Controlling Addiction & Dopamine: A Practical Guide | Dr. Anna Lembke

Addiction is a chronic disease driven by a dopamine deficit, but recovery involves abstaining from drugs, addressing contextual factors, and forming meaningful connections through psychological interventions and support networks 

Questions to inspire discussion 

• What role does dopamine play in addiction?

  —Dopamine is a neurotransmitter that plays a crucial role in pleasure, reward, and motivation, and its release in the brain's reward circuit is what makes substances or behaviors potentially addictive.

• How does addiction affect the brain's balance?

  —Addiction disrupts the balance of dopamine in the brain, leading to cravings and motivation to continue seeking the drug of choice.

• What are the diagnostic criteria for addiction?

  —Addiction is diagnosed based on the four C's: control, compulsions, cravings, and consequences, with quantity and frequency not included in the criteria.

• How long does it take for dopamine homeostasis to be restored?

  —Abstaining from the drug of choice for at least 30 days can restore dopamine homeostasis, reducing depression and anxiety symptoms in about 80% of cases.

• What is the recommended treatment approach for addiction?

  —The treatment for addiction involves a biopsychosocial approach, including abstinence, psychological interventions, and support networks. Medication may also be used to restore homeostasis.

Key Insights 

Treatment and Recovery Methods

• 🎯 People with addiction will relapse to their drug of choice even weeks and months after they've stopped using, due to the long time it takes for homeostasis to be fully restored.
• 🔄 "30 days is the bare minimum to begin to reset reward pathways, two weeks is Almost Never Enough."
• 🧠 The first and most important step in treating addiction is to restore homeostasis or baseline dopamine firing through 30 days of abstinence from the drug of choice.
• 🧠 Insulating ourselves from triggers and reminders of our drug of choice is a crucial part of recovery, to avoid the edge of the abyss and the temptation to jump in.
• 🍸 Alcoholics Anonymous seems to be one of the best methods of treatment available for a lot of people.
• 🔄 The 12 steps work through multiple mechanisms, including sober social networks, spiritual transformation, and leveraging pro-social shame to motivate recovery.

Neurobiology of Addiction

• 🧠 Dopamine is the most important neurotransmitter for the experience of pleasure, reward, and motivation, and is the common pathway for all reinforcing substances and behaviors.
• 🧠 Dopamine may be even more important for motivation than for the experience of pleasure itself.
• 🤯 Our brains adapt to increased dopamine by down regulating dopamine receptors and dopamine production, actually going below Baseline levels, which is the key piece of neuroadaptation.
• 🧠 The more dopamine a substance or behavior releases in the reward circuit and the faster it releases dopamine, the more likely it is to be addictive.
• 🧠 Addiction hijacks the reward centers, leading to a loss of autonomy and ability to choose.

Clinical Diagnosis and Criteria

• 🧪 The clinical diagnosis of addiction is based on the continued compulsive use of a substance or behavior despite harm to self and/or others, with criteria including control, compulsions, cravings, and consequences, but not quantity and frequency.
• 🧠 Tolerance alone isn't sufficient to make the diagnosis of addiction, it must be associated with compulsive out of control behaviors in the face of ongoing consequences.
• 🧠 Addiction is a disease and people should not be blamed for their behavior in that state, even though it seems very volitional.

#PersonalDevelopment #MentalHealth #Neuroscience 

Clips 

• 00:00 🧠 Dopamine is a crucial neurotransmitter that plays a role in pleasure, reward, and motivation, and addiction occurs when the release and decrease of dopamine create cravings and motivation to continue seeking the drug of choice, but recovery involves abstaining from the drug long enough for homeostasis to be restored.
  • Dopamine is a neurotransmitter that plays a crucial role in pleasure, reward, and motivation, and its release in the brain's reward circuit is what makes substances or behaviors potentially addictive.
  • Dopamine is not only related to pleasure but also plays a crucial role in motivation, as shown by experiments on rats with no dopamine receptors in their reward circuit, where the absence of dopamine took away their desire to strive for rewards, and in addiction, where the release and decrease of dopamine create cravings and motivation to continue seeking the drug of choice.
  • Pleasure and pain are co-located in the brain, and the brain works to restore a level balance by down-regulating dopamine receptors and production when there is an increase in dopamine from pleasure.
  • The urge to find and use more of our drug of choice can be overwhelming when the balance is tipped to the side of pain, but if we wait long enough, homeostasis is restored.
  • In addiction, the need for more potent forms of the drug arises to maintain balance, leading to withdrawal symptoms and a narrowed focus on the drug of choice, but recovery involves abstaining from the drug long enough for homeostasis to be restored.
  • Repeated exposure to pleasure weakens our initial response to it and strengthens our response to pain, leading to a reset of our pain and pleasure thresholds, requiring more pleasure to feel any pleasure at all and causing even slight pain or the absence of pleasure to be experienced as pain, which is a result of a neural circuitry that evolved over millions of years for survival in a world of scarcity and danger.
• 09:39 📝 Addiction is a compulsive behavior driven by a dopamine deficit, and abstaining from drugs for at least 30 days can restore dopamine homeostasis and improve symptoms of depression and anxiety.
  • Addiction is a severe form of psychopathology characterized by continued compulsive use of a substance or behavior despite harm to oneself or others, and is diagnosed based on the four C's: control, compulsions, cravings, and consequences, with quantity and frequency not included in the diagnostic criteria.
  • Addiction can be described as compulsive overconsumption, and the likelihood of something being addictive is determined by the amount and speed at which dopamine is released in the reward circuit, although there is variability among individuals, and the availability of a wide range of drugs and drug-like activities increases vulnerability to addiction.
  • People use drugs to either seek pleasure or solve a problem, and once they start using regularly, they develop a dopamine deficit state and engage in compulsive drug use to alleviate pain or restore balance.
  • Tolerance alone is not enough to diagnose addiction; it must be accompanied by compulsive behaviors and chronic dysphoria resulting from chronic exposure to drugs, which can contribute to depression and anxiety.
  • Patients who abstain from their drug of choice for at least 30 days can experience a restoration of dopamine homeostasis, resulting in a reduction of depression and anxiety symptoms in about 80% of cases.
  • After two weeks of abstinence from drugs, individuals still experience a dopamine deficit in the nucleus accumbens, indicating the persistence of withdrawal symptoms, and it is advised to abstain for 30 days to see improvements in mood, anxiety, sleep, and concentration.
• 20:12 🚫 Stopping alcohol can resolve depression in alcohol addicts, addiction has various entry points but becomes a primary progressive disease that requires a biopsychosocial treatment approach, early warning signs include lying about consumption, pay attention to signs of out of control use and cravings, treatment involves abstinence and medication but is not a complete solution.
  • Stopping alcohol alone can resolve the symptoms of depression in individuals addicted to alcohol, as shown by a study, and withdrawal from any substance or drugified behavior can lead to universal symptoms of anxiety, irritability, insomnia, dysphoria, and craving.
  • Addiction can have various entry points, such as seeking fun, self-medicating psychological problems, or escaping negative experiences, but once addictive substances are used regularly in large quantities, it changes the brain and becomes a secondary problem.
  • Addiction is its own primary progressive disease that cannot be resolved by treating underlying issues such as depression or trauma, and requires a biopsychosocial treatment approach for recovery.
  • An early warning sign of addiction is developing a habit of lying about consumption, which can extend beyond drug use and impact other areas of life.
  • Pay attention to signs of out of control use, compulsive use, overwhelming cravings, and the disconnect between our behaviors and the impact on ourselves and loved ones when it comes to addiction.
  • The treatment for addiction involves a biopsychosocial approach, including restoring homeostasis through abstinence and potentially using medication, but it is important to recognize that this is not a complete solution to the problem.
• 28:16 🧠 Addiction is a chronic disease with intense cravings, but recovery involves avoiding triggers, using medications, and psychological interventions to form meaningful connections and address contextual factors, while a higher level of care may be needed for severe addiction.
  • Addiction is a chronic disease where cravings can resurface, as even the anticipation of the drug can cause a spike in dopamine followed by a deficit, leading to intense cravings that are difficult to resist.
  • Recovery from addiction involves avoiding triggers and reminders of the drug of choice, and medications like Naltrexone can help by blocking the reinforcing effects of cravings.
  • Psychological interventions, such as individual and group therapy, are effective for addiction by teaching individuals how to form meaningful connections and addressing contextual factors, while also addressing the double life often associated with addiction.
  • Prescribing radical honesty, including abstaining from lies, for 30 days can help reset reward pathways and aid in addiction recovery.
  • For individuals with severe addiction, a higher level of care such as an intensive outpatient program or residential facility is recommended to provide a restricted environment that allows them to regain control and make choices about their lives.
  • Once addicted, individuals lose their autonomy and ability to choose, but with encouragement, support, and an understanding of neuroscience, they can potentially stop on their own and improve their well-being.
• 34:50 🧠 Addiction recovery is a challenging journey that requires time off work and support, and engaging in challenging activities can help reset reward pathways, but living in a world of overabundance and constant stimulation adds unique stress; risk factors for addiction can trigger relapse, severe pain can lead to compulsive drug seeking, and Alcoholics Anonymous is successful due to its components.
  • Prepare for a difficult journey of addiction recovery, as the first two weeks will be particularly challenging and may require time off work and support from loved ones.
  • Addiction is a disease that should be treated seriously, and in addition to being honest, engaging in challenging activities such as exercise, cold water baths, and meditation can help reset reward pathways.
  • Living in a world of overabundance and constant stimulation leads to a unique and unprecedented kind of stress, as every deviation from our neutral baseline position tilts the pleasure-pain balance and triggers our own endogenous stress hormone.
  • Poor people living in wealthy nations face the stress and trauma of unemployment, poverty, and racial discrimination, while also having access to highly potent and cheap forms of dopamine due to income inequality and the availability of luxury consumer goods.
  • Risk factors for addiction can trigger relapse, and severe pain can cause a dopamine release that leads to compulsive drug seeking, while Alcoholics Anonymous is a successful treatment method due to its inherent components.
• 39:59 📚 Alcoholics Anonymous provides a sober social network and spiritual transformation to help individuals overcome addiction, while self-binding strategies and focusing on one day at a time can renew willpower and create barriers between desire and consumption; our culture's "Work Hard Play Hard" mentality and normalization of substance use contribute to addiction.
  • Alcoholics Anonymous was founded in the 1930s by two men who overcame their own alcohol addiction and realized that by sharing their experiences and surrendering to a higher power, they were able to help others achieve sobriety, making it a successful grassroots fellowship.
  • The 12 steps of Alcoholics Anonymous work by providing a sober social network, promoting spiritual transformation, leveraging pro-social shame, and helping individuals reset their brains during the critical period of abstinence.
  • Alcoholics Anonymous has ritualistic aspects, such as attending meetings, sharing personal stories, working the steps, and using specific lingo, which provide a sense of belonging and support for individuals in recovery.
  • Focusing on taking it one day at a time and utilizing self-binding strategies can help individuals overcome addiction by renewing willpower and creating barriers between desire and consumption.
  • Our culture promotes a "Work Hard Play Hard" mentality where people use rewards to bookend their work, but over time these rewards can become disappointing and lead to addiction, especially when used at the end of the day when we are tired, hungry, lonely, and angry.
  • People often normalize their substance use by affiliating with others who use similarly, and they may justify their excessive use by considering it as only occurring on special occasions.
• 51:28 📚 Healthcare professionals must take responsibility for asking and exploring addiction issues with patients, creating a safe space for discussion, and being alert to enabling behaviors, while the speaker shares their personal experience with addiction and the challenges of managing sleep expectations in the modern world.
  • The speaker initially had little knowledge or interest in treating addiction until a patient revealed their heroin addiction, leading to a realization of their own ignorance and the need to address addiction as a brain disease.
  • Patients are not responsible for disclosing addiction information, it is the responsibility of healthcare professionals to ask and explore these issues, and by doing so, they can learn from their patients and create a safe space for discussion, which can be challenging for doctors transitioning from shorter appointments to longer, more meaningful interactions.
  • It is important for healthcare providers to be alert to the possibility of enabling patients' addiction and to have empathic discussions with them about their motivations and how to help them make a change.
  • The speaker discusses their personal experience with insomnia and how they became addicted to romance novels as a way to fall asleep, leading to neglecting other aspects of their life.
  • The speaker shares their personal experience with addiction and the difficulties they faced when trying to stop, highlighting the lingering challenges with sleep and the importance of managing expectations around sleep in the modern world.
  • Normal sleep involves intermittent awakenings throughout the night, and while some people believe that normal adult sleep is in two chunks with a period of wakefulness in the middle, the use of Ambien may make individuals amnestic to these awakenings, giving the illusion of deeper sleep.
• 01:03:08 👍 Success for the speaker is having a good day, which is achieved by accomplishing small tasks and enjoying quality time with family.

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