The Joe Rogan Experience - #1708 - Anna Lembke

Episode Date: September 16, 2021

Anna Lembke is a psychiatrist, author and specialist in the treatment of addiction. Her new book, "Dopamine Nation: Finding Balance in the Age of Indulgence," is available now.

The Joe Rogan Experience. Train by day, Joe Rogan Podcast by night, all day. Hello. Hi. Thanks for doing this, appreciate it. I'm happy to be here. I'm very excited to talk to you about this. This is a very interesting subject.

I have had problems with addiction my whole life. Okay. Particularly, like I had a really bad video game addiction at one point in time. And I had a quick cold turkey. It was like an eight-hour-a-day addiction. And when was that? 20 years ago, somewhere around then. Okay.

Yeah, a little more than 20 years ago. Okay, so you were in your 30s? Yeah. And how did you realize that you were addicted? Oh, I knew. Okay. So you were in your thirties? Yeah. And how did you realize that you were addicted? Oh, I knew. Okay. You knew from the very beginning? Well, it was very fun. I was playing this, uh, online video game called Quake. And what it is, is you play online and you hear like sounds in 3D and the graphics are amazing and you're running around shooting at people and they're shooting at you and it's really exciting. It's very thrilling, but it's not real life and it'll eat your whole life away. Yeah. So I'm curious, how did you, I mean, did you know from the very beginning that you were addicted?

No. So at what point, like how long into it did you say, gee, this is a problem, I should change this behavior? Well, I would go to bed in the morning. Because I would come home from like a comedy show and I would literally play all night long. Okay. And then I would realize it was like 8 o'clock in the morning, and the sun was up, and I was just going to bed. I was like, this is terrible for you.

Like, what am I doing? I'm basically working a night shift. And I was also realizing that I was tired a lot because I was just really wrecking my system by doing that, by staying up. And also, the game is so exciting. You're like, you know, you're redlining and then you get out of there and you're like, you'll, you feel cracked out. Yeah. So usually, you know, as we become addicted to something, we don't see it, um, until there's some sort of threshold where maybe we have a bad consequence or someone else

makes a comment or just something happens so that we start to look at our behavior in a different way. So I guess I'm wondering with your video game addiction, what was it for you? Do you remember what the tipping point was where you said, I have to stop doing this? Well, I do a lot of self-auditing. I think I was pretty aware that I was screwing up. I wasn't focusing enough on my career, like my stand-up. I wasn't focusing enough on other aspects of my life. I was just way too into it. And I was realizing also there's there's the the reward it's it's i have a problem

i'm an obsessive person like i get into things the things that i like all that i just think about them all the time it's not balanced because i have this um obsession with getting really good right whatever i get into like it becomes like too much of my life I was watching this documentary recently about my late friend Anthony Bourdain and in the documentary they were talking about how he used to be addicted to heroin and then later on it actually became a healthy thing became jujitsu but it was like this addiction where he talked about it constantly and all the people that were working with him were laughing about how like he never stopped talking about it he was just addicted to it

and so he was getting good at it it was healthy his body was getting very healthy but it was this it was the same sort of function in the mind. Right. That's what I want to talk to you about. What is that? Yeah, yeah, yeah. So, I mean, it's a great question. It's something that people used to call the addictive personality. We don't really call it that anymore. We just use the idea of the disease model. So we say that somebody has the disease of addiction. It's a chronic relapsing and remitting problem. People come to it with different degrees of vulnerability. And the risk for it can essentially be summarized as nature, nurture, and neighborhood. And just to briefly describe that, if you have a biological parent or

grandparent with addiction, you are at increased risk compared to the general population of getting addicted yourself. If you have a co-occurring mental illness, you are at increased risk of getting addicted. If you have certain character traits, like you're more impulsive, you have a hard time putting a break between the idea to do something and actually doing it. Or you're at increased risk for addiction. So that's kind of all in the sort of nature risk category. There's also the nurture piece of it. So if you grow up in an environment where you experience a whole lot of trauma, you are at increased risk for becoming addicted. If you grew up in an environment where your

caretakers model using drugs and alcohol or other addictive substances or behaviors as a coping strategy, you are at increased risk of becoming addicted, or even if they just implicitly condone it. And then that brings us to the whole neighborhood idea. And this, I think, is a really under-recognized aspect of our risk for addiction, which is just simple access. So if you live in an environment where you have more access to highly reinforcing drugs and behaviors, you're more likely to try them. And just simply in being exposed, especially with the increasing potency, variety, and novelty of drugs today, you're at increased risk of becoming addicted. So if you go see a doctor who's more free with their prescription pad, you're exposed to opioids or benzos, you're more likely to get addicted. If you grow up in a

culture where people are playing a lot of video games, you're more likely to try them, more likely to get addicted. So this nature, nurture, and neighborhood are the risk factors. But again, people bring different degrees of vulnerability to this problem of addiction. And some people are more vulnerable than others. And you may indeed be in that category where you're just somebody who, you know, once you find something that's reinforcing for you, you just go, vroom, and you just want to do it again and again and again. When you say reinforcing, what do you mean by that? I mean that it's rewarding in some way. Rewarding. Right. So it's pleasurable at first. Now, the thing about addiction and the way that it changes our brains is that that thing that initially is pleasurable and has us engaging in approach behaviors,

if we continue to consume that substance or engage in that behavior, it ultimately actually puts us in a dopamine deficit state such that we want to continue to do that behavior, not to feel good, but just to stop feeling bad. And that's kind of one of the fundamental things about the disease of addiction. It's innate vulnerability to start added to the changes that occur in the brain as a result of ongoing consumption of our drug. And those brain changes are what drive continued compulsive use. So that's the difference between being enthusiastic about something that you enjoy versus something that consumes your life. So you're kind of chasing

the dragon, like the initial, like that's what they talk about it with heroin addiction, right? Don't they say chasing the dragon? The initial rush that you get from the first uses of it, you're always chasing that, but really what you're doing later on in life is just trying to not be sick. Yes. Not having it in your body makes you feel terrible. Right. So interesting, that term chasing the dragon, it comes in part from, as you describe, like the elusiveness of trying to recreate that initial high, which with continued use becomes harder and harder. But it also literally comes from when heroin is inhaled. So if you put it on a piece of tinfoil and you light it underneath, you get this kind of smoke. Then that plume looks like a dragon's tail. So it's

got a couple of different meanings. But yes, I mean, what you're saying is exactly right. And the way that I describe this to patients and describe it to medical students is imagine that in your brain there's a balance, kind of like a teeter-totter in a kid's playground. And one of the most interesting findings in neuroscience in the past 75 years is that pleasure and pain are co-located, which means the same parts of our brain that process pleasure also process pain. And they work like opposite sides of a balance. So when we do something that's rewarding or reinforcing or pleasurable, our balance tips slightly to the side of pleasure. We get a little release of dopamine, the pleasure neurotransmitter in that part of our brain, our reward pathway, and we feel good. But the thing about that balance is that it wants to remain level. And the brain will

work very hard to restore a level balance, or what's called homeostasis. And it does that by tipping the brain an equal and opposite amount to the side of pain. So again, the way the balance restores homeostasis is to tip to the opposite side. That's the come down after using, that moment of wanting to do it again, the hangover. If we wait long enough, that feeling passes and balance is restored. But if we don't wait and we continue to use our drug again and again, we end up with a balance that's essentially weighted to the side of pain. And I imagine that like these little neuroadaptation gremlins hopping on the pain side of the balance. Not very scientific, I know. But the point is that with

repeated use, we get enough gremlins on the pain side of the balance to fill this whole room. And then we're essentially working from a dopamine deficit state. We've downregulated our own dopamine. We've downregulated our own dopamine transmission. And those gremlins like it on the balance. So they don't get off after the hangover is over or the acute withdrawal. They can persist there for weeks to months to years, which is why people with addiction, even when their lives have become so much better, will relapse because they're not walking around with a level pleasure-pain balance. They're walking around with a balance tipped to the side of pain. They're experiencing the universal symptoms of withdrawal from any addictive substance or behavior,

anxiety, irritability, insomnia, dysphoria, and intrusive thoughts of wanting to use their drug again. Now, with enough time elapsed, and again, with people in people with severe addiction, it can take months to years, those neuroadaptation gremlins will hop off. We will regenerate our own dopamine and our own dopamine receptors and our level balance or homeostasis will be restored. Is it scientific to call them gremlins? Super scientific. I'm hearing it's like, well, that's a great way to put it. Because like people that are like Jamie can attest to this.

We had a relapse of our video game addiction. We at the old studio had a bunch of computer set up and we started playing again. And then we wind up playing like hours and hours every day. And I had to stop again. I go, oh, I see what's happening here. Right. I'm right back into this. But this was like decades later.

Yes. Well, I mean, and there's a couple interesting points about that. So one is that in creating easy access at your other studio, the temptation was you're not able to withstand it. And that's. Oh, no, there was no. It wasn't temptation. It was a plan. Like we planned to set this up.

I thought it would be fun to have. But then once I knew there was no temptation, like we never went, maybe one time again. One time we did it. We went back and played again after like a year of not playing. We played a couple of times when the Doom guys came, but never went back to it again. I was like, oh, I know what that is. And so the room just sat there with these computers and we never used it. But the way of looking at it like gremlins is a very interesting.

Is that your thought process? Yes. You look at it like gremlins. Yes, that's how I. So I for me, just a nice way to think of the neuroscience and a nice way to teach it is to imagine this balance that gets tipped to one side or the other. And the little gremlins, which represent neuroadaptation, hop on one side or the other as the opponent process mechanism to try to restore homeostasis. What are those things? What are the actual gremlins?

Don't call them gremlins. Okay, so the gremlins? Like if you don't call them gremlins. Okay. So the gremlins represent neuroadaptation. It's the way that our brain, it's our innate re-regulating mechanism to restore a level balance. So if we ingest a substance or engage in a behavior that causes a very large release of dopamine in the brain's reward pathway, our brains will immediately respond to that by down-regulating our own dopamine production and our own dopamine transmission.

They will put us into a dopamine deficit state. So it's not that we just go back to a level balance or homeostasis. We go below baseline dopamine levels. So, okay, so if you think about dopamine firing, we're always firing at a tonic level, a baseline rate of dopamine. And dopamine goes up or down depending upon what we're doing. And it is what really governs our approach and avoidance behavior. But every time we have a big surge of dopamine upwards, there's a price to pay for that. And it is that dopamine levels then go below baseline to compensate for that before bringing dopamine back to our baseline tonic levels. And if you repeat that behavior

again and again, the initial response to the stimulus gets weaker and shorter. And the after response, the dopamine deficit state gets stronger and longer until you've essentially put yourself in a chronic dopamine deficit state. Where you're always chasing the dragon. That's right. And where when you're not doing that behavior or ingesting that substance, you are in basically something akin to a clinical depression. You're in a dopamine deficit state. So you feel lousy. What if you have multiple addictions and you use those to balance out your dopamine release? Yes. Would that be a good strategy? No.

And you know, and this- But a lot of people do, right? Yes, right. So this comes up a lot in clinical care. So for example, I'll ask a patient, how many times a week do you drink alcohol? They say, oh, just once. It's not a big deal. Okay. How many times a week do you use cocaine? Oh, just once. No problem. It's Tuesday. Yeah, right, right. It's Tuesday. So what you end up discovering, and this is increasingly common, is like daily polypharmacy, right? Where in their minds, they're not addicted to anything because they're only doing it once a week. But if you add it all up, they're doing something that's addictive every single day.

Wow. And all of those substances end up basically working on the same common dopamine pathway, having a compounding effect. What is the evolutionary biology reason for this? Yeah, yeah, I love that. So I mean, you know, these are sort of these evolutionary stories are sort of just so stories, but we can, I think we can speculate and tell them. I mean, we evolved over millions of years to approach pleasure and avoid pain, and it is what has kept us alive in a world of scarcity and ever-present danger, right? I mean, if we – so when like we travel across the desert and we find some water, woohoo, you know, dopamine, that's good. But if we stayed in that, you know, euphoric celebratory state, we really wouldn't be aware of the fact that night's coming or there's a predator that's going to get us. So our brains have evolved to very quickly bring us back down to baseline, again, by going below baseline. And that keeps us sort of,

you know, ever vigilant, ever seeking new and greater rewards, which is exactly what we need in order to survive in a dangerous world and in a world where we don't have the kind of abundance that we're talking about now. And one of the things that I think has happened is that humanity has reached this really unprecedented state in which our primitive brains are completely mismatched for our modern ecosystem, which is an ecosystem of incredible overabundance and quantity, potency, and variety of these novel drugs. So we're designed for essentially like a hunter-gatherer life. That's how the human body is designed. And I'm sure a lot of those obsessive and dopamine reward system, all the release comes from this idea of finding food. Yeah.

The idea of figuring out how to survive and feed the family. Yeah. When you're successful on a fishing trip and you come back with food, everybody's happy. Like that kind of thing makes people strive to be obsessed with success in that particular area and hunting. Yeah, yeah, yeah. We're always looking for the next thing, never satisfied with what we have. Because we can't be because we have to get more food tomorrow. That's right. That's right. So it's sort of like a built-in human reward system.

That's right. It absolutely is. And one of the things that I think about people with addiction in our modern times is that, you know, first of all, addiction is endemic in the population. Since the beginning of human history, you can find accounts of people getting addicted to intoxicants. It's not a new phenomenon. What is new today is the increasing numbers of people with minor addictions and just the increasing numbers of people with addictions all across the board. But one of the ways that I think about people with addiction is that they're people who, you know, thousands of years ago probably would have been highly adapted to the environment because they would have been our seekers. You know, they would have been the people who, you know, were always pushing the envelope. But in the

modern world, it can really be a curse to have that kind of temperament and that kind of physiology because modern life is everything sort of, we've got everything we need. We don't have to do anything to survive. We don't even have to really do anything to, you know, we don't have to get off the couch even just to eat. So it can be very challenging to have that chemical makeup in this modern environment. Now, what's the best method for recognizing whether or not you have an addiction or whether you're just an enthusiast. Yes. Like if you are, whatever, if it's a sport or whatever, it's maybe a gambling thing. Like how does one know when it's a real problem and how much recreation can you have without it being addictive? So great question.

And I think the answer is going to be different for every person. There's not like a one size fits all. In general, when we are diagnosing addiction in clinical care, it's not based on quantity or frequency per se, although daily users tend to be people that we are concerned about. But the diagnosis of addiction is really based on behaviors and can be briefly summarized as the four C's, control, compulsion, craving, and consequences, especially continued use despite consequences. So like what if you're addicted, like I have friends that are addicted to golf and they just can't wait to go play golf. What's the consequences?

Well, it might be that their spouse says, gee whiz, why are you playing golf all the time? Maybe they just need a new spouse. Well, okay. Okay. So this actually comes up a lot in clinical care. Like to what extent is it my problem and to what extent do I have to change my life? Right. is it my problem? And to what extent do I have to change my life? And I always say to patients,

you know, that is a great question and not one that I can answer for you, but maybe together we can find the answer. Because the truth is sometimes it is a question of needing to change your life, right? And I wouldn't presume to necessarily know, especially with cases on the border. Now there are certainly- On the border. I mean, on the border of like... Consequence. Pathological. Yeah. I mean, there are some cases where like, okay, you don't need to be a psychiatrist to diagnose that this person has addiction. It seems open to interpretation in the world of what you would call extreme winners,

like the Michael Jordans of the world, the people that are just absolutely, completely obsessed with winning, that seems like you could kind of call that an addiction. But then they are the most celebrated people in all of the world. Right. So you're tapping into something that is really important to talk about, which is that our society rewards certain types of addictions and not others. We certainly reward professional athletes who have become obsessively focused on their sport. We certainly reward workaholics of all types. And again, it's not to say that we should pathologize all types of intensity or all types of commitment to a behavior. of intensity or all types of commitment to a behavior, that's not what it's about. But what I think is important is to recognize that the same mental machinery that approach and avoid

behavior mediated by dopamine that is at play when we become addicted to something can be at play really in all different aspects of our lives, not just drugs and alcohol. So you're essentially looking at this very objectively. You're not making a judgment call. You're just saying the same mechanism is in place, whether it is extremely beneficial, like you are, Michael Jordan, or whether extremely detrimental, like you're a person who's addicted to crack or you're a gambling addict who keeps blowing all their family's money. It's kind of you're on the same human neurological pathway. That's exactly right.

It's the same mental machinery that's being applied. And again, there are certain types of addictive behaviors that our society rewards. But even in those cases, I think it's important for people to really closely evaluate potential hidden consequences. And I feel like that's happening. I mean, just using the example, again, of athletes, I feel like there are more and more and more there are athletes who are in different ways kind of questioning their lifestyle or the things that they have to do, you know, which I think is good. I think it's always good to look at the pros and cons. Basically, there's never the light without the dark. You know, it's really that dialectic that comes into play really in all aspects of our lives, which I think we need to

talk about and think about. We celebrate the people that are extreme winners. We celebrate the people that are absolutely, completely obsessed with performance, and they have everything dialed in, including their calories, their macronutrients, the amount of sleep they have, the amount of recovery that they seek out, how they do it. But they have a massive reward for that, right? The massive reward is the glory of being a Michael Jordan or being a Mike Tyson or being a Sugar Ray Leonard or whoever it is at the peak of their performance when they're on top of the world. performance when they're on top of the world, there's a great deal of benefit to having what many would just call extreme discipline. So what's wrong with that? Well, what we hear very little about is when that road comes to an end and that escalating glory and

reward dries up and what those people's lives are like after that. And my sense is that unless they've worked very hard to cultivate other aspects of their personality, when that dopamine trail dries up because they get injured or they just age, then they have to contend with the comed know, the comedown, you know, the dopamine deficit state, not to mention all of the other aspects related to loss of identity. You know, who am I if I'm not this person who's winning? And, of course, that's an old trope. I mean, we know that, but we don't hear about those athletes after that. I would say that you point out in that description, which I think is also key to the process of becoming addicted, is the ways in which addiction is also about controlling and changing the way

we feel in the moment, rather than tolerating the feelings or the uncertainty of what's next and just letting it wash over us. So a really key important aspect of what you call discipline, but which I think in some contexts might be addiction, is wanting to control what we're feeling when we feel it. And I think this is also deeply embedded into modern life and modern culture. Explain that, wanting to control what we're feeling and when we feel it. And that's what separates discipline from addiction. No, I think there's overlap there. So let me go back. So part of what drives the phenomenon of addiction is that people control what they feel when they feel it. So for example, in this moment, let's say

I'm struggling, right? But I feel like, oh, I can get through this because when this is over, I'm not saying I'm struggling, but I mean, if I were- I know what you're saying. Yeah. Because when this is over, I'm going to reward myself with X, Y, and Z. So like if you go running and then afterwards you can have a slice of pizza. That's right. Exactly. So it's the way that we bracket our endeavors with rewards. And this is just like deeply embedded into our culture. And the control aspect is a big part of the addictive aspect because I'm now going to control the way I feel when I feel it, which is a very different way of living if you were to eliminate rewards as a way to shape time. If you were to think, I'm not going to do anything to

reward myself today. I'm just going to get through the day. It totally changes the arc of our experience in the moment. But is there a bad thing with rewarding yourself for doing something that's difficult but that's ultimately beneficial, like getting a run in? Like say if you're going to run five miles. It's not easy to run five miles. If you decide, okay, I'm going to run five miles. When I get back, I'm going to reward myself with some ice cream. Is that negative? I don't think it five miles, and when I get back, I'm going to reward myself with some ice cream. Is that negative? I don't think it's negative, and we all do it.

And it's good to do the hard thing before you do the easy thing. That's probably just generally a good coping strategy. We should teach our kids to do that. Do your homework, and then you canving around this process of rewarding ourselves. And it's just really the way that we shape time. And I do think that it's also a way in which we are not present in the moment because actually to be present in the moment is mostly unsatisfactory and unpleasant. Is that good to be unsatisfactory and unpleasant? You're painting a very gray world. I'm getting sad.

You know, I know. My message is. Stay gray in the moment. Right. It's not a dark message. It's really it's really not. Although it's it's it's a hard sell. Well, let me see how I can put this differently. For a long time, I think this idea of of using rewards to kind of shape your day can work. But eventually, you know, it tends to stop working because whatever we do that's rewarding,

we develop tolerance to, we need more and more of it, a more potent effect. Couldn't you just shift the reward? Sure, and people do it all the time. But there's cross addiction. So ultimately that new reward will only work for so long or we'll get addicted to the new reward. So I think that there's a better, harder solution that is about not using rewards as a way to shape time, but instead letting our experience unfold with uncertainty and embracing that uncertainty. I don't know if I'm communicating this, but you can let me know if it makes no sense. I kind of see what you're getting at. And what you're getting at is that there's a benefit in living in the moment instead of seeking out these constant rewards.

So difficult things, obsessive things, then the reward for that obsessive thing. Right. What is the benefit of living in the moment? Well, first of all, let me just say that for a long time when I would hear people say, you know, be in the moment and I would try to do that, like I thought I was doing it wrong because I thought if I could just be in the moment, I would like distress of just fully being in the moment, right? And that's all the harder to tolerate because we have all these rewards that are waiting for us, and we'd rather go there. So being in the moment is tolerating the distress of being in the moment? Uh-huh.

What's the benefit of being in the moment? Uh-huh. What's the benefit of being in the moment? Well, the benefit of being in the moment for me once I acknowledge that I'm not necessarily going to feel good is that I can really be present and then open to positive experiences that are not of my own making. Like what? Really unexpected. Really unexpected. And not that frequent. But when they do come along, they're lovely. What are these experiences, though?

They're unpredictable. And they're incredibly fleeting. Are these miracles? Are you talking about miracles? No. No, I'm not talking about miracles. Maybe I am talking about miracles, but I don't think of them as miracles. I mean, let me ask you this.

Okay. What are some of the happiest moments that you've had in your life? Or just think of one of the happiest. Like where were you and what were you doing? Oh, well, that's very difficult. I've had a very happy life. I've been very lucky. I've had a lot of very fun experiences. Okay. Okay. So, you know, you could be baseline temperament, just a happier person than I am, which is perfectly possible. Cause I do think we come into life with sort of different degrees of happiness and I'm probably a little bit on the unhappiness side of things.

This is my position though. My happiness has often come from very hard work. Yes. And then a reward. Right. So my happiness has often come from accomplishments. Accomplishments that were very difficult to achieve. Other than love, family achieve. Uh-huh. Okay. So. Other than love, family. Right.

Those kind, that kind of happy. Okay. It's a different kind of happy. Okay. So, so let me ask you this. Have you had the experience where you worked very hard to accomplish something, you, you got it, you accomplished it and it felt kind of hollow for you? No. Never?

Not really. No. No. felt kind of hollow for you? No. Never? Not really. No. I seek out very, very difficult things to do. And in getting better at those very difficult things, I believe that you're challenging your human potential and that you're trying to figure out how to master your emotions, your discipline, your focus. And I think there's great reward in that. I think there's great reward in discipline. There's great reward in sticking to a difficult schedule, like particularly physically, that's hard to stick to like a physical workout schedule or a meditation schedule, yoga, things along those lines.

Like if you can do that on a daily basis, I believe it alleviates a considerable amount of anxiety and it, uh, it fills the mind up with challenges that I believe the mind requires. I think your mind requires a certain, at least my mind, I should say. My mind requires a certain amount of challenges. It requires difficult puzzles to solve. I think that's why I got addicted to games. I used to be addicted to pool. I've been addicted to martial arts. I've been addicted to a lot of difficult challenges. I think for sure I've been addicted to stand-up comedy, which is also a difficult mental challenge. But I find great reward in

seeking out these challenges and trying to do my best to solve them. Yeah. So I mean, what you're describing is something that I actually recommend to patients who are trying to get into recovery from addiction to things like drugs, alcohol, or other highly reinforcing things like games or pornography. If we think about the pleasure-pain balance again, what I actually recommend they do, in addition to abstaining from their drug of choice, is to actually intentionally press on the pain side of the balance. Because then those neuroadaptation gremlins I talked about hop on the pleasure side and ultimately can reset our pleasure pain pathways to the side of pleasure. So how does one step intentionally onto the pain side? By doing the very kinds of things

that you talk about, effortful engagement in daily practices that are not easy. So you've really figured it out in terms of what you need. You need a certain amount of friction in your life. 100%. Right. And you need maybe more friction than average. And you've determined that the best way for you to get that friction is to do things that are hard. And that is what I've learned from my patients and what I now prescribe to them. One of my patients said to me, if there's one thing I've learned about recovery, it's that the hard way is usually the right way. So your reward comes from this effortful engagement and probably results in you having dopamine release, right? Not as an immediate factor, but as the opponent process or the after effect. So that's all very good.

But I guess, you know, where my mind goes, you know, thinking about you and your experience is whether or not, I mean, it's certainly we can, we can get addicted to pain, right? And we can push too hard on that side of it and take that too far. I mean, it sounds like what you do is you, you do that for a while with one activity on the pain side, and then you switch to another one. So there's just that little bit of novelty to stretch yourself again. But I guess I wonder, is there a point at which you kind of get burned out on all of that? No. Okay. Well, stand-up comedy, for sure, no. I've been doing that for more than 30 years. Martial arts, for sure, no. I've been doing that more than that. I've been doing that for almost 40 years. No.

Okay, so this is still working for you. I just find things that are difficult. My problem, I do have issues with obsessive things like games. I still play pool, which I find I think there's a mental reward and there's benefit to the focus that I get from the geometry of pool and the calculations of the maneuvers and how to move the ball around, all those different things. I think it's a mental exercise that I think is actually very good for me. But I want to play it eight hours a day.

Right. So I have to force myself. I've got to go, okay, it's X amount of time, and then that's it, and then it's over, and then I've got to go home. I just know my brain, and I know that if I did fall into the addiction side of it, and I started playing 10, 20, which I did used to do when I lived in New York, I used to play eight hours a day. When I fall into that, then I don't

feel good. Then I feel like wrecked and I feel like I'm wasting my life. And it doesn't feel like recreation. It feels like a negative obsession. So it's, it's for me, it's about finding this balance. The things that I find that I get obsessed with that turn out to be beneficial are usually the things that enhance my life. You know, like we were talking before the show started about comedy. And there's a great reward to putting a set together and then the audience has a great time. And you feel great because these people came out to see you. They scheduled their evening around this. They have a great time.

And everybody walks out of there and they feel good. That's an amazing feeling that's worth all the effort and reward. And it also, again, it's this complicated puzzle that the mind has to solve. Yes. And I think, I mean, I don't know how other people feel, but I think a lot of people, myself included, need difficult things to solve. They need a challenging but yet rewarding occupation. They need something that stimulates their mind.

And I think, do you remember when going postal was a thing where post office workers, for some reason, were just shooting a bunch of people. And I was, I remember having a conversation with my friend about, I'm like, imagine the monotony of like just sorting things out by zip codes or just whatever it is that force. I mean, what is it that you was for? And it stopped somehow or another with post office pay people more money. I don't know what happened, but they stopped shooting people. But it was a thing where like multiple post office workers were like going on rampages to the point where there's games called going postal, like a video game. And I was always wondering,

is that because that's not challenging? It's not rewarding? What is it? What is it about it that makes people so frustrated or that builds up this angst or this anger? But then some people love a job like that where they just show up and they talk to their friends

at work and they have a coffee break and they have a great time and they feel completely satisfied by that. Maybe they go home and they watch a little TV or they watch a game. Maybe they'll play a little video games before they go to sleep and they can have a happy life like that, at least allegedly so is it that you have to find the balance for your own personal your own personality your own personal biological makeup your own life experiences and all the levels of neurotransmitters you have in your brain as opposed to other people is that that what it is? It's like finding your own personal balance? Yeah. I mean, you know, addiction is called a

biopsychosocial disease. And it's a really great construct because it speaks to the fact that there's a biological component. You know, you're sort of innate biochemistry. There's a psychological component, the way that you problem solve or, you know, have insight or not into your behaviors. And then there's the social component, like what's your life? You know, what are your opportunities? I mean, you seem like somebody who has had opportunities and also has made the most of those opportunities. But there are lots of people who probably don't have those types of choices and opportunities. So then they need to figure out, you know, people who, I mean, I don't know what it's like to work in a post office, but

I mean, it might be very interesting. It might be very boring. I do think that there are ways you can make it interesting by, again, trying to be more present and focus on it. But what can happen in a lot of jobs that, like, lack the same level of fascination is that people kind of get through that and then reward themselves at the end of that. With boos. Right. Exactly. Right. Yeah.

So, you know, again, speaking to kind of the difficulty of modern life for many people, I mean, you have what appears to be a really interesting job. And you've made, I mean, I gather you're a self-made person, right? So you've made these opportunities for yourself, you know, which is a testament to your own discipline, but also there's an element of luck there. Would you agree? Yes. Yeah. So, but, but gosh, not everybody has that. And so how do they, how do they make, you know, a life worth living even within that context? Also, I just want to emphasize again that, you know, you've tapped into something that I think in your own life that I think is really, really important in that you realize that the best way to get your dopamine is through the opponent process mechanism. So instead of getting it by like ingesting something that immediately releases dopamine in your brain's reward pathway, you do hard things by pressing on the pain side of the balance, which then triggers your own endogenous opponent

process or re-regulating mechanism to create dopamine in response to that, which is potentially a more enduring source of dopamine, less likely to lead to tolerance and addiction. I don't necessarily know that I would agree that it's a pain side of things, though, because I think a lot of it is the, um, the way you approach things. Yeah. Well, again, I use that term pain very broadly. That would include, um, doing things that, you know, that are effortful in any way, doing things that are creative. Maybe pain's not the right. Yeah. I, for me, it's the pleasure pain balance. That's a metaphor that I use.

But you're absolutely right. This is, broadly speaking, not just physical pain. We're talking about emotional effort, creativity, cognitive complexity, things that take effort on a daily basis where the reward is delayed. It's also really true that the pleasure-pain balance is an oversimplification and that we can experience pain and pleasure simultaneously. For example, when we're eating spicy food. It's also true that the meaning that we give to our suffering can absolutely change that experience. very famous experiment done by a Dr. Beecher who interviewed World War II soldiers right after they had on, you know, on the battle lines, right after they had received these grotesque injuries, guts spilling out, amputated limbs. And he found that approximately two-thirds of them had no pain in the immediate aftermath of their injury. And through his research, he concluded

that the reason for that was number one, they realized they were still alive and happy to be so. And number two, they realized they were probably going home. And so the meaning for them of the injury was going home. So it's really, our prefrontal cortex, you know, that area right behind our forehead communicates with our lower brainstem, lizard brain reward pathway and incredibly, you know, modifies and modulates that experience. To sort of describe, you know, a corollary example, there was a case report of a young man, construction worker who jumped on a giant nail that went right through his boot, through his foot. He showed up in the emergency room, intense pain. They gave him opioids. It wasn't enough, still screaming in pain. They gave him more opioids. It wasn't enough, still screaming in pain. They finally had to give him so many opioids that he became unconscious. They slowly removed the nail. They slowly removed the

boot. And it turns out the nail had gone right between his toes. So he, in fact, had no tissue injury, but his mind saw the boot, the nail sticking up to the boot, and he experienced real pain. So that pain was real for him. It wasn't made up, but his brain had elaborated that pain. A less charitable person would not look at that man that way, especially people who've actually been injured. Well, you know, I tell you, the ways in which our brains can manufacture pain. But is that really our brain?

Or is it, well, I guess it is, right? Because it's all happening inside the mind. Yes. But that seems like a baby, a big grown man baby, right? Which I'm not saying, look, obviously terrible that the like a baby, a big grown man baby, right? Which I'm not saying, look, obviously terrible that the man was injured, sort of not really injured much. But that's kind of that's like the caricature of men when they get sick, right? No, no, no, no.

Where their mom has to take care of them or their wife has to take care of them and they act like a big baby. No, no, no, no. No? No, to me, I mean, it's an extreme example. But to me, it shows how our interpretation of what has happened to our body has a huge impact on how we experience that injury or that stimulus. And it's real. I mean, it's... Right. But is that interpretation because the person has not experienced actual real injuries before and it's just massive anxiety because they've lived a sheltered life?

Well, okay. So anxiety exacerbates pain. So for example, people with chronic pain, we know that when they have anxiety, it opens up the gates to the experience of pain and their pain gets worse when they have stress. But pain is very subjective, right? We don't know what a person's feeling. That's right. Like people have told me that some things are painful and then I experience them like, what the fuck are you talking about? This is nothing. Yeah. You know, like tattoos. I remember before I got tattooed, people were telling me, oh my God, it's the most painful thing ever. And I was getting tattoos like, this is hilarious god it's the most painful thing ever and i'm i was getting tattoos like this is hilarious this is the most painful thing ever obviously there's parts of your body that are far more sensitive and i found that out the hard way but even those parts like your elbow

and like towards your upper shoulder it's uh i guess your chest and your rib cage supposed to be very painful it's not that bad it's not childbirth. Like I've been there when my wife was giving birth. It's painful. I've had broken bones. I've had surgeries and torn ligaments and torn meniscus, things that are very painful. It's not that. Okay. So people have different innate pain thresholds and you- Is it innate or is it learned and tolerant? Part of it is innate. Part of it is innate. Do we know this for sure? Well, how do we know that well i know because i'm as a mother i saw that in my own kids right but don't don't one of your kids complain more than the other one isn't one kid more likely

to just deal with stuff that that's right that's that's the innate But is that or is that a way of interfacing with reality? Is it a way of seeing things and just dealing? Or is it actual, is there a registered number, right? So like you say, like that guy was experiencing pain. What was his number? Like if he had one to ten, ten is you're about to die. You know, one is you got a mosquito bite. What is that pain? Some people hit four and they cry like a little baby. And some people, they can get all the way

up to nine and they won't budge. Okay. So I agree with you. There's no pain-o-meter. There's no way to measure somebody's subjective experience of pain. But it is true that people are born with different pain tolerance. For example, some people are born insensitive to experiencing any pain at all. But isn't that rare? And it's very different. It's rare. But it's very different, right? It's rare.

But let's acknowledge that people are different in all kinds of parameters. Yes. You can accept that maybe people are born in all kinds of parameters. Yes. Okay. You can accept that maybe people are born with different pain, innate pain thresholds. Now, you add to that exposure to pain, regular, graded. Yes. And then people develop tolerance to pain, right, where they can tolerate. Acceptance.

Yeah. Well, and it's not just, though, a cognitive acceptance. It's actually this pleasure-pain balance at at work it's real neuroadaptation but the neuroadaptation isn't measurable well it's not measurable so how do we know that it's real okay how do we know that it's not just taught this tolerance is just not just acceptance like if you injure yourself some people will freak out and they'll have massive anxiety. And I've seen it from martial arts in particular. And then other people go, okay, looks like I'm hurt. Like the soldiers coming back from the battlefield, like this concept, like some people can

just handle it. Like, but clearly this is, there's a psychological element that you highlighted earlier when you were talking about these soldiers, that they be disemboweled, losing limbs, but yet they weren't experiencing pain. Because of the psychological element of the fact they were coming home, the fact that they were alive, so they had put this injury into a different place than the average person would, say, if you were in a car accident and experienced the same injury. This is a psychological thing. This is not an innate tolerance. So I guess I would agree with you that there's a huge psychological and learned component. And with graded exposure, we can develop tolerance to pain.

Like that is absolutely true. But I also think that that's innately, there are innate differences there between individuals. Just like there's an innate psychological and personality differences. Yes, yes. And maybe those are the same thing. I mean, there are experiments, for example, showing that if you apply a pain to different parts of the body at the same time, the stronger pain will lessen the experience of the lesser pain. So there's something biological that happens, again, as our brains adapt and process those dual signals. So, I mean, you know, psychological differences are also brain differences, right? Those are innate differences.

And a lot of them are based on life experience, though. Yeah, right, right. Yeah, so resilience is based on graded exposure. So, for example, people with anxiety disorders or specific phobias, a treatment for that is actually to expose them in measured ways to the thing that they're afraid of. Like spiders? Like spiders, like driving over bridges, like going on airplanes, like talking to people, which more and more young people have social phobias. Exposing them to other difficult things, does that make them more resilient in other ways? Like one of the things I've gotten into recently is cold plunges. Have

you ever done one of those? Yes. Did you enjoy it? No, not at all. What did you do? Explain. We were in Iceland and you know, the real deal. Yeah, right. And they have the very hot one and the very cold one. And I really could, I had a very difficult time with the cold water. That's something I really cannot do for any measurable amount of time. But I bet you could. Yes, if I practiced it. Yeah. Yes, I could. Yeah.

And particularly if you learn some breathing exercises. Yes. Although I've heard about the breathing exercises and I've tried them and I can't get it to work. With cold? Yeah. How many times have you done this? Oh, well, I tried it quite a lot when we were in Iceland. Did you?

How many times did you try it? Like, I don't know, every day for a week. It didn't get any better. Do you know what I mean? Was it the kind where you were in a frozen lake and they cut a hole in it and you climbed right in? No, it was like in a spa with a bunch of old Icelandic people who all had no problem with it. Yeah, well, they're just like so used to it, right? Yeah, right. It's not comfortable. But my question was, I wonder if exposure to difficult environments

like that builds resilience in other aspects of your life. Like, I wonder if you can, like, regularly expose yourself to extreme cold or maybe the sauna, extreme heat, and that can actually build resilience if resilience is almost like a psychological aspect that can be nurtured. Is that possible? Oh, absolutely. I mean, that's so much of the work that I do with patients is trying to get them to do things that are hard, that builds up their actual biological, psychological resilience to hard things, but also importantly, gives them a touchstone for confidence and competence and self-efficacy. That they can get through that. That's right. I did that so I can do this other

thing. And that is so key in life, like knowing I endured that thing. And it's like you get to steal from that and apply it to the next thing. But it doesn't always cross over. So there's like a great anecdote about Alex Honnold, you know, who El Capitan. He's been on a couple of times on the podcast. Oh, neat. Okay, great. Yeah. And, you know, there's, they, they like studied his brain to see if his amygdala was different because how could he, you know, do it. And they came up with this theory that he was, his amygdala was different and he was born with a different amygdala. But he basically refuted that and said, I think it's just graded exposure from all of the climbing that I've done. You know, I've built up this kind of, you know, mental calluses to be able to climb. But apparently when they were putting him in the MRI machine to study his brain, he had almost had a panic attack.

I mean, this is hearsay. You know, I'm not friends with that. Let me ask him. Let me ask him. to study his brain he had almost had a panic attack i mean this is hearsay i you know i i don't i don't i'm not let me ask him let me ask you ask him if that's true because i read that i read that he's pretty mellow but but i mean the point is that like there's not always cross tolerance for these things like i think in many ways there can be cross tolerance and you can again in that self-efficacy you can you can it. But it doesn't necessarily mean you can do everything. Well, the thing about the climbing to him is it's not painful in that it's not scary. He's so good at it and he's done it for so long.

The way he described it very specifically is like, it's home. It's pretty chill. He goes until it's not. And then if it's not, there's a real problem. It's like like but he just stays calm and just climbs he just gets his hand there and pulls himself up right it's here and pulls himself up it's a mellow thing it's not a frantic thing like for you or i they would look down like i can't even i'm my hands are sweating right now thinking about him climbing i freak out

yeah like my friend kelly sends me he sends me these videos all the time because he knows i freak out of like people riding their bike on the ridge of a cliff or that kind of stuff or people who are jumping from like ledge to ledge like that kind of shit that my hands start sweating like crazy yeah no i i'm i'm terribly afraid of heights too and It drives me nuts. But it's not just that. It's like willfully putting yourself in these positions that could be avoided. Yes.

There's something about it's not just the fact this guy wants to ride a dirt bike around the rim of a cliff. It's that he's doing it and he doesn't have to. They're like, don't do that. Right. You know, like my brain says, don't get down, Alex. You don't have to climb up there. Yeah. But for him, that's what he loves.

He loves just the, and I wonder what's going on with him. Like when he gets that top, I wonder if you could measure, if you had an fMRI, you could just like plug them to it right away. Like plug them in in the beginning, plug them in at the end. Like what is, what's the activity? What do you think is happening? Well, you know, I think. My hands are so sweaty.

Feel my hands. Okay. Oh yeah, they are. Soaked, right? Sorry. Sorry I made you do that. But that's what that's from. I wanted you to know I'm telling the truth.

I really freak out. career found climbing incredibly reinforcing, you know, got a huge dopamine hit in his reward pathway. And then, you know, climbing is sort of naturally a thing where you can always escalate it, you know, harder, harder mountains, no ropes, you know, higher and higher. And so there is a way in which, and I have a patient who's a climber. He's addicted to alcohol. He's in recovery. But he says he has to be very careful that he doesn't apply those same sort of addictive tendencies to climbing because he said it would be very easy to do that. And then get hurt maybe? Well, that's right.

He says he knows a lot of people who have died because of that escalating process. He knows a lot of people who have died? Well, okay. He knows some of the people who have died. I mean, a lot, but you know, I don't know. Imagine, you know, 50 people, 30 of them died climbing. Right. Well, but see, it's hard to do that, right? Once you've devoted all that time and energy and creativity. And then also, I guess, you know, again, importantly, people then also rely on it for their homeostasis and maintain their dopamine levels. Right. So that if you were to stop doing that, naturally there would be a come down.

Right. I know a lot of folks who had addiction issues with substances who got into endurance sports. A lot of them, like they got into triathlons or Ironman or, you know, marathon running, ultra marathon running, that kind of thing. Yeah. Yeah. And I actually prescribe exercise to my patients who are trying to quit drugs and alcohol and pornography and gambling and whatever it is, because we do know that exercise is a great way to get that opponent process, dopamine, the after effect dopamine that our own bodies make. And we do know that it helps tolerate the withdrawal from drugs and alcohol. There are good data on that. But there's always a risk then of getting addicted to that behavior. And there's some interesting animal studies showing rats, for example.

Interesting animal studies showing rats, for example, we used to think that. So, for example, if you put one of those running wheels in a rat's activity or as a healthy alternative to self-drug administration. But over time, scientists began to see that the running wheel was in and of itself reinforcing. So a rat or mouse will run longer in a running wheel than they will on a flat treadmill or in the wild. Some mice or rats will run so long in the running wheel that they'll actually, their tails will curve up and remain permanently curved in the shape of the running wheel. And some rats will run on that running wheel until they die. And that was the first indication that that running wheel in and of itself can be a drug, that it has its own reinforcing properties. I'm sure you're aware of the studies that they did with rats with heroin and cocaine and that they did it in cages and they found that these rats would self-administer heroin and cocaine to the point where they

would drink the water that had heroin and cocaine in it and avoid the regular water and they'd do it until they died. Until they set up a happy environment for these rats. And this is what gets me to this whole hunter-gatherer thing again. When they set up a happy environment for the rats, they rarely, if ever, used the cocaine or the heroin. environment for the rats. They rarely, if ever, used the cocaine or the heroin. And if they did, they just used it and then went about their day because they had a very large environment where there was trees and plants and all sorts of things that seemed normal and natural for them.

And that the environment itself of these cages with the bright fluorescent lights, these were extremely distressful. And so the rats were essentially self-medicating to avoid the distress that they were being put into. Now, are we doing that to ourselves? This is the question. Addictive behaviors that exist in human beings today, are they exacerbated by the circumstances

of our modern world cubicle life commuter life like being you know on the subway or whatever you're doing where you're just like droning in and out and constantly being around people and constantly being in these unnatural environments and then again the this theme of doing something you don't want to do all day long, something that's not rewarding and not interesting, and then you get home and you medicate. Right, right. Okay, so great. I'm glad that's the famous rat part experiment. I'm really glad you brought it up because I have some thoughts to share about that. So, yes, you know, absolutely, you know, this idea of our not being in an enriched environment that's conducive to help, to good health, can absolutely lead to the problem

of addiction. However, I think that a central problem today, which is not appreciated, is that we have turned rat park into rat amusement park. access to so many highly reinforcing drugs and behaviors that are mediated through technology, access, potency, novelty. So a couple examples. If you put a running wheel in this enriched rat park environment that you talk about, rats will spend an inordinate amount of time on the running wheel and they won't explore the maze right right so there's something about the maze in the rat park yeah they won't they won't explore this wonderful enriched environment they'll spend a lot of time on the running wheel so they enjoy the the wheel they they really enjoy the wheel is it dependent upon the size of the environment like if you have a warehouse you know i'm saying like if you have a warehouse, you know what I'm saying? Like if you have a rat

in a warehouse, fill the trees and natural sunlight and all the things that a rat would experience. Like if you have a warehouse with a glass roof. Yeah. Yeah. So Leiden University in the Netherlands, they took running wheels and they put them in the wild and they found out that animals, rats, slugs, frogs will intentionally go on the running wheel, even in the wild, independent of any kind of food reinforcement or other secondary gain. There's something about the running wheel that is intrinsically rewarding. And that's what I'm trying to get at, Joe, that technology has changed the world such that we are chronically ingesting and engaging in these highly reinforcing drugs and behaviors, which have engendered a dopamine deficit state, making us all more anxious and depressed. And it's not necessarily a matter of trauma or social inequality or not having an adequate maze. Those can be contributors.

But even when everything isn't ideal, even when you and I live in the best rat park in the world, there are so many running wheels, There are so many levers for cocaine and its equivalent that we've all become more vulnerable to this problem of addiction. It's fascinating that in the wild, rats sought out the running wheel. Yes. And they put it both in an urban area where feral mice voluntarily and obsessively ran in the wheel, and they put it in a more rural environment, in a dune setting, where animals obsessively engaged in this kind of— Wow. Yeah. What does that mean?

What is the running wheel to a rat? What is the reward of getting on that thing? Is it just wee? Is it just like a child on a Ferris wheel? Yes, yes, yes. And they discovered just in general, looking at the reinforcing properties of a running wheel, that mice, for example, prefer a square running wheel and they prefer a running wheel with little obstacles in it. So there's something about- A square running wheel?

Uh-huh. There's something- How so? Well, because it's more complicated, right? What do you mean by a square? Well, it's actually a square, but you have to run on it. Oh, so it flops over? Yeah, and you can see these mice kind of flip themselves, right, and going over. And they enjoy it.

Oh, they love it. They absolutely love it. Yeah, I mean... What would be the, again, evolutionary benefits? What would be the evolutionary benefit of a mouse playing in the wild? I mean, they're essentially prey animals. Right. Well, I mean, I think this is the crux of the matter is there is no evolutionary benefit. It's a mismatch now between what was a neural network that was adapted to the world, which is no longer adapted to the world we have created.

Right. But with humans, I would imagine that a video game sort of piggybacks on your need to problem solve and you're dealing with like combat scenarios that would sort of highlight parts of the brain that were designed to fight off neighboring warring tribes or something. And the whole treasure hunting, you know, part of our brains wanting to find that next best thing. Sure. Those are all innate good things, but you know, then we've turned it up to 11, right? I mean, or 12 or, you know, 500. I mean, so we've, you know, turbocharged these digital products in a way that our minds really don't have the capacity to manage. And then we're just absolutely sucked in there.

Do you think that all of those things, I mean, like there's a, for sure, there's people that make a living out of playing video games. Yes. Are they addicts too? Okay. When I treat young, mostly young men with serious video game addiction. How many young men do you treat with that? I don't know.

Too many. Are they common? Yes. Increasingly common. Okay. And these aren't ambiguous situations. These are young people who are depressed and suicidal primarily because of their video and game addiction.

Is it mostly men? Oh, yes. Far and away, mostly young men. And almost every single one of them will tell me that the way they rationalized to themselves that the amount that they were playing was okay was because they were going to be that guy, you know, who was like a world famous video.

They were all going to be that guy. And so, you know, to me like a world famous video, they were all going to be that guy. And so, you know, to me that, that, that's, again, that's how our brain, even when we're very far from being that guy, everybody thinks they're going to be that guy. And that's part of that rationalization, the justification or the denial that can happen in this whole process. But someone is that guy. Yeah. One in a million. I mean, not everybody gets to be Joe Rogan, right? You're that guy. But a lot of people won't. So it's not to say that nobody should try. Well, I don't know if I'm a good example,

because the things that I'm talking about, the things that I've been successful about, I don't necessarily think you could call podcasting an addiction unless I'm addicted to conversation. Right. I mean, podcasting is maybe a good addiction because people are hopefully learning. I don't think it's an addiction. Because when it's over, I'm good. Okay, not for you, but maybe

for some of your viewers. I don't know. Your listeners? Well, I think people get entertained and they get stimulated by these conversations. And I for sure think that many people are enriched by guests like yourself that can provide all this insight to the way the mind works or whatever subject we're discussing. I think there's a great benefit. It certainly is for me. And I think that's what a lot of people

get out of it they get stimulated yeah and they get stimulated while they're doing other things like driving in their car right on the train or whatever but I don't think that's an addiction but I think that as we said before I'm very lucky I'm, very, very fortunate. But also I'm a person that like when I find fortune, I buckle down and get going and I don't take breaks. I don't relax. I don't slack off. You don't rest on your laurels. I'm not into that. I'm into keeping going and I'm into just pushing it. And then that's where the rewards come because of success. But I don't know if that's an addiction. It might be the one thing that I do that's not

an addiction. Yes. And I'm not saying it is an addiction. Not everything is an addiction. Again, the reward pathway is harnessed in many different endeavors. We mean, you know, we get dopamine arborization in the reward pathway when we learn. So, you know, and that's a good thing. And in other effortful activities. But it's all dopamine. Well, it's not all dopamine. But I mean, a lot of like what's pushing us. Yeah, that motivation is, at the end of the day, dopamine is probably the most important neurotransmitter when it comes to motivation.

In fact, an interesting experiment trying to distinguish between motivation and pleasure. Scientists engineered a rat so it had no dopamine at all. And yeah, so a de-dopaminized rat. What did that poor guy do? I know, poor guy. I know. Poor guy. And when they put food in the rat's mouth, it would eat the food and seem to enjoy it, however much you can determine that, you know, looking at a rat. But the rat ate it and chewed yummy. But when they then placed that food a single body length away from the rat, the rat starved to death. Whoa.

Right? So this distinction between liking and wanting is really interesting. And dopamine probably has a lot more to do with wanting more than liking. So it's that motivation to go get the reward that is so key with dopamine. And by the way, how does our brain get us motivated? It puts us in a dopamine deficit state. That's craving, right? We're in a little mini dopamine. So for example, if we, let's say I'm addicted to alcohol, I go by the bar where I would normally drink. As soon as I see that bar, I have a little mini

spike in dopamine above baseline, that kind of euphoric recall, just thinking about it. But no sooner does that spike happen than I get a little mini dopamine deficit state. It doesn't go to baseline. It goes below baseline. Then I'm in craving. And patients will describe really literal physiologic sweats, stomach aches. And then the intrusive thought that the only way to feel better is to go and get the drug.

And then we're driven to go get it. And then we get a much bigger spike of dopamine when we actually ingest our drug. It makes so much sense what you're saying about the rat when you talk to people that are depressed. Because one of the things they say is they don't have the motivation to even get out of bed. It's very hard for them to get out of bed. So when they're at this dopamine deficit state, for them, there's just no momentum. There's nothing to get them moving. Right.

So when patients come in to see me, and often their chief complaint is depression and anxiety. It's not, can you help me stop drinking alcohol or can you help me stop playing video games? But what I will often recommend as a first pass is a month of abstinence from their drug of choice. And I explain the pleasure-pain balance and the way that there's this opponent process mechanism. The gremlins. The gremlins. Thank you. And they're very skeptical that a month of dopamine fasting is going to reset the reward pathways. But if they're willing to do it, 80% of them will come back after a month and describe that they feel much better. And the reason for that is because they've been in this dopamine deficit state. If they abstain, the gremlins hop off. They start

to make their own dopamine again. And then they restore homeostasis. And they're able to take pleasure in more modest rewards. Telling someone to just abstain, to just take time, just, hey, put the video games down, stop gambling for a month, whatever it is, stop drinking for a month. Is that enough? Or do you give them tools that aid them in abstaining? Is there something that you can do? Like, is there a guidebook or a framework that they can follow? Yeah. So, I mean, I've developed this acronym, which you probably don't want me to go through. Sure.

Please do. Okay. We have all the time in the world. Okay. Okay. Well, first of all, let me say, you know, this is a spectrum disorder, and people on the very severe end are not going to be able to stop on their own. Those are individuals who have to go into hospital or go into a residential treatment

setting. For games? Oh, yes. Really? They go to hospitals? Well, into a residential treatment setting. For games? Oh, yes. Really? They go to hospitals? Well, there are residential treatment settings for video game addiction. So they just lock these kids up and no games? Yes.

And you isolate them in a building and force them to read actual books made out of paper or something? Well, you know, hopefully you're not forcing them. I mean, in some countries this does happen by force. Here in the United States, try to make everybody on board with the plan with the hope that, you know, they'll feel better if they abstain for a month. But recognizing that in their current environment, their willpower will not do it. And that's just a matter of the severity of the illness. But for people who have more mild to moderate addictions, this outpatient approach of the dopamine acronym, which is basically D stands for data, gather specific information about how much you're using, what you're using.

The O of dopamine stands for objectives. Why are you using? What does it do for you? It numbs me. It's an escape. It makes me feel better. The P of dopamine stands for problems associated with you. So really thinking aloud about what are the negative and unintended consequences, like you did with video games, realizing, wow, I'm up all night and I'm exhausted. I am not ready for the day.

Just writing that down or expressing those to another human being really makes it alive for patients that it's not necessarily going to be when it's just pinging around in their heads. So you make them write it down. Write it down. I have to stop gambling or whatever it is. How many hours a day are you in gambling? How many hours a day are you spending doing it? How much money are you actually winning or losing?

Why do you do it? What does it give? It's validating that it does something positive, why do you do it? What does it give? You know, it's validating that it does something positive or people wouldn't do it, but also having people really talk about what they're actually doing. So it can't remain hidden in that dark closet of denial. Is cold turkey the only way to get off of that? Or is there a slow drip method? Yeah, yeah, yeah. Great question. So the A of the dopamine acronym stands for abstinence or this four weeks of abstinence. You know, so I mean, maybe some people can gradually

taper. And obviously, if they're physically dependent on something like alcohol or Klonopin or opioids, they wouldn't want to cold taper. It could be dangerous. So they'd want to do a medically supervised taper. But in my experience, for people who are on the addiction spectrum, if they're able to just stop, it's better than if they try to go down slowly. There's something about abstaining for a single month that people can wrap their head around. It's not a lifetime. It's 30 days in the broad scheme of things. You know, can you do that? And what I warn patients about is that they're going to feel worse before they feel better. Their pleasure-pain balance, once they get rid of that constant

reward, will tip to the side of pain. And in those first two weeks, they're going to experience withdrawal. But if they can just wait long enough and get to a month, the gremlins will hop off, homeostasis will be restored. And, you know, again, 80% of folks and get to a month. The gremlins will hop off. Homeostasis will be restored. And, you know, again, 80% of folks will come back a month later, those who've been able to do it, and say that they feel a lot better. Now, that other 20% are individuals who probably have a co-occurring psychiatric disorder, anxiety, depression, whatever it is. That's also really useful information, right? depression, whatever it is. That's also really useful information, right? Like, okay, we need to treat this co-occurring psychiatric disorder at the same time that we address this compulsive overconsumption problem. And then the rest of the acronym, just really quickly, is DOPA, M stands

for mindfulness. This is what I was talking about before. Instead of trying to do something to escape feeling bad, just tolerating it for a period of time. The N, wait, dopamine, can I spell? You forgot your own acronym? I can't spell is the problem. Dopamine, mindfulness, I stands for insight. So I'll have a lot of patients who will say to me, wow, I didn't really think I was addicted until I tried to stop. And then I realized how much I had become dependent on it. So there's really a lot of insight that's gained. The N stands for next steps. When patients come back after a month of abstaining, we talk about the pros and cons. And then we make a plan for the next month. And then the E of dopamine stands for experiment. With this plan in place, whether it's another month of abstinence or whether they want to try to go back to using,

but using in more moderate amounts, which is what most people want to do. Then we make a plan for that. What kind of self-binding strategies can they put in place so that they can use less? Because most people want to use less. So that month of absence, not only does it reset reward pathways, but it also allows people to look back and see true cause and effect. Because when we're in our addiction, we really can't see the true impact of those behaviors on our lives. Yeah, you just kind of get caught up in the momentum of it all, right? Yeah. When I was talking about people that are addicted that eventually go into endurance sports,

it seems like there's something about endurance sports in particular that is very attractive to people that are former addicts or recovering addicts in that you are you're completely at the mercy of this activity while you're doing it like um my friend john joseph he is, he's the lead singer of the Cro-Mags, this band, but he's also a hardcore triathlete, and he was an addict when he was younger. And he now abstains, lives a very healthy lifestyle, eats very healthy. And all he does is, I mean, he trains constantly because he goes on these massive bike rides these long swims and it seems like the difficulty of these endurance sports whether it's running or ironman or any of those things like it's it's so hard to do that you have to be in the moment you you're you're thinking about every step you're taking as you're running

because you're exhausted. You're thinking about every breath. You're thinking about every stroke of your arms when you're swimming. It's not something you can fake. You have to actually do it, and you have to actually do that work. And there's something about that that's very appealing to a lot of former addicts. There's been quite of former addicts.

There's been quite a few addicts that fight in MMA as well and one of the things I noticed about them is so many of them are incredibly determined, like unusually determined, like unusual endurance, unusual work ethic, unusual ferocity in competition and I wonder if that also is like whatever led them to be an addict, to be like obsessed with drugs and just ruining their life. When they turn that around and can focus it on something positive, they have an extraordinary amount of focus.

Yes, I agree with you. I mean, I think people with addiction are some of the most tenacious people that you will ever meet. And when they can redirect this tenacity to something that's a more adaptive behavior, and I do think sports can be that. You know, it's a very good thing, and they tend to be very successful at it. The other thing I would say is I think that many of us seek that state of non-being where we're just not thinking or not thinking about ourselves. Yes. And drugs are a way to get there, but there are other ways and these intensely, let's

say painful, and I know you don't love that word, but I think of it as painful, you know, physical activities or endurance sports. They also are a way to escape ourselves because we're so fully in our bodies when we're doing them that we're not, you know, dealing with our constant ruminations. Well, I think with endurance sports, I would call it painful. Yeah. You know, it's particularly like long-term running, long-distance running. They all talk about the ability to drown out the pain. Right. That's, you know.

And it also becomes a way to achieve a new set point, a new hedonic set point or a new joy set point. Joy set point. Joy set point, hedonic set point. Because again, they're in these like increments on a regular basis. They're pressing on the pain side. And then the neuroadaptation happens to the side of pleasure. So it's a way that they maintain a kind of baseline positive increase in dopamine levels.

It seems to me like to be an extreme winner, though, and I keep coming back to Michael Jordan, to be a person like that, you almost have to be an addict. Yes. Right? Yeah. You have to have that single-minded pursuit. I mean, I guess maybe we need to better define what is addiction. Right. Because if they're very healthy, and they're doing really well, and maybe they've narrowed down their obligations outside of that, so all they do is focus on maybe just their narrowed down their obligations outside of that. So all they do is focus on maybe just their family and then their work. And that's okay. I mean, addiction broadly defined as the continued compulsive use of a substance or behavior despite harm to self and or others. And if there's not harm to self and or others, then it's probably not an addiction, even if it's a very intense,

focused endeavor. The problem is that a person who is in their addiction may not be able to see the harm to self and or others, whereas people around them can see it. And I think there's also a problem in that it's just part of being a human being in America. We value success that's measurable above all other. Like when we think about a person that's successful, say if a guy is a businessman who works 12 to 14 hours a day and he's worth a billion dollars, but his personal life is a shambles. We don't think of that. He's been divorced five times. We don't think of that. All we think about is like, that guy's worth a billion dollars. He's the head of blah, blah, blah company. And he's got his own jet. That's what we think of.

We don't think of the consequences and what the rubble of his life that's laid out other than the financial success. Right. And one of the interesting things as a psychiatrist is that I really get to look under the hood of a lot of different types of people, including a lot of people who on the outside look like they have it all, but on the inside are really, really suffering. Give me an example without revealing the person. Oh my gosh. I mean, so many, you know, I mean, I work in Silicon Valley. I see incredibly wealthy people, you know, brilliant scientists, really smart people, you know, who on the face of it, you would never in a million years imagine that they're struggling in any way,

much less with a serious addiction, but they are. What are their addictions? Oh my gosh. Pornography addiction, gambling addiction, drug and alcohol. I believe Adderall is a big one, right? Especially with people that work in tech. Yes. I see that a lot. Yeah. Journalists too. A lot of journalists get addicted to Adderall. Okay. Yeah, that I've never seen. Yeah. I have friends who are journalists who say, like, you'd be amazed. It's like 9 out of 10.

Yeah. Because I've not tried it, but apparently it's amazing. Right. Have you tried it? No. Do you avoid everything like that? Yes, I do. Everything.

Well, I would imagine. That's your business. Yes. Except for endurance sports. Oh, you endurance sports. That's my thing. What do you like? I like biking and hiking and swimming. That's about all I like. Those are good ones because they're low impact. They don't destroy your body. Exactly.

Unless you crash on a bike. Right. There's always that danger. Yeah, but still the impact is so much better. Yes, yes. Yeah. But still, the impact is so much better. Yes. Yes. Yeah. Yeah. Yeah. I mean, I have a regular practice of biking up Page Mill Road in our neighborhood, which

is a very steep mountain. And I never want to do it before I start out, but I'm always happy afterwards. So you've developed your own mitigation methods for dealing with all these problems that we're talking about. Absolutely, I have. Yes. So say if you have a person that is dealing with maybe a pornography addiction or something like that, and you encourage them to abstain from a month, do you also encourage them to engage in some sort of difficult physical activity? Yeah. So, I mean,

it depends on the person, right? If like sports or exercise is not really their thing, I still encourage it, but I don't expect that that will be the solution for everybody. But I absolutely prescribe other effortful activity, difficult cognitive activities. Creative endeavors are great. Like, for example, you know, when you're getting ready for stand-up, right? Like, really engaging and creative, and you get an idea, and, you know, you showed me kind of your notes, and then you're thinking about it and puzzling out how to best present that idea. That's so great because it's this really focused flow, definitely leads to a good type of dopamine. Prayer, meditation, any spiritual practices, super, super important.

I do believe that we have a part of our brain that's, you know, evolutionarily designed for prayer. And so when we can engage that in some ways, that's super helpful. You think there's a part of the brain evolutionary designed for prayer? Yeah. That's interesting. Yeah. So is it just thankfulness? Is it a worship? Like what do you think it is? I think people call it by many different names. I mean some people call it gratitude being in gratitude for other people it's my meditation practice for other people it's you know prayer, the way we usually think about that. But there's no doubt in my mind that, like, there's a part of our brain that needs to be active in that regard. And if we neglect it, it's not great for our mental health. So if my patient has any kind of pathway to any kind of

spiritual practice, I ask them, you know, what kind of spiritual practices are you familiar with? Have you tried? And I recommend that they do that too. The other thing that I also often recommend in that month of abstinence is that they tell no lies, not about anything, not even little white lies about, you know, why they were late for a meeting. And the reason for that is really something that I learned from my patients in recovery, that telling the truth about all things is absolutely key for recovery. And I've explored some of the neuroscience behind why that is, but I actually prescribe that to patients when they're trying to quit a substance or behavior that they've become addicted to.

That's interesting. The prayer thing, I'd like to get back to that, though. Where do you draw this from? Like, why do you think that there's like an evolutionary need for prayer? Okay, so I'm still studying the neuroscience of that. I'm thinking about that for maybe a future book that I'm writing. So I'm still sort of at the neuroscience of that. I'm thinking about that for maybe a future book that I'm writing. So I'm still sort of at the tip of that. But there have been interesting studies sort of showing the parts of the brain that light up when people are engaging in meditation or people who have very strong meditation practices or prayer practices, how their brains might be the same or different.

I'll have to come back another time when I've learned more and tell you about that. But you're pretty confident there's something going on with that? I do. I do. Yes. You know, my clinical work, I mean, so many people in recovery have gotten into recovery through a spiritual practice of one sort or another. And I just think it's fundamental. And it's been really important in in my own life um you know having this kind of like just for lack of a better word i'm just going to call it spiritual it's sort of

a loaded term um but i think you know some kind of practice that that sort of you know relates to transcendence hmm transcend so does that it's it's interesting because there's a real argument that that's been a part of human beings from the beginning of time. Yeah. Which is fascinating. Yes. I always wondered why. One reason why I think we struggle with this today is light pollution. And I got this out of an experience that I had once in Hawaii

where I went up to the Keck Observatory. And it was the first, I've been there several times, but this is the first time and the only time I really nailed it in that we got there at a perfect time where there was no moon at all and you get to see every star. It is spectacular. It's very high up in the mountains, so high up it's on the big island that when we were driving we had to drive through the clouds and i was like oh no it's cloudy this

is gonna suck and then you drive through the clouds and then all of a sudden you're at the top where the observatory is i forget how many thousands of feet up it is, but it's very high up. And the image of the galaxy, when you see the Milky Way in front of you, it is so humbling. It's so humbling and majestic and magnificent. And it's so valuable. I remember thinking, how did we ruin this view with like street lights? Because that's what we did. We've eliminated this image, which I think was with human beings from the beginning of time. And when human beings start to take into consideration their environment and the parameters of their world and where things are.

And then you're faced with this impossible vision of size and of scope and of just this epic proportion. When you see all the stars and you see how big it is and you can't imagine that those things are literally thousands of light years away and you're looking at this you're like what is all that yeah this is crazy yeah and i think there's something about that that instills a very just a natural sense of awe that we're missing i think it's one of the reasons why people are so detached. I mean, ancient cultures and ancient civilizations always look to the skies for their gods.

You know, I mean, there was gods in nature, there was gods in the water and all sorts of gods, you know, that had to do with all sorts of spectacular things that were on the ground with us. But the big theme with so many of them was the gods in the heavens. And I think it had something to do with the epic scape of the sky when you would look up and you would see, and we don't see that anymore. Yeah. I mean, so awe is a really interesting emotion, which has been defined as that experience of encountering a stimulus that is more than our mind can process. And I think that's an interesting definition because I think there's something to that. It's kind of mind exploding. It's both wonderful and terrorizing at the same time.

To me, that's awe and that's that kind of feeling that you get or that I get, you know, when looking up at the stars. And I do think you make a really good point about overstimulation. One of the things that I noticed during quarantine, which of course was tragic for people who were ill, for people who, you know, had family members die. But I saw for a lot of my patients, it was actually a really positive experience because it was de-stimulating. It was like all of that frantic running around and all of that sort of, all of those constant, you know, stimulating multiple interactions with multiple people a day,

it all kind of went away. And for some of my patients, it was like, oh my gosh, this is what, this is how my life needs to be. Like that way I was living before was really crazy making. So I think, you know, I think you're absolutely right. I think there's a way in which we're all overstimulated. And that way we really need to dial that back for our mental health. I think we're definitely overstimulated. And I think there's definitely an argument that we learned something from the pandemic with a lot of people. They're able to work remotely. They're working from home. I think that's great too. But what I was getting at is just the whole need for prayer and this understanding that we are part of something that's so immense. Any sort of egocentric ideas that you may have are preposterous when you're faced with the Milky Way.

Yeah, right. I mean, so a central aspect, just bringing it back to addiction and recovery, is humility. And that experience of feeling yourself as very small potatoes, you know, and how healthy and good that is. Even though, you know, oftentimes it comes with a very painful experience or feeling of brokenness or feeling like, you know, you're not good enough. Well, you know, when we can arise from that and sort of hang on to that humility, I think it's really, it's a very good and positive thing in our lives. Yeah, I think so too. And the experience of nature, you know, I grew up in the Northeast and the Northeast gets very cold in the winter and you get a lot of snow.

And it's, you know, I lived in Massachusetts and it gets it's just part of life. You have to deal with that. There's none of that in California where, you know, Los Angeles at least. And I remember thinking of Los Angeles like these people don't understand nature. Like you're only encountering nature occasionally. Right. And I think there's a there's a spoiled child aspect to the people that live there because of that they have this detachment from the real the real place in the overall spectrum of life they feel like it's all revolving around them which is really the perfect place to set up something like hollywood right where you know the goal is to

make it all about you the goal is to get a show or a movie where it's all about you. That's weird. And so this sort of lack of dealing with the consequences of the world and the environment itself, like snow and rain and, and all that. I mean, occasionally deal with fire. And when you do deal with fire, people get so much more humble. It's so fascinating. They calm down and they realize like, wow, okay, where we really are, at least for now, all in this together. Yeah. I'm always amazed at how good I feel when it rains, like just the rain outside, like it calms me down. In California, sure. Well, we do occasionally get rain up north. But I mean, just how that kind of restlessness,

in me anyway, kind of quiet with a good thunderstorm. Yes. But I would argue that this is not just an L.A. problem. I would argue that this is a modern rich nations problem. Yes. You know, we're very detached from nature. I think all the time that people are spending on screens. I mean, some people's only experience of nature is like, you know, a Photoshopped version of it.

Right. So this is something that I think, you know, ideally we would all get, you know, back into nature. I remember watching recently one of your episodes because my son was trying to get me, you know, prepped for this. And he showed me an episode where you talked to these folks who had gone out, I think, and were hunting. And they got attacked by a bear or something. Oh, yeah. My friend Steve Rinoa. Right, right. But, I mean, I think people really crave those types of experiences.

Being attacked by bears? Well, you know, something that feels… Humbling? Yeah. And sort of real and like at survival level. I do think we need that. Yeah. No, and sort of real and like at survival level. I do think we need that. Yeah.

No, I think so too. I think there's something about it even as terrifying as like an encounter with a bear where it sort of lets you understand like you are walking through life with blinders on. Right. Which is why, you know, there's a pretty robust therapeutic intervention for people with severe addiction, which is called wilderness. And of course, you know, there's a lot of criticism of different types of treatments, but that can be really transformative for some young people to be out in nature. My friend Dan Doty does that. It's one of the things he does. He takes folks out and and especially young guys and that have like real behavioral problems and and he they camp and they live off the land meant to live any way because I think people are meant to live a bunch of different ways. There's a lot of people that are very happy doing things that wouldn't make me happy. And I think there's obviously a lot of variety with human beings.

But I think that the way our bodies are designed is not much different than the way the bodies of people that were designed 10,000 years ago were, or people that lived 10,000 years ago were rather. And those people, their lives were around community. Their lives were around their whatever crafts and whatever skills that they had to develop in order to survive and contribute to the tribe. Hunting and gathering. And then it was about raising children and teaching them the rituals of adulthood that were all designed to facilitate your growth and advancement so that you could contribute to this tribe. So that everyone could all sustain and stay alive together and feed each other. And that's how human beings lived.

And now we're talking shit on Twitter. And you know what I mean? And now we're staring at TikTok all day and now we're doing all sorts of weird things that we're not designed for. And that's one of the things that led me to my video game addiction. I was recognizing that I'm not designed for this.

Like that it was, this was a hijacking of whatever systems that I had that were in place that craved excitement and stimulation. And I was getting this digital version of it, which if you could handle it, it's really fun. But if you can't handle it and if you're a person like me who obsesses on things, you know, you could say an addiction or you could say, why do you choose to call it? Why do you think it's an addiction or a disease rather than an addictive personality disorder? So, I mean, that change in language has occurred over approximately the last 20 years or so, moving away from calling it like an addictive personality to calling it the disease of addiction. And the reason for that is, I mean, there are many reasons. One is just the simple neuroscience, the explosion in neuroscience,

showing real brain changes that occur as people become addicted, and the physiologic, you know, differences in dopamine levels and this dopamine deficit state that continues even with protracted abstinence, which I think is really powerful. But there are also practical reasons for calling it a disease. A disease allows for more research dollars. A disease potentially improves access to treatment because it destigmatizes. So when we call it a disease and we treat it like a disease in the healthcare system like any other, people get better at the same rates that they do from other chronic relapsing and remitting disorders like type 2 diabetes, heart disease, obesity. So I think there are just practical reasons as well for calling it a disease.

And again, you know, you and I have used the term loosely to define a broad spectrum of behaviors and a broad spectrum of severity. And when I do that, it's not at all to trivialize severe addiction and the kinds of very serious life consequences that it has for people. It's rather to explain that the same neural networks that drive compulsive overconsumption of checking our phones is at play in people who become severely addicted to drugs and alcohol. It's really just a matter of severity. The brain itself varies, right? Like human beings, their desires, the things that they seek out, the kind of artistic and creative endeavors that they seek out, the pleasure endeavors that they seek out, all the different things that they seek out. When you're dealing with an individual patient, you call them patients? I do. Yes. Cause yeah, cause I'm an MD. So they're patients. If I were a psychologist, typically the nomenclature is that they're clients. When you're dealing with a patient, how long does it take you to sort of

sort out what type of personality they are, like where they fall into and maybe what is this addiction coming out of abuse when they were young? Is it coming out of maybe, how do you do that? Yeah. So one of the things that I have concluded is that there's no point initially in spending a lot of time trying to figure out, number one, why the person got addicted, or number two, whether or not they'll be able to get better. Number one, it's a waste of time to figure out why initially, because it doesn't matter. Whatever your doorway into addiction was, once you develop addiction, the intervention is the same and recovery starts with abstinence and requires all of the interventions that we do. Later on, you can spend time kind of trying to unpack, gee, how did we

get here? What are some of the early antecedents, including like childhood antecedents or trauma? Although, again, there's a danger there in focusing too much on the why and not enough on, okay, how do I get better? Right. The other thing that I've learned after many years of being a psychiatrist is that I am terrible at predicting who's going to get better and who isn't. I used to think that I could tell when someone walked into there, oh, this person's, oh, they're going to do great. And this person, there's no hope. Not true. I have had many patients I thought, wow, this is nothing I'm going to be able to do for this person. You know, miraculous recovery. Other people I was certain would, you know,

get better in a jiffy. And no matter what I did, I couldn't help them. So I don't predict anymore. I don't try to predict. I just take each person as they come and just try to, you know, essentially be a witness to their journey. Interesting. That is so telling, right, this idea that you can't predict. Yeah. And that some people, you see them, you go, well, this person's successful. They're well-educated.

They're clear-minded. They've got a directive. They're going to go, they're going to figure this out. Right. And then, nope, doing heroin again. Yeah, yeah. Right. And one of the really, the tricks, or at least my Achilles heel that I've learned over time is if I identify with the patient, I'm more likely to think that they're going to get

better and more likely to think that they're going to get better and more likely to miss some key things. Are there any sort of standard things that you notice about people who do well versus people who don't? Is it a denial thing? Is it people who are more deceptive or can trick other folks into thinking that they're OK? Maybe people who are more charismatic? Mm or, you know, can trick other folks into thinking that they're okay? Maybe people who are more charismatic?

Yeah, it's a great question. I mean, insight is certainly useful. So when people have insight into the fact that they are addicted, that is helpful, but that's not necessarily a guaranteed winner. I have had patients who have incredible insight into their addiction and don't get better. So that's not the key, although it's helpful. One of the things that I've noticed over the years is that if I have a patient who comes in and they tell their story in a way that blames everybody else for their problems, that person is... They're fucked.

person is... They're fucked. That's the case with everything. Let me just say it's a slow road. I wouldn't say they're totally not going to get better because one of the very interesting things that happens in the process of recovery is people start telling their story differently. They start... Interesting. Yeah. And that's, of course, part of the 12 steps of Alcoholics Anonymous is kind of acknowledging our part and our responsibility and where we've contributed to the problem. And when people are in really good recovery, they get really good at that. Because, of course, it's a muscle, too, that you practice. And they, you know, are constantly taking their inventory, saying, okay, you know, where did I, how did I, I'm feeling uncomfortable, you know, how did I, where did I mess up on this? So that's really interesting.

Alcoholics Anonymous is always referred to as Friends of Bill, right? Yes, it can be, right. And that's based on the guy who started Alcoholics Anonymous, who developed this 12-step program. You know, he was into LSD. So I don't know much about that history. Enlighten me. Well, I think it was something that they felt was very controversial to the point where they didn't want to have it a part of the program. But what I've read about him, and Jamie, see if you can pull up the history of Alcoholics Anonymous and LSD.

And Jamie, see if you can pull up the history of Alcoholics Anonymous and LSD. And Wilson wrote a letter to Heard saying, I'm certain that the LSD experiment has helped me very much. I find myself with a heightened color perception and an appreciation of beauty almost destroyed by my years of depressions. Most Alcoholics Anonymous people were strongly opposed to his experimenting with a mind-altering substance. And then there's another one from The Guardian. LSD could help alcoholics stop drinking. AA founder believed.

This was all in – when was this? What was the year? I want to say it was in the 40s, right? When did he experiment with LSD? This article here says 20 years after setting it up in 1935, so the 50s, 55? Oh, okay, the 50s. Well, when did Hoffman synthesize LSD? Because it was before there was a stigma attached to it, right? There was a sweeping psychedelics acts of 1970, which essentially made all these things that used to be used for clinical research illegal, including MDMA. And well, MDMA was later, but-

43. 43. So these people were, there was no stigma attached to using these substances that in many ways, I'm not, and I've experienced LSD, but I'm not an enthusiast. I haven't had enough experiences to really talk about it. But one thing that people who have had multiple, like, very heavy trips have told me is that they gain an insight into themselves that they don't think is available without it. It removes them from them and allows them to look at themselves in a deeply introspective way. This is also true of Ibogaine. And Ibogaine has had tremendous impact on people with addictions,

including a friend of mine, my friend Ed, who started up a clinic in Mexico. He got addicted to pills. He had a back injury and got hooked on opiates and was trying to find some way around this and trying to figure out what to do. And in the process, he found out about Ibogaine, had an Ibogaine experience. He did a session and then completely cured himself of that and then wound up opening up his own Ibogaine retreat because it was so beneficial to him and he wanted it to be available to other people. What are your thoughts on those sort of treatments? I am not an expert in that area. I haven't taken the time to really research it.

research it. In general, I always have concerns about using, you know, a potentially addictive mind-altering substance. I don't think Ibogaine's addictive. I think it's so brutal that nobody wants to do it again. If you do want to do it again, you want to wait a long time. I don't think it's addictive. So it may not be addictive for the vast majority of people, but for my patients who are vulnerable to addiction, it definitely can be. Because anything that leads to a mind-altering experience of that kind of potency and intensity will be a draw for them. You know, it's like a 24-hour thing. Uh-huh. It's a 24-hour trip. Right.

Have you ever experienced it? No. No, I haven't either. Yeah. I mean, again, for my patients, the longer the better, you know. So I am open to the possibility, and I do understand what you're talking about. I do believe that, you know, getting a totally new perspective on our lives can be life-changing in a positive way. Here's what I wonder, though. I wonder if there are other better ways to get there than through, you know, this kind of microdosing. Well, I don't think this is a microdose. I think the Ibogaine thing is a tremendously powerful and often painful experience for the people that get involved in it. But there's also – Google, what is the mechanism that helps addicts with Ibogaine?

Like what method does – in which method does Ibogaine help addicts with addiction? Because there's something that happens where it rewires certain aspects of the brain. passed through the FDA and how to get it brought through the, you know, whatever the regulations are in America and start to slowly implement this sort of therapy for people that have had consistent problems with drug and alcohol abuse. But it's also, again, I'm talking out of school because I haven't had this experience, but for the people that I know that have had it, it's the same kind of thing like this ruthlessly introspective thing that doesn't allow you to bullshit yourself and forces you to look at your life and look at all these addictions that you have for what they are and what their sources are. But then on top of that also rewires the pathways that cause addiction. Again, I don't

know too much about this. So yes, and I will be the first to Again, I don't know too much about this. Yes. And I will be the first to say that I don't know too much about it either. And that I do know, though, that these are done, that the studies are done under very controlled circumstances, often involving psychotherapy. So it's like psychedelic mediated psychotherapy. So it's not usually just the drugs by themselves. Right. It says Ibogaine seems to influence withdrawal in two primary ways. First, it helps regulate levels of dopamine and serotonin in the brain. Ooh, your favorite subject. Both of which are chemicals associated with pleasure and the feelings of well-being. Second, it helps restore damaged areas caused by long-term substance abuse. So then it goes into detail about the regulation of dopamine and serotonin,

how does Ibogaine work, control release of the feel-good and reward chemicals in the brain. When certain substance or alcohol reach the brain, they can attach to specific receptors like those that stimulate the dopamine command centers. Think of a lock and key mechanism. If the drug, which has a unique chemical shape, finds a corresponding keyhole on the command center, it activates the center and tells it to release its chemicals such as dopamine. Ibogaine is able to work by regulating dopamine surges that occur in addiction

because it can inhibit the access to some of these dopamine receptors. In other words, it gets in the way and will not allow the drug like an opioid or an opiate to attach to the receptor and stimulate it. Ibogaine can also block transporter molecules that work to shift dopamine into brain cells. This is interesting stuff, right? Yes. What do you think about this? Well, I think it needs more research. Right.

Yeah. Yes. What do you think about this? Well, I think it needs more research. Right. Yeah. It'd be nice, though, if that would just blast off on Ibogaine and then go, Doc, I got it. Thank you. Give me a hug.

Appreciate you. I'm not doing heroin anymore. Yes. That would be wonderful, except that history would say that whenever there was going to be a new drug that was going to fix addiction, it usually didn't turn out very well. Yeah, but this is a new. Well, OK. A new old drug.

Yeah. I don't know. You know, I wonder. Well, listen. I wonder because of my friend who has a very positive experience. And you know what? That's important. Right.

But we also need to think about the set and setting, as they talk about, of how it was done. And we need to think about the potential public health consequences of something like this being more readily available. So it's always going to be risk, benefits, and alternatives when we're thinking about the utility of any medication. What do you think public health issues would be if it was readily available? Misuse and diversion, right? People not using it the way that it was studied to be used. People using it, self-administering it. And again, not with Ibogaine, but with psilocybin, MDMA. I have patients who are in recovery who relapsed because they decided that they wanted to have this kind of spiritual awakening.

It was lacking in their lives. So they got one of these substances on the dark web, self-administered, and were administering every 10 minutes for a week and ended up in the ICU. So that's the world I'm coming from. I understand your concern. Yeah, that makes sense. I'm all for adults being able to make their own informed decisions, though. And I think that the way they have these things set up, the way I know they have set up in many of these clinics,

is you're dealing with people that are trained professionals that have had these experiences personally and have had great benefit from it and they're dedicated to guiding people through this addiction process. But then I don't think you have to worry about Ibogaine as a recreational one. As I said, I don't think it's fun. Mushrooms, I think, is a different experience, and I think it is fun. But do you think that substances like that can be used responsibly without the threat or the danger of addiction? Yes, yes. I mean, when I talk about self-binding strategies, one of the self-binding strategies that I talk about is categorical self-binding, meaning that we put the substance into a category. And that can be a category that we either will use or we won't use. But one of the categories is actually the category of the sacred. And that

would include, in a way, the category of medications administered by modern day shamans, you know, doctors potentially, right? Because when we regard these molecules as sacred and special, we develop rituals around using them. We use them in discrete ways that have shown to be helpful. We don't use them in other contexts. I absolutely think there's a role for that. I'll never forget, I'm not remembering the details of like what society or village this was, but I remember reading about a quote-unquote primitive village, you know, some many years ago, where the entire village would become intoxicated, including children, one day a month. But they all did it together,

and it was part of a sacred ritual. So it wasn't like a binge drinking pattern of addiction. It was a sacred substance done in a safe, ritualized way. And I definitely think there's, you know, a role for that, for sure. The problem is when, you know, we sort of ignore set and setting, when we ignore the sacredness, so we use more often, when we, you know, don't respect that ritualized environment, which is so necessary to keeping it safe. Right. The difference between a sacred shamanic setting versus the way you feel when you go to the bar to have a few beers. Yes. Right. Or just trying to even, you know, even if you're telling yourself, I'm going to have, I'm doing this because I'm going to have a spiritual awakening.

So I'm going to do it with my friend, you know, at the top of Kite Hill. Probably not a good idea. Yeah. You could fall down too. I, I, you know, I always wonder about these things like what would happen if they were made freely available and legal and how much abuse would happen and how much we could mitigate that abuse with education and just time. I mean, there's plenty of abuse of alcohol. Right. Right. But we allow alcohol. Well, alcohol is legal. But there's no real benefit other than social lubricant. Occasionally, you know, you come up with some great ideas when you're a little lit. But the benefit of psychedelics is so well established in terms of the way it makes people reframe their life, the way it shifts your

perceptions and allows you to think of things in a different way that might not really be possible without them. There's nothing like them. You know, again, I think we need more data. It's not clear to me that the potential benefits outweigh the potential risks. For addicts? Right. For certain individuals. And, you know, how would we screen to make sure that, you know, the right people get it in the right way? I just really think that we need more data. And the good news is that research is very active now. And a lot of, you know, young people that I mentor are really excited about this area. So there's a whole generation of people coming up who are excited about this and are working on it and want to work on it. And I think that's great. I just think we need to wait, wait for more data.

Well, thank you to MAPS and Rick Doblin and all the great people that have done some incredible work with psychedelics and working with people with PTSD and all sorts of issues and doing it the right way. Doing it with controlled studies and doing it with, you know, out in the open and completely legal and approved. Yes. And they found great benefit with some of these things, particularly like MDMA with people with PTSD. That's one that they're working on a lot with soldiers and with other people that

have experienced trauma. I'm open to the idea. Yeah. Yeah. I'm open to the idea. I'm not convinced. I understand. Sorry. It's okay. No, I get it. How often do you find people that are actually healthy, like mentally healthy? Like what, I don't want to say what percentage, but is it a rare thing to find someone who's truly balanced? Or how many people are kind of like keeping it together, but behind the scenes, barely hanging on? Well, I mean, I think some of the healthiest people that I have ever met and will ever meet are people with addiction in robust recovery. Interesting. Yeah.

So like there's almost maybe a benefit in recovering from addiction? Absolutely. Really? Oh, yeah. And, you know, I hear that all the time from patients in recovery that they're actually grateful for their addiction because without their addiction, they would have never found recovery. Wow. So recovery and sort of the structure that it provides has been so beneficial to them in giving them like a clear, like a scaffolding or a framework for life that it's better to have gone through it. Yes, a little bit. You know, we were talking earlier about humility and how important, you know, humility is to a life well lived.

And there's, boy, nothing that will humble you more than, you know, getting seriously addicted and having to crawl your way out of that. So, yeah, these are incredibly courageous, humble, wise people. And I've learned a lot from my patients. Isn't it fascinating that that seems to be a tenant of most religions? Is this humility, humbling yourself towards God, humbling yourself towards the divine? Yes. Yeah, I think so. You know, I think that self-aggrandizement is really at the core of so much of our suffering. And when we can figure out how to let that go, we're really free and ultimately, you know, live better lives. I think it's also not just the feeding of the ego, but why the ego wants to be fed.

Like, what is it about you that wants to proclaim yourself that you're so great? Yeah, I'll never forget when I was pregnant with our daughter and I went around to different nurseries, you know, nursery schools to look for one that would fit her. And I was scanning the room, looking around at all these little kids. And this one little girl sees me scanning the room and she goes, look at me, look at me. I thought, my God, that's my younger self. But there is this, I mean, this has even been described in the psychoanalytic literature as a kind of a healthy narcissism. So not all narcissism is unhealthy. We need a certain amount of healthy narcissism.

What is healthy narcissism? It's where we're willing to invest our energy, our creativity, our libido into a project, right? Invest ourselves. It's also the area where we're most vulnerable to injury because once we've invested ourselves, if our competence is threatened, then we experience a narcissistic injury and that goes right to our core. It's incredibly painful. The most common reaction to that is narcissistic rage and retaliation. We'll find ourselves like retaliating, like not even maybe to the person who injured us or at another time that has nothing to do with the way that they injured us. But nonetheless, there is this

concept of healthy narcissism. It's when narcissism, you know, goes to like anything to a pathological degree that it becomes very bad. And unfortunately, our culture really feeds this kind of narcissistic self-preoccupation. Getting back to athletes, you know, I think that's one of the real dangers about being, well, a celebrity of any sort is that the media kind of wants you to, you know, to be all about you, even when you don't want it to be all about you. And what happens, you know, essentially, narcissism separates us from our tribe. You know, we stand out from our community. And when we do that, we're really deprived of the good kind of dopamine that we get from those close intimate attachments. So it's a very dangerous but

highly seductive thing because it's sort of the trope of our modern culture. And the opposite is very detrimental too, which is not having any sense of self-worth. Yes, yes, absolutely. That's probably maybe even harder because I think it's more easy or it's it's easier to dial it back than it would be to become confident or to become to have feelings of self-worth. who looks at all these other people and thinks everyone's better than you and you're not valuable and you're worthless. I mean, there are people like that out there for whatever reason, whether it's abuse as a child or whatever has caused them to think like that. That may be worse. I guess I wouldn't see one as worse than the other. I mean, I think pathological narcissism is really destructive for the individual.

Yeah, I shouldn't say worse, but I would want to say harder to recover from. Well, I mean, gosh, people recovering from narcissism, first of all, they don't show up very often in my office, right? Because they don't see any... They don't think they have a problem. Yeah, right. It's all the people, the dead bodies around them. Whereas people with, you know, like chronically low self-esteem and lack of confidence, that's in some ways more treatable because they're often more treatment-seeking. And the harm is mostly to themselves, not necessarily to other people. But just to turn it on its head a little bit, there's also a way to be narcissistic about being the worst person.

And that sometimes comes up in clinical care. Interesting. Yeah. Where there's a kind of- Self-loathing narcissism? Well, actually in AA, they call it terminal uniqueness. This idea that I'm the worst piece of crap that ever was. I'm so unique. Nobody can ever help me. That's how messed up I am. So narcissism can manifest in a lot of complicated ways. That's fascinating.

I never thought of it that way, but that makes sense. They wallow in their own self-pity. That's right. Yeah. But my perspective was just that from my experience and just people doing things that are difficult to do, that confidence is very important and it's extremely difficult to get someone to develop confidence. Whereas you can get a narcissist or at least someone who's kind of like made a mess out of their life to recognize how much of it is their

fault and how much of it is the way they interface with people around them and how much of it is these narcissistic tendencies that maybe could be exposed by experiences whether they're negative experiences or psychedelic experiences or maybe even just some sort of therapy where you're recognizing patterns in your life oh yeah yeah i mean you know for you know for the narcissist the treatment is you know the shattering of the ego and the the you know, engaging in a kind of selflessness and merging with others as opposed to seeking that self-aggrandizement. But I do, in my experience, people who have low self-esteem and lack self-confidence, they can also get better.

And again, their project is then, you know, engaging in difficult things in small incremental ways and seeing success and then being able to use that as a touchstone. Oh, wow, I was able to do that. You know, I can do the next hard thing and the next hard thing after that. And a little bit that's just getting back to like psychedelics. That's a little bit one of my worries, too, about that kind of intervention, because, you know, there are other ways to get to that top of the mountain. intervention because, you know, there are other ways to get to that top of the mountain.

And if you do it through your own hard incremental work over a long period of time, maybe you get to the same place as the person who used psychedelics, but you did it through your own work. And that means then your new perspective also relies on this touchstone of self-efficacy, which is why I like the idea of like psychotherapy better than this kind of like one-time medication thing. But those two can be combined too, potentially. Yeah, I think there's probably a bunch of different ways to get better at pretty much everything, right? But the idea is that you're focusing on getting better. Yeah, right. I've always felt like one of the things that's troubling for people, one of the things that we have a problem with is there's no real guidebook on how to live your life. That's for sure. And oftentimes bad parents who also have those bad patterns, they instill those bad patterns in the children and the children will install them in their children. And it's like this perpetual process.

Yes. And it would be great if there was some way to establish some guidelines of how to live your life. And it's one of the things that I think is so beneficial about these sort of tribal rituals that you were talking about is that people have these guidelines. And I think holidays and festivals and rituals and the thing about those things that are good is that they sort of establish some sort of structure. And for whatever it is about people, there's something about having

no structure that for a lot of people, it feels very lonely and confusing. Oh, for sure. Yeah. Oh, I mean, you know, it's amazing to me how often when I'm working with patients, I have to tell them things that really should be absolute common sense and things that they and try to show up and try to show up on time and tell the truth and all these kinds of things that we kind of knew once, but we sort of forgot. But you're absolutely right. Structure is really key. And, you know, the whole wellness movement now really is about trying to create guidelines for people to remember stuff that we seem to have forgotten. I think one of the more interesting things about your work that's very beneficial to people is recognizing what is going on.

Like recognizing that there are these chemical pathways, that there's these real things that are happening inside your mind, and this is not just some sort of a psychological, airy- just some sort of a psychological airy fairy sort of like an idea that these are this is this real science behind this. Yeah. And that really clearly resonates for people now. If you get them if you give them a neuroscience framework for approaching their lives, people that that's exciting for people. Whereas if like let's say I

were to use a religious framework or a moral framework people are not gonna cotton on to that in quite the same way at least some people yeah some people that's right especially people that really value sort of evidence-based things they write they want to know like what is causing this right and you see it and then maybe you can recognize in your own behavior, oh, I'm leaning into the gremlins. Right, right. I love that term too. Thank you. Yes. I had somebody contact me and say, you know, I'm trying to quit smoking. I've had a really hard time. But now whenever I crave a cigarette, I just think about the gremlins hopping on the

paints on my house. And he said, it's really silly, but it's really helpful for me, you know, because I know if I just wait long enough, they'll hop off and homeostasis will be restored and I'll be able to move on. Yeah, it's hard in the moment, though, right? It is hard. When you're gripped with addiction, it's hard in the moment. It sure is. Yep. You know, you talk about that little dopamine rush that you would get when you would pass by a bar if you were an alcoholic. Right, right.

I used to get that from passing by pool halls. I would see a pool hall. I'd get excited. I'd want to go in there and play. And I would say, well, that's something I enjoy doing, though. What's the big deal? But it was that, but it was also there's some element of escape that's a part of that. Oh, absolutely.

You've got to figure out how much of it is just fun and how much of it is you are avoiding real things in your life. Yes. And even if the original reason was to avoid real things in your life, when you get caught up in that loop, it's like a circling drain. It's hard to pull yourself out even when you want to. And that's where I think the neuroscience comes in and makes it more understandable. It's like, oh, wow. Okay, this is because it's happening in my brain. I've lost some ability to actually choose not to do this.

And just that awareness, I think, can help people. All right. Well, that was an awesome conversation. I really enjoyed that. Oh, well, thank you. Me too. Very enlightening. And please tell people the name of your book and where they can get it.

It's available everywhere. Yes, it's called Dopamine Nation, Finding Balance in the Age of Indulgence. Do you have an audio book? I do, an audible. Did you read it? I did. Yes! I love that.

I hate when some actor person reads anyone's book. Yeah. I was really nervous. Oh, there it is. Yep. I was really nervous to read it myself, but people seem to be okay with it. Great cover, too. What is that supposed to be? That is a Rorschach test because there's a brain in there. And if you don't see it, then join the club. Because I didn't see it either when I first saw that. My daughter pointed. She said, you know, that's a brain. I was like, oh my gosh, you're right.

That is a brain. It seems like a brain with a disease, though. Well, maybe a brain with a lot of vibrant colors that maybe went splat. Oh, yeah. Or maybe just putting out all this positive energy. Yes. Let's look at it that way. That's a much better way.

Well, thank you very much. Really appreciate it. It was wonderful talking to you. Do you have social media? Do you have anything where people can find you? No, not really. Good for you. Good for you.

That's a good place to be. But thank you. You're welcome. Your book's out right now. It's out. It hit the New York Times bestseller list, and so it's temporarily out of stock. All right. Nice.

But hopefully my publisher is working on it, and I know they're working on it. Congratulations on that. That's excellent. Thank you. Yes, it's unexpected and exciting. Go buy it, kids. All right. Thank you very much. Thank you.