptors, we make the alcohol less reinforcing, which means people can use it, not just to help them stop drinking altogether, but actually to reduce

the amount that they're drinking. And that's a really nifty tool because a lot of people don't want to stop altogether. They want to use in moderation. And when they use Naltrexown, what they say is that I'm just better able to stop it two or three drinks rather than progressing to six or seven drinks. I also just want to jump in and emphasize that addiction really is a spectrum disorder, mild, moderate, and severe.

And this dopamine fast intervention is only really going to work for folks who are sort of on the borderline between being addicted and being a little addicted, or maybe a mild to moderate addiction, in terms of just asking people to do it on their own. For people who are more severely addicted, the dopamine fast is equally important, but they probably won't be able to do it entirely on their own. They may have to go into

a rehab, a residential treatment center, or they may have to be given medications like an opioid receptor blocker in order to even make it possible for them to abstain. So I just really want to emphasize that. We're talking about a spectrum disorder. And my book is mainly targeting people who are a little bit addicted, although the ideas in their apply really to addiction more broadly as well. Is there a certain type of person who's more likely to become addicted or more likely to have multiple addictions across multiple domains? Yeah, so are innate vulnerability to addiction varies and some people are definitely more vulnerable than others.

I'm about 50% of the risk of getting addicted is biological or inherited. So there are studies showing that if you have a biological parent or grandparents with addiction, you are at increased risk compared to the general population of becoming addicted yourself, even if raised outside of that substance using home. So there are really interesting adoption studies

showing that when people with a biological parent with addiction are raised in a non-substant using home, they are increased risk of developing an addiction themselves. Do you know if a cross is domains? Do you know if someone who has an alcoholic father is more likely to be a gaming addicted son? That's very interesting. I don't think we have data on that.

These data are mainly looking at alcohol use disorder in fathers and sons, but that would be great to look into. What we speculate, though, is that this is a general vulnerability to addiction rather than a specific vulnerability to only one substance. And we know that because many times when people will get in recovery from one addiction, one of the dangers is cross addiction that they'll go on to become addicted to something else. Hmm. What about psychological life events? So we've got 50% of this is heritable because behavioral genetics is just this emerging

immutable bastard of a field that keeps on telling everyone that perhaps the freedoms you use to think that you have, they're not quite as free as there were. What about psychological life events, stuff that happens in early childhood are the things that predispose us to addictions? Yeah. So there are certain types of mental illnesses that make people more vulnerable to addictions separate from the illness of addiction itself. People with bipolar disorder are more likely to get addicted, or any

kind of intense emotion dysregulation, certain types of anxiety disorders, attention deficit disorders is correlated with increased risk of addiction. But not just innate mental illnesses, also early life experiences, like early life trauma and epigenetics can contribute to addiction risk. We know that people experience significant trauma in early life, art increased risk to go on and develop addiction, but also other environmental factors, like living in poverty increases the risk of becoming addicted, unemployment increases the risk of becoming addicted. And then very importantly, access is really important.

So if you live in a neighborhood or a region of the country, or a society where addictive substances and behaviors are more readily available, you are more likely to get addicted. And I think that's one of the most important risk factors today, but it's seldom appreciated. Well, that's Robert Ploman argument where he talks about, you can have all of the genes for alcoholism,

but if you're raised on a desert island that doesn't have any alcohol, it doesn't come to fruition. You can have 100% likelihood of being an alcoholic, but if you're not raised around any alcohol, it's not happening. So yeah. Exactly. Yeah, and the converse is true too.

You can have very little risk for becoming addicted to alcohol. And yet, if you're constantly surrounded by it, 24-7 is true too, you can have very little risk for becoming addicted to alcohol. And yet if you're constantly surrounded by it 24, seven and tempted and encouraged to use it, and you use enough of it, it can change your brain and you can become addicted to alcohol. So I think that that's right. It's this interesting stress vulnerability diathesis, which is true for most mental illnesses, whether it's anorexia nervosa, or psychosis, or addiction, it's this interplay between our innate God-given

vulnerability and the environment that we live in. What are some of the other risk factors then? Loneliness, you mentioned poverty is one of them, just having a family or having a dog, does that make you less likely to be addicted? Have you looked at these? Yeah, yeah. So in general, people who have intimate, supportive human connections in their lives are at decreased risk for becoming addicted. People who have meaningful work and are gainfully employed are at decreased risk of becoming

addicted. People who actively participate in religious organizations are at decreased risk of becoming addicted. But again, remember, these are large epidemiologic studies. So these are from a population level. On an individual level, nobody is immune. You can have the best family and the best job and be the most spiritual person on the planet

and you can still get addicted. What's happening with the dopamine levels to do with religion and family and connection and jobs and stuff? What's happening with the dopamine that's permitting those people to be less susceptible? Well, probably what's happening is that they're getting their dopamine in more adaptive ways, right? I mean, one of the things I talk about in the book is what are some healthy and adaptive sources of dopamine? And certainly intimate supportive human connections is a really essential

and important and healthy source of dopamine. But also, meaning and purpose in life, you know, having work that you believe in and that keeps you busy and that you feel like is valuable for the world. That's very important to giving people, you know, making them less likely for them to get addicted. General psychological resilience really helps, and that's typically fostered by other wellness practices, like for example exercising and making sure that you're physically healthy, getting enough sleep. There's a great acronym in alcohol synonymous called

Halt. It stands for hungry, angry, lonely, entire and it's just a nice way to warn people that when you're hungry, angry, lonely, entire, you're at risk of using your drug. So try to be aware and take care of those things before you get to that point. That's amazing. I'm trying to work out. You mentioned about meaning and purpose there.

And some of the more ephemeral, difficult to define longer term life goals, some of these are quite conservative views, things to do with family connections and so on and so forth. A lot of the time what people are trying to chase, whether it be through internet use or drug use or finding a new game or getting themselves into a community of some kind or whatever it is, they're trying to chase some sense of pleasure. And if dopamine is the primary key pleasure giving hormone that we have in our brain. Hormone, chemical?

Yeah, chemical neurotransmitter. Neurotransmitter, yeah. Ah, I knew that. If that's the case, starting a fresh, trying to really step back from the urgent day-to-day things that you're doing with your life, and actually trying to connect to a deeper sense of purpose. That must be one of the most robust ways that you can actually ensure that you have a scalable continuous sense of pleasure throughout the remainder of your life to try and find and really really genuinely deeply connect with the things that you are doing and it seems like. What we have in a hyper convenient world is a very shiny object that sits over the top

like a shiny glaze that people continue going back to that doesn't allow us to get to the much more replicable and consistent deeper meaning that you get underneath. Is that right? Yeah, I mean, I would agree with that. I, you know, the pursuit of pleasure for its own sake ultimately leads to Anhedonia or the absence of pleasure in anything that we do.

And so, on some level, pursuing pleasure is a mistake. I mean, we're constantly being told that we should pursue pleasure and that there's pleasure out there waiting for us and that if we're not happy or, you know, ecstatic, then something's wrong with us, we need to get new friends or a new job or a new spouse. But the truth is that, that again, just this relentless pursuit of pleasure actually makes us miserable.

And what we need to do is stop looking for it, stop looking for that dopamine hit and essentially try to find a way of being in the world that isn't primarily focused on rewards, but instead, you know, fosters a different meaning and purpose for being. And you, you know And you hit on it exactly. Even people can get this in different ways, but finding a sense of purpose in the world or a reason for living, typically this is living for others that can really make us feel like it's all worth it

without necessarily making us feel that we're experiencing pleasure. But really, almost more that we can endure the pain of being alive because being alive is actually pretty painful and that it's worth it. It's worth sticking around for because we want to be here to accomplish some greater goal or we have, we believe that we have a some meaning and purpose in life. So I do, I do really think that that's really important and that we need to shift our whole frame around, you know, this mirage, really, of the pursuit of pleasure.

Unfortunately, it is the natural byproduct and the dark side of capitalism, you know, a successfully capitalist society will ultimately tell us that the highest good is to consume and that the more we consume and the better the stuff that we get, the happier we'll be. And of course, it's not true. Is dopamine related to the hedonic treadmill then? Oh, absolutely. I mean, it's fundamentally related, right? Because if we just this relentless pursuit of dopamine hits ultimately drives down our own endogenous production of dopamine and we end up less happy than where we started. Whereas the pursuit of pain, and I use

that term very broadly to mean not just physical pain, although I include that too, but also just doing things that are hard and inconvenient and require effortful engagement. Those are the things that lightly press on our pain side and ultimately cause our own endogenous re-regulating mechanisms to upregulate, dopamine and norepinephrine and serotonin, all those feel good hormones, but not with the initial stimulus. They're the delayed reward as the compensatory or healing mechanism for the initially painful stimulus. The brain's managed to turn everything into a drug, hasn't it?

The end result, the net end result of everything is neurotransmitters and different levels. So whether that be buying the £200,000 car and then thinking, oh, well, that one hasn't quite got put the £250,000 car, that's right. And it'll be, once I get the new lights in the driveway and then thinking, oh, well, that one hasn't quite got put the 250,000 pounds car. That's right. And it'll be once I get the new lights in the driveway and then when I upgrade the house, someone I do, and that is just the dopamine system playing out in real life. But when people talk about the fact that keeping up with the Joneses, what is that? It's the dopamine system existing in the real world, manifesting in people's purchasing behaviors. Yes, exactly. I mean, you're exactly right. We created this world and it's sort of the natural

endpoint of our pleasure pain balance because we're constantly, we're wired to constantly seek out pleasure and avoid pain. But I'm hopeful that it's not the end of us, although the data would suggest it just might be 70% of global deaths are attributable to modifiable risk factors that is to say smoking, diet, and lack of exercise. So if we don't rapidly turn around the way that we're constantly consuming, then, you know, we're probably going to go extinct. So we're going to sort of titillate ourselves to death. Humans are amazing in their adaptability. I am optimistic that with these kinds of conversations, we're going to say, wait a minute, we need

to change something here. What's a new way to orient on this, as you say, hyper-convenient world? Let's talk about the other side of the sea, so then, how can people utilize pain effectively or discomfort to make their lives better? There's a whole science of hormesis, and hormesis is Greek for to set in motion. And the idea of hormesis is that by exposing ourselves to mild toxic or noxious stimuli,

we can actually become stronger and heal. And the way that works is that when we expose ourselves to noxious stimuli, and examples would be extreme temperatures, starvation, exercise, exercises and noxious stimulus at the cellular level. What that does is that sets in motion our body's own helium mechanisms and it tells our body, oh boy, there's an injury here. You need to upregulate dopamine serotonin orpenephrine, all those feel good hormones.

And so, hormises is actually a way to press on the pain side of the balance in order to get the gremlins to hop on the pleasure side to reset the hedonic set point to pain side of the balance in order to get the gremlins to hop up on the pleasure side to reset the hedonic set point to the side of pleasure. And it really does work and I think it is the necessary modus operandum for this dopamine overloaded world. We have to intentionally and willfully invite pain into our lives. And that means we need to do things like exercise, take cold water baths, do things that are effortful and hard, expose ourselves to things that make us anxious. And we have to do it on purpose. And we have to do it on a regular daily basis in order to keep our

hedonic set point to the side of joy. What are some of the discomforts, pathways that people might not realize are. So it's something like trying to learn a new language or trying to write an article or trying to learn something, these the same, are there any others? Yeah, anything that requires a kind of sustained concentration, and by the way, that's getting harder and harder because we're constantly interrupting ourselves with intrusive thoughts of wanting to check our devices. So putting all the devices away, turning off all the alerts, and just allowing ourselves to try in the moment to focus,

and to notice when we're interrupting ourselves, but to not let ourselves be distracted with something else, and to try to stay in that moment, write it out, and then continue to concentrate. That's a simple example, to do something creative, or to read something that's kind of difficult, or learn something new, learn a language, those are all learning is a great, great example.

Other things can be things that are just boring, right? I mean, we're so, we've sort of lost the ability to be bored, we're so constantly entertained, whether it's music pumping in one direction or what have you. So just kind of letting ourselves, you know, in some ways, some people call it meditation or breathing or just going for a walk without headphones in, allowing ourselves to be bored, anxious, paying attention to the constant ruminations of our own brain, which are mostly boring and annoying

and negative. But, you know, instead of trying to just drown them out, just saying, okay, I'll be, I'll let's be curious about that and try to learn something about ourselves in the world. Try to focus on the world. So I think we do so much trying to escape into a fantasy world and pay less and less attention to our immediate environments, but just try to like pay attention to the environment and tolerate the distress of being in the moment. One of the things I think is important to emphasize is, you know, there's this kind of language like be here now and be in the moment. And when I was in college, I kept trying to do that and thought I was doing it wrong. Because every time I would do that, I was like, I hate this feeling. Being

here in the moment, it's miserable, it's boring, it's awful. And I thought I was doing it wrong somehow compared to other people because I thought, well, if I could just get this right, I would feel good. But what I finally realized is no, being in the moment is it's hard. It is all those awful things, including being bored and being anxious. And that's kind of the point that letting ourselves be here now and tolerate the distress of being alive is something that we need to do on purpose. What's happening in the brain? We spoke about smartphone addiction. What happens when we have that desire to check our phone? Let's say that the notification hasn't gone off, but we have a compulsion. What is that? Is that myelination? Is that just that we have a bunch of very well rehearsed pathways in our brain that wants us to do it? Or is there something else that's thrown in balance? What's going on?

brain that wants us to do it or is there something else you throw an imbalance? What's going on? I think basically what's happened is, you know, we've gotten into the euphoric recall loop. So people with severe addiction will often talk about euphoric recall, have their own memory of using itself becomes a trigger that then triggers cravings and drives use. And that can happen with all of us, like for example, with the phone where suddenly, you know, we have, and part of craving is, with the phone, where suddenly, you know, we have, and part of craving is, by the way, intrusive thoughts. So it's not like we intentionally have the thought, the thought just barges in on our current thought process. And we can

have that all the time with our phone like, oh, you know, I wonder, so this is my, we don't have alerts, which is like, oh, I wonder, I wonder who emailed me. I wonder, you know, I wonder who texted me. And then that's essentially euphoric recall. And that drives dopamine up, followed by dopamine deficit, followed by craving. And then we're really in physiologic withdrawal. And we feel like this feeling can only be resolved by my checking my phone. And indeed, we check the phone. And it does temporarily resolve the feeling because now we get a bigger hit of dopamine and we've restored homeostasis, but right afterwards,

it's going to drive it down even further, which it sets up these loops. So euphoric recall is like a self-perpetuated, self-created cue. Yes, exactly. Fuck, the human brain is so great. And then there's some things and you're like, why is that there? Who put that in there? That's such a stupid feature. Yes, I know that's it's so true. But again, I just look at it from an evolutionary perspective.

Like if you, you know, we're sitting around, you know, and you eat in all the berries and like, and he just could chill out there for like a week That would not be good, right? You would you would probably starve to death because but he wouldn't have gotten up and and put enough effort into finding the next berry bush or Whatever running away from the lion. So I just think it's you know, it's how we evolved for a world of scarcity But as you say, it's really messed up for our current ecosystem What would you give people as advice, overall, to keep dopamine under control? Let's say that someone doesn't have a outstanding use addiction. Maybe sometimes they spend too much time on the phone. Maybe sometimes when they're on a night out, they struggle to not go from five

drinks to 10, but just a very sort of standard user of dopamine. What are some of the ways that people can, the habits that people can take away that they can instantiate into their daily life? Yeah, well, I do recommend starting out with a dopamine fast in order to restore homestay static baselines. And if you can't do a month, can you do two weeks? You know, in my experience, to really reset reward pathways, it does take a month of not using do two weeks? You know, in my experience to really reset reward pathways, it does take a month of not using our drug of choice. But if you can't spare that, do

a couple weeks. If you can't even do that, just do a single day. And notice in that day, how you will go through experiences of craving, intrusive thoughts, you fork, recall, triggers, how hard it is, how you'll be restless, anxious. I think just becoming mindfully aware of that process is a good and helpful first step. Then when we go back to using, keep in mind the balance and the gremlins and try to use in moderation so that you don't get into this vicious cycle

of too many gremlins hopping on the pain side of the balance so that you're in this dopamine deficit state where you're basically net negative, and you have to keep using just to feel normal. And ways to do that are to engage in pleasurable activities that are not too potent and to do it not too often, so that you leave enough space in between for the gremlins to hop off and for homeostasis

to be restored. Certainly, once we're in today's use of it's much harder to keep our balance in check. And I would also add that a lot of times people would be like, well, I only use cannabis once a week, but I only use alcohol once a week. And I only use poppers once a week, but at the end of the week,

they've used something every day. So you also want to be mindful of that. And what we're really talking about is that you want to have two or three days at least every week where you're not using any kind of potent on rewarding behavior. And again, that's all to leave enough time for homeostasis to be restored. And then you want to put, you know, self-binding strategies in place. These are going to be physical or metacognitive. That's things like not keeping your drug easily accessible in your home, or putting your phone on grayscale.

These are all things people have talked about to make it less potent or deleting certain apps or keeping a careful record. Anything that kind of keeps you accountable, but also puts a little bit of a pause between a little bit more friction, exactly between you and your drug of choice. And then a meta cognitive strategy that I find is really useful is telling the truth. If we force ourselves to tell the truth about what we're doing, where we've been, what we've consumed to other humans, we're much more likely to be truthful with ourselves. And also, there is evidence that telling the truth, which is an active and

engaging and difficult thing to do, probably up regulates or potentially up regulates the prefrontal cortex, that big gray matter area behind our foreheads. And the prefrontal cortex is really important for helping us regulate our pleasure pain balance. So telling the truth about things large and small, what I call radical honesty, is really, really important for being able to delay gratification and also hold ourselves accountable, not just to our past selves, but also our future selves. Is that why vulnerability and opening up to people can sometimes inherently feel pleasurable? Yeah, so as I said before, deep human connections are a really healthy and adaptive source of dopamine.

And one of the ways to create intimacy is to be honest with people, especially when it's hard to do, especially when we're telling them something about ourselves, which casts ourselves into somewhat negative light, or makes us look, you know, not as awesome as maybe we would like to look in their eyes. And we always think that when we do that will like people will run away from us. But in fact, the opposite happens. People experience a shared a sense of brokenness and a shared sense of vulnerability and actually feel closer to us. Let's say that someone's had a behavioral addiction.

It could have involved a substance or it might not have done. It could have been phone use or smoking. And they've engaged in this behaviour consistently for a long period of time and then they stop. Do those neural pathways ever disappear? Do they ever atrophy or are they always there? Are we always going to have an increased level of susceptibility? The reason I ask this is I want her to story about a young girl who used to go horse riding and when she turned 14 or 15 she started smoking when she was horse riding because her parents weren't around and they couldn't ever smell it on her because she came back to think in a horse is not smoke and then 10 or 15 years later she had a daughter and she wanted to take her daughter horse riding. She'd stopped smoking when she got pregnant. She'd

stopped smoking when she'd had the daughter took the daughter horse riding. She'd stopped smoking when she got pregnant. She'd stopped smoking when she'd had the daughter. Took the daughter horse riding again, got on a horse for the first time in 15 years, immediately wanted to have a cigarette. So is it the case that we need to be incredible, the pathways that we lay down early in our lives are with us for the rest of time, or can we actually get them to atrophy and go away?

So a little bit of both. There is evidence that once we become addicted to a substance or behavior, there's a latent scar of that addiction that will always be there and will never go away. And the example that you gave is a is a really good one. And what what often happens with people with severe addiction is when they're triggered or exposed to the drug itself or another drug that can plummet them, not just into moderate use, but right back to where they were in the deepest depths of their addiction. There's also interesting animal studies showing that if you take a rat and you inject it over seven successive days with cocaine, what you will find is that the rat will go from hovering

on the edges of the cage to running around in the middle of the cage. And by the seven day, it's in a running frenzy. And that can be measured by how often it breaks beams of light that are across the cage. Now, if you take that cocaine away for a whole life, for a whole year, which is essentially a rat lifetime, and then you expose that, see, and what will happen is they'll stop running and they'll start going back to their normal behavior.

But then if a year later you expose that rat to a single injection of cocaine, they'll immediately be back into that running frenzy as if they were on day seven. Very strongly suggesting that there's some fundamental brain change that occurs, that never goes away. On the other hand, although the evidence supports the idea that there are damaged areas of the brain that never heal, there's also really interesting work being done by my colleagues here at Stanford,

showing that recovery is characterized by building new neural pathways around these damaged areas. So recovery can happen, it can be, it's robust, people can get into recovery and be in recovery their whole lives and never relapse again. And what's probably happening is again, they're building new neural networks that reroute around those damaged areas. What I'm thinking about is the common addiction that pretty much everybody has, which is overuse of phones, and that you really do set the tone for your later life with the actions

that you make in your earlier life. Yes. And if it's the case that every time that you have something in your pocket that you automatically go to pick it up to take it out You have your apps in the position you can almost navigate with your eyes closed. Yeah to go through these sorts of things the implications are like really really grave and It sounds like they're quite it's we should pick up behaviors with real trepidation. Yes, I agree with you. It's why I strongly advocate that children not have their own devices until they're at least 12 or 13. Why so?

Well, just as you say, you know, those are formative years. The brain is developing rapidly. The coping strategies that kids learn early in life will ask them a lifetime. And if we don't in that time teach them healthy coping strategies, if we don't foster social networks with people in real life, if we don't teach them about, you know, how to be well with exercise and diet and spiritual practices. And we just give them a phone, and spiritual practices. And we just give them a phone. That's going to be very bad for their ability to reverse those behaviors later on. So I think it's essential that kids be shielded from these devices for as long as possible. And I once they become teenagers, they're just going to

go out and get their own devices if you don't get them on them. But even then, monitoring their use, just gonna go out and get their own devices if you don't get them on them. But even then, monitoring their use, data show that parents who are actually know where their kids are and what their kids are doing and what kinds of things they're doing online. Those kids are less likely to develop serious addictions to social media and other things than parents

who are super hands off. So it does require careful monitoring and discussion early in life so that people can be mindful. But having said that, I will say that I have seen people with very severe addictions get into recovery and mid and late life. So it's really remarkable what people can reverse in terms of these incredibly addictive

and reinforcing behaviors when they decide and when they have access to the resources, help them get into and maintain recovery. That's reassuring to hear. A bunch of things floating around in my mind. James Clears saying, first we make our habits and then our habits make us, that every action that you take is a vote for the future sort of person that you're going to become. And then there's a Jordan Petersonism that says, don't practice what you do not want to become. And that reminds us that each of the little individual actions are pushing us towards one particular type of future or another. And every time you do it, it's making doing it again more likely tomorrow and the next day and the next day. It really is. It

doesn't surprise me that your book hit the best sellers list because it's such a pervasive, ubiquitous problem that pretty much every person that's living in the first world now has. What does it mean to be in a hyper convenient world where we can get whatever we want, where discomfort is something that we can evade at the touch of a button, where boredom is something that we can eliminate by getting anything out of our pocket. Yeah, that pleasure-paying balance has been skewed in a manner that is quite unhealthy.

Yeah, I think that's right. And then on top of it all, you know, data show that people are getting more depressed and more anxious. And the richer the nation are getting more depressed and more anxious. And the richer the nation, the more depressed and anxious we're getting happiness surveys show that people were less happy in 2018 than they were in 2008. And then added to all that unhappiness is the guilt for being unhappy because we look around and we say, why, you know, why

on earth? Like, I should feel really good. And, I don't. I'm unhappy. And that's where I think understanding the neuroscience of pleasure and pain is super helpful. Because it's just, it makes us realize that, oh, I get it. I'm unhappy because I'm constantly surrounded by pleasure. And that pleasure is, my brain is wildly trying to accommodate that fire hose of dopamine and is making me miserable as a result. And there are actionable things that we can do to reverse that. And that's what's so exciting. And we can insulate ourselves from pleasure. And we can intentionally challenge ourselves and do things that are hard. So crazy to hear. We can insulate ourselves from pleasure in the pursuit of fulfillment and leading a better life. Yeah, I know.

It is paradoxical, but it's real. It works. Anilemky, ladies and gentlemen, dopamine nation finding balance in the age of indulgence will be linked in the show notes below. Where should people go if they want to find out more of the stuff that you do? Well, let's see. I'm not on social media, but on a Lemki.com is sort of a website that has

other information. And of course, he shows like yours are, you know, great, great opportunity to have great conversations. So thank you. Oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh, oh,