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The future of addiction

Addiction can take many forms, but new knowledge and new approaches to dependencies of all sorts are on the horizon, says this expert in addiction and treatment.
Multicolored neural cells with intricate connections.
What role does dopamine play in addiction? | ScienceSource/Mark and Mary Stevens Neuroimaging and Informatics Institute

Guest Anna Lembke is a psychiatrist and a specialist in the behavioral sciences who studies addiction.

While there is tremendous variety in the things people can be addicted to, all forms are tied to dopamine, a biochemical that is key to human senses of pleasure, reward, and motivation. She says that new treatments are combining traditional abstinence with programs that help patients reenergize dopamine centers in the brain through physical exercise, which is a known producer of dopamine. If patients can reach 30 days of abstinence there is a good chance at recovery, Lembke tells host Russ Altman on this episode of Stanford Engineering’s The Future of Everything podcast.

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[00:00:00] Anna Lembke: When we talk about addiction, we are talking about a form of psychopathology we consider to be a brain disease. Uh, it's a spectrum disorder, you know, defined as the continued compulsive use of a substance or behavior despite harm to self and or others. But there's no brain scan, there's no blood test, right?

[00:00:16] We're basing this on patterns of behavior, people could disagree. And importantly, as we ourselves become addicted, we often don't see it happening, right? Other people can observe it. We're in this state of denial. As one of my patients said, denial is don't even know I'm lying.

[00:00:38] Russ Altman: This is Stanford Engineering's The Future of Everything. And I'm your host, Russ Altman. If you're enjoying The Future of Everything, please hit follow in the app that you're using right now. This will guarantee that you never miss an episode and you'll never be surprised by the future of anything. 

[00:00:53] Today, Professor Anna Lembke will tell us that addiction can take many forms.

[00:00:56] Yes, it can be drugs or alcohol, of course. But it also can be behaviors that cause harm to our social relationships, our business and professional relationships, and even to our health. It's The Future of Addiction. Before we get started, please remember to follow the show so you'll get alerted to all of our episodes.

[00:01:21] You know, addiction seems to be increasing everywhere in our life. We've all heard about the opioid epidemic, we know about alcohol, we know about other drugs. But we also are now worried about addiction to social media, addiction to YouTube, addiction to behaviors that cause us pleasure. Well, it turns out that all of these addictions share a common mechanism to some extent. It's dopamine. We are addicted to dopamine, and we will do things to increase the dopamine level in our brains. The problem is, as we do those activities, it gets harder to get the dopamine levels that we crave, and so we need to do those activities more and more. What's worse is if we stop those activities, the dopamine levels can go very low, and it can get us very cranky.

[00:02:07] Well, Anna Lembke is a professor of psychiatry and behavioral sciences at Stanford University. And she's an expert at addiction of all kinds. She knows how to diagnose it, and she knows how to treat it. She'll be telling us about her own addiction and ways in which it illustrates many of the principles of how to diagnose and treat addictions.

[00:02:27] Anna, I'm sure we're going to talk about very serious, life-threatening addictions. I know you work on opioid, alcohol, many other things. But I want to start out a little bit lighter. In our common parlance, people are all the time saying, I'm addicted to, I'm addicted to YouTube. I'm addicted to social media, doom scrolling. I'm addicted to my exercise. And of course that's just a turn of phrase, but from your perspective as an addiction expert, are those really addictions or are there elements to what they're saying that is true, or is that just what they're saying and it's not really something that you would take seriously as an addiction expert?

[00:03:01] Anna Lembke: Yes, yes, and yes. So basically, I mean, we do overuse and trivialize that term, you know, and I used to joke, I'm addicted to romance novels. But it turns out I really was addicted to romance novels and I didn't see it, right? 

[00:03:17] Russ Altman: So now we're talking.

[00:03:18] Anna Lembke: Now we're getting into it. Now we're getting into it. 

[00:03:23] Russ Altman: So tell me about that. 

[00:03:24] Anna Lembke: The romance novels or the, 

[00:03:26] Russ Altman: and the whole story.

[00:03:27] Anna Lembke: Yes. 

[00:03:27] Russ Altman: This sounds good.

[00:03:29] Anna Lembke: Okay. Okay. So, yeah, I mean, so first of all, we overuse that term, we trivialize it, you know, when we talk about addiction, we are talking about a form of psychopathology. We consider it to be a brain disease. It's a spectrum disorder, you know, defined as the continued compulsive use of a substance or behavior despite harm to self and or others.

[00:03:48] But there's no brain scan, there's no blood test, right? We're basing this on patterns of behavior. People could disagree. And importantly, as we ourselves become addicted, we often don't see it happening, right? Other people can observe it. We're in this state of denial. As one of my patients said, denial is don't even know I'm lying.

[00:04:07] So I will use myself as an example. You know, um, my early forties I was turned on to romance novels for whatever reason I hadn't discovered them earlier in life, but I'd always been a reader, escape fiction, that was my big escape. Then I read the Twilight Saga, vampire romance novels. Totally got hooked on vampire romance novels, got a Kindle, became a chain reader, was reading every night, you know, late into the morning, going to work tired, hungover, um, started not enjoying, 

[00:04:36] Russ Altman: So there's the harm, because in your definition of addiction, you said there needs to be harm, and I was wondering if it was like, if it was an idle and an innocent, you know, reading habit.

[00:04:46] Anna Lembke: Right. 

[00:04:46] Russ Altman: But you said this began to have actual measurable harms. 

[00:04:50] Anna Lembke: Right, and the harms can be subtle, right? Like not getting enough sleep and then not being able to be your best self in the other things that you care about. The other harms in my case were not really, uh, you know, being present for my children and for my husband in a way that I value. And that's important to me. The other harm was kind of a low degradation, a gradual degradation in my mood, uh, in my interests and other things like my interests narrowed. All I wanted to do was read romance novels, to the point where we were literally invited to a neighborhood barbecue. And I took a romance novel with me, hid it in a room at these people's house to read romance novels. Now that is really weird. That's genuinely weird. 

[00:05:31] Russ Altman: Were you already an addiction expert? 

[00:05:34] Anna Lembke: Oh, I was already an addiction expert. I was teaching it, I was treating it. And like the low point for me, there were a couple lows, but basically I started to take romance novels to work. And in the ten minutes between patients, ‘cause you know, the psychotherapy hours, fifty minutes, then you can have ten minutes to reflect and keep it, I was reading my romance novels. So, and I didn't really see it, but I would joke about it. Oh, I'm addicted to romance novels. But really I had become a little bit addicted to romance novels and it was an insidious and gradual progression. 

[00:06:02] Russ Altman: Okay. So that's, that's a great example. And then all of us are now taking a, uh, an inventory of our activities. So let's use that as an example and tell me what was going on in your brain. And then of course, I think people are very interested in is if it's an ongoing struggle for you, did you do cold turkey? 

[00:06:20] Anna Lembke: Yeah, right, right. 

[00:06:21] Russ Altman: I think people, if you're willing to share, I think a lot of people would be interested.

[00:06:24] Anna Lembke: Yeah. Happy, happy to. 

[00:06:25] Russ Altman: Tell us about what was happening in your brain? 

[00:06:27] Anna Lembke: Okay. So now, first of all, nobody stuck a probe into my nucleus accumbens and measured dopamine level. So we are inferring, 

[00:06:33] Russ Altman: Right. 

[00:06:33] Anna Lembke: Based on animal and human studies, what was happening in my brain. But essentially we're always releasing dopamine at a kind of baseline tonic level. Dopamine is essential for the experience of pleasure, reward, and motivation. It's kind of like the little heartbeat of the reward center of the brain. When we do something that's pleasurable and reinforcing, we temporarily increase dopamine firing above baseline. Hey, that feels good. 

[00:06:53] Russ Altman: Okay.

[00:06:54] Anna Lembke: That gets me to want to do it again and again and again.

[00:06:56] Russ Altman: Does that happen in the matter of seconds or minutes? Like how long does that take? 

[00:07:01] Anna Lembke: Great question. And it's controversial. Some people think that it happens immediately as in a matter of seconds. Other people think, especially that neuroadaptive, well, first of all, the dopamine hit happens instantly, I mean, in matter of certainly seconds. But what happens next is that our brains adapt to that increased firing by down regulating dopamine transmission, not just to that baseline tonic level, but actually below baseline to a dopamine deficit state. Which if we don't consume again and again, eventually levels out back to baseline tonic levels. That's what neuroscientists call homeostasis, and as you know, we're always trying to get back to homeostasis and our brains work very hard to achieve that. 

[00:07:41] So what happens in addiction is that with repeated exposure to the same or similar reinforcing stimulus, and by the way, what's reinforcing for one person may not be for another, for me, it was romance novels and the broad category of human attachment, sex, you know, romance novels are in many ways, socially sanctioned pornography for women. So, and over time, by the way, 

[00:08:02] Russ Altman: That's a whole ’nother discussion, which I'm going to put aside. 

[00:08:05] Anna Lembke: Maybe we want to eliminate that. 

[00:08:08] Russ Altman: But for people who didn't understand the addiction, that last sentence is very helpful to see why it might be addictive. 

[00:08:14] Anna Lembke: Yes, right. And so what happens over time with repeated exposure is essentially our dopamine levels settled down at this, in this lower sub threshold dopamine deficit state. And that's the addicted brain. Now I need more of my drug in more potent forms, not to get high and feel good, but just to bring it back up to baseline and feel normal. And when I'm not using, I'm walking around in that dopamine deficit state, experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, depression, and craving.

[00:08:49] And that's essentially the place that I got to with romance novels, right? I was more anxious, I was more depressed. Things that I used to enjoy were no longer enjoyable. Really important aspect of this flow. Huge opportunity costs. Other things that I wasn't doing that I valued more than reading romance novels were going by the wayside because I was reading romance novels. So that's essentially, you know, what we can surmise was happening in our brain. 

[00:09:14] Now, if you want to know the course, course of my trajectory, very interesting. I did not really realize I had a problem till I was interacting with a young psychiatry resident in an exercise where we're teaching them motivational interviewing, which is how to screen and intervene. So we were one student short. So I played his patient. He said, is there a habit you want to change? I said, I'd like to change my late-night reading habit. He said, oh, tell me more about that. I did not tell him in detail what I was reading. I just said, I'm staying up later than I want to spending my time, finding it's kind of compulsive.

[00:09:46] And he said, well, what's one thing you could do to change that? I said, well, I could get rid of my Kindle or my e reader. The point is the next day I could not unsee that behavior. That conversation, and this is really important because in our therapeutic role as addiction medicine doctors, we are encouraging patients to narrate that experience.

[00:10:08] And in doing so, we get the information, but even more importantly, they get the information, right? They see that behavior when they put words to it in a way we're really not able to see when it's, you know, hidden in the dark recesses. So the very next day, even though I was still reading romance novels, I was watching myself reading romance novels. And I thought to myself, you know what, I really do want to stop this behavior. 

[00:10:29] Russ Altman: Right.

[00:10:30] Anna Lembke: And then I basically did with myself the same intervention we do with patients. 

[00:10:31] Russ Altman: Did that, and I want to hear about that. But did that trainee know that this was a real thing and not something you were making up just for the purposes of, uh, of the training?

[00:10:44] Anna Lembke: So he did not know, oh, he knew that it was a real habit for me. 

[00:10:48] Russ Altman: He knew it was a real habit. 

[00:10:49] Anna Lembke: I think he could sense, I mean, kind of a benign, you know, I didn't get up there and said like, I, you know, I've got a problem with heroin. 

[00:10:54] Russ Altman: Right, right.

[00:10:54] Anna Lembke: Or like, oh, I've got to, you know, kind of, it sounds sort of anodyne. But actually he had no idea the extent to which that conversation actually helped me in the long. I did tell him later ‘cause I wrote about it in my book. I told him later and I said, you know, you're in the book and he's like, oh yeah, I remember that. 

[00:11:10] Russ Altman: That is fantastic. And then, so, um, let's go right to the treatment, either your treatment or the approach to treatment. And I also wanted, ’cause I know that at our last discussion, uh, by the way, you're a second timer on The Future of Everything, which puts you in an elite high level group.

[00:11:27] You said that you were disappointed with the ability of healthcare professionals to detect addiction when they're interacting with patients. And it sounds like you were training this and so, maybe let's talk about that right now. How have we made progress in our ability to detect? Are you getting it out?

[00:11:42] I guess first to other psychiatrists, but also to primary care physicians and family docs who are on the front line. How good are they at it these days and have they gotten better and what's the prospects look like? 

[00:11:53] Anna Lembke: Huge paradigm shift in medicine, huge improvements in terms of educating our medical workforce to screen and intervene for addiction. But I can't take any credit for it, and I'm not sure any of my colleagues can either. What changed was the opioid epidemic. With the opioid epidemic, doctors had to recognize their complicity in a problem that, that they had previously been able to say, well, that's those people over there. All of a sudden it was like, well, no, actually those are our patients and we're giving them the drugs.

[00:12:24] So that we've seen a huge scene change in the last fifteen to twenty years in terms of not just, uh, you know, the level of, and for information, education for health professionals. 

[00:12:36] Russ Altman: Yeah, yeah.

[00:12:36] Anna Lembke: But also the interest. It's so wonderful. I mean, you know, ten years ago, I couldn't have scraped a medical student up off the sidewalk to come and rotate in my addiction clinic. It'd be like, uh, what's that? And, you know,

[00:12:48] Russ Altman: It's a penalty. 

[00:12:49] Anna Lembke: Right, and now they're like beating down the door. It's so awesome. Also in 2016, addiction medicine was recognized as an actual medical specialty. So there's been a lot of movement. We have a long way to go. Don't get me wrong, but it's a lot of progress.

[00:13:03] Russ Altman: I'm also struck by the parallel of how you articulating the romance novel issue got you to introspect, and it sounds like the medical community as a whole has articulated its problem, so to speak, 

[00:13:15] Anna Lembke: Yes.

[00:13:16] Russ Altman: With prescribing opioids, and it had a similar effect of kind of sunshine on the problem is like the first step towards, uh.

[00:13:23] Anna Lembke: Right.

[00:13:23] Russ Altman: Okay, so let's go back to the issue of treatment and the novel treatments, especially. We're going to talk about, I'm sure we're going to talk about opioids and the physical, uh, and the, and the medications. I don't know if there are medications for romance novel or for whatever my favorite, you know, I'm going, I really am going through my head and there are certain YouTube channels that I know I need to stay away from. 

[00:13:45] Anna Lembke: Oh gosh.

[00:13:45] Russ Altman: Because it's just a rabbit hole.

[00:13:47] Anna Lembke: Doctor Pimple popper?

[00:13:48] Russ Altman: Well, yes, exactly. 

[00:13:51] Anna Lembke: I mean, what's your poison? That's that. 

[00:13:53] Russ Altman: My poison is, um, there's a guy who takes apart and reassembles mechanical watches. 

[00:13:59] Anna Lembke: I love it. I love it. 

[00:14:01] Russ Altman: And at first I called it like ASMR because it was very Zen and he doesn't talk or he hardly talks. 

[00:14:06] Anna Lembke: Right, right. 

[00:14:06] Russ Altman: But now I realize that I'm seeking this out when like I have to prepare for my interview with Dr. Lembke instead. 

[00:14:12] Anna Lembke: Right, right. Love it. 

[00:14:13] Russ Altman: And so that is like on the border. 

[00:14:14] Anna Lembke: Love it. Yeah. And you know, right after, you know, right after this, people are going to go and look for that guy, right? 

[00:14:20] Russ Altman: Yeah. 

[00:14:21] Anna Lembke: So like there's that social contagion phenomenon too. Like, well, what you're doing that I want to do, it's really fascinating.

[00:14:27] Uh, yeah. Yeah. Thanks for sharing that. 

[00:14:30] Russ Altman: So yeah, yeah. No. And we could go on because, um, well the other one I like to say is that many years ago I had some health scares and I started doing exercise, and I was very aware of, uh, of a low level addiction in the sense that I get extremely crabby and kind of a little bit cantankerous, quite cantankerous if there's anything blocking me from doing my regular kind of workout schedule.

[00:14:53] Anna Lembke: Right, right. 

[00:14:54] Russ Altman: And I'm, and you know, there's. There's the, I don't know if it's a dopamine high or whatever, kind of, wherever that high comes from, it's real. 

[00:15:01] Anna Lembke: Yeah, yeah. 

[00:15:01] Russ Altman: And I get very, um, I needed to protect that, and I need to be aware of how, if I don't feed that dopamine, uh, itch, I can really be kind of, uh, antisocial.

[00:15:13] Anna Lembke: Yeah. So that's a great little, you know, uh, sort of segue into how we treat it. Because dopamine is not only important for pleasure, reward, and motivation, it's also essential to movement. Like even the most primitive nematode will release dopamine in response to its food and its environment, allowing it to locomote.

[00:15:28] We know that in Parkinson's we have a depletion of dopamine. So um, part of what happens in addiction, or really how we're wired is to have to move and do a lot of physical work to get our rewards. But today we don't have to move, right? We can just sit there and have them come to us. So that means part of the treatment of addiction is actually getting people to reconnect to their dopamine firing, to their physical movement and body. 

[00:15:51] Russ Altman: Ahh.

[00:15:52] Anna Lembke: So we actually prescribe what we call hormesis. Hormesis is Greek for descent and motion. It's actually the science of how pain is good for us. And we ask people to intentionally do things that are physically difficult, challenging, painful, or mentally, so that they can get their dopamine indirectly. So the idea is that intoxicants spike our dopamine, followed by a dopamine deficit state, which is the state of craving.

[00:16:13] But exercise, we see a gradual rise in dopamine over the latter half of the exercise. It remains elevated for hours afterwards, and then it goes back down to baseline. And it really typically doesn't go into that dopamine deficit state. But it's also possible to get addicted to exercise right if we overdo it.

[00:16:30] Russ Altman: So I love what you said about during the second part of exercise. Because for me as like a runner and a cyclist, it's obvious why, because when you get to the halfway point, you know it's going to end soon. 

[00:16:41] Anna Lembke: Right. 

[00:16:41] Russ Altman: And so I can tell my mood getting better and better as I approach 

[00:16:46] Anna Lembke: Oh yes. 

[00:16:47] Russ Altman: The end of a run, because I know that I'm going to be in such a great mood at the end. 

[00:16:51] Anna Lembke: Yeah, yeah. 

[00:16:51] Russ Altman: And so it's kind of, of course you're happy. 

[00:16:54] Anna Lembke: Yeah. You're a man after my own heart, because sometimes I'll talk to people like, but I look forward to exercise. I'm like, really? You're in the lucky category. When I'm sitting, like standing by the edge of the pool in the morning, I would rather stab myself in the stomach than jump into the pool. You know what I mean? It's like, within half a lap, I'm already like, okay, it's better. 

[00:17:12] Russ Altman: This is great. Well, this is The Future of Everything. I'm Russ Altman and we'll have more with Anna Lembke next.

[00:17:31] Welcome back to The Future of Everything. I'm Russ Altman, your host, and I'm speaking with Professor Anna Lembke from Stanford University. 

[00:17:36] In the last segment, we discussed the general principles of addiction. We heard an interesting story about Anna's experience with romance novels, but we didn't get the end.

[00:17:45] So in this section, we're going to hear what happened to Anna's addiction. And we're also going to turn our attention to the opioid epidemic, and get an update from Anna about how it's going, and whether the future looks promising. 

[00:17:55] I want to deliver, Anna, on the promise to get the end of the story. So when we last left you were having introspection about this and maybe not being happy with your level of romance novel reading. And tell me how it ended. 

[00:18:12] Anna Lembke: Well, 

[00:18:12] Russ Altman: Or did it end? 

[00:18:13] Anna Lembke: Yeah, good question. So, you know, addiction is a chronic relapsing remitting disorder. Um, and when I finally saw my double life of addiction to romance novels, I decided to do a self-intervention like we do with our patients as a first pass, which is a dopamine fast, abstaining from our drug of choice for thirty days. Why thirty days? 

[00:18:33] ‘Cause we find experientially that's the average amount of time it kind of takes to get out of the craving state and reset reward pathways. Knowing that those first ten to fourteen days are super painful because we are in withdrawal. But then things start to get better. And so I abstained from romance novels for thirty days.

[00:18:50] I was shocked at how difficult it was for me. I had lost the art of putting myself to sleep without this particular behavior. And I had incredible insomnia, restlessness, and also just incredible anxiety. The anxiety that we get when we cannot engage in these habitual kind of protective behaviors and especially escape behaviors.

[00:19:11] Uh, and it was intense and boy, did it give me a whole new level of empathy for people with, you know, severe life-threatening addictions to people that I treat. Uh, but I was able to do it. And by the end of four weeks, I'm like, hey, I'm feeling great, better than I have in a long time, not craving romance novels.

[00:19:27] I think I'll give, give a romance novel a read this weekend. And I had something we call the abstinence violation. I binged all weekend long, went to work that Monday, bleary eyed. And I was like, oh dear, that was a disaster. I guess I have to abstain for longer. So then I committed to a year. And you know what? It was a good year. And since then, which is some decades ago, um, you know, I've tried occasionally to read romance novels and for the most part, zero pleasure. Zero pleasure. 

[00:19:57] Russ Altman: Ah. 

[00:19:57] Anna Lembke: It's like I've burned out that neurotransmitter system. I still have euphoric recall for how it felt, and I still want to read them. But they just, they're completely non pleasurable for me, which is kind of the cost, right?

[00:20:11] So that's kind of, it's like, I've sort of now deprived myself for the rest of my life of, really enjoying that. Now I have switched to other genres. I'm like a big, you know, mystery, uh, thriller. But even then I have to really watch out because once I start, it's difficult for me to stop. And I don't want to get, 

[00:20:28] Russ Altman: Do you do any of these other dopamine increasing activities, either during that month or during that first year. Like, I mean, you talked about exercise or did you flirt with a different addiction that got you a little bit of dopamine on the side? 

[00:20:41] Anna Lembke: Yeah, yeah, yeah. So, I mean, 

[00:20:43] Russ Altman: You can imagine all of these strategies. 

[00:20:44] Anna Lembke: I mean, my real, so that, yes, so cross addiction is real, so we're giving up one addiction and going to another. I've always tried to start my day with pain. You know, get up, exercise because that sets me up for better, my mood just is a lot better. Um, but I don't think, especially as I've aged, I haven't really been able to do more exercise. In fact, I've had to pull back. So that's sort of been a natural protector for me.

[00:21:07] You know, workaholism is real, right? This kind of flow state that you get into when you're working. I, sometimes it's hard for me to stop working, right? 

[00:21:15] Russ Altman: Yeah. 

[00:21:15] Anna Lembke: Which is like really weird. And it's usually detrimental, you know, we're not present again for our families, we're not cultivating other activities and hobbies, um, we become sort of reliant on that, that to do list and that sense of like accomplishment and validation we get, but like, you know, at the end of my life, do I want to get, you know, look back, oh wow, I did all, no, that's not where, I know that's not where, you know, meaning and connection is. To some extent it is, to the extent that I can be altruistic at work and support other people's careers and help patients. But a lot of it's just about my own anxiety and managing my own anxiety by chunking through this to do list.

[00:21:54] Russ Altman: I think our colleagues at the, at a medical school, we're filled with people like that. Okay, I want to move to the opioid epidemic because it's the one, it's the addiction that people are thinking about the most and I think you would probably agree it deserves a lot of thought. 

[00:22:05] Anna Lembke: Oh yeah. 

[00:22:05] Russ Altman: But before that, just one quick question. Is the idea of an addictive personality a thing? 

[00:22:11] Anna Lembke: It's a thing. We don't use that terminology anymore in the field of addiction medicine. But basically what it's talking about is somebody with a big genetic load for addiction. And that is real. 

[00:22:19] Russ Altman: Wow. 

[00:22:20] Anna Lembke: People come into this world with differing degrees of vulnerability to addiction, some a lot more than others, just like some people are predisposed to bipolar disorder, depression, or schizophrenia, anxiety, what have you. We know this from family studies. If you have a biological parent or grandparent with addiction, you're at increased risk for addiction even if raised outside of that substance using home. So that's real. The terminology we use though, instead of the addictive personality is more like vulnerable to the disease of addiction or heavy genetic load for addiction or strong family history for addiction.

[00:22:51] Russ Altman: A little gentler and a little perhaps less judgmental, so good, good. 

[00:22:55] Anna Lembke: So what I would also add, which is important is that, you know, when we think about vulnerability or innate vulnerability, it's very tied to drug of choice, which is to say, like, I'm pretty much invulnerable to alcohol. It does nothing for me. I wish it did. Caffeine, same thing. But once I discovered my drug of choice, romance novels, attachment, you know, all those social, uh, you know, sex related stuff, boy, I was off and running. So we may be exploding this idea of vulnerability as we get new, more drugs online that more people are susceptible to.

[00:23:29] Russ Altman: Yes. Yes. Okay. So in the last five minutes or so, I wanted to talk about the opioid epidemic. Uh, it, um, it had, I think you and I last spoke probably during the pandemic, maybe before the pandemic. But I think everybody has heard that the pandemic had a huge impact on the epidemic, that it is an ongoing epidemic.

[00:23:47] And as the pandemic has receded, opioids are still here. Uh, we've heard about big legal settlements and you've made some actually very optimistic statements about doctors being more aware of their role in this. So from your perspective, as somebody who has an addiction clinic, where are we? And what is the situation with the opioid epidemic? And what should people know about it? 

[00:24:07] Anna Lembke: So I think the best way to conceptualize it through time is that there were essentially three waves. The first wave was over supply of prescription opioids due to over prescribing due to the hoodwinking of the medical establishment by the pharmaceutical industry.

[00:24:21] Then as prescribing started to go down, many people who were already addicted turned to illicit sources. That was heroin, approximately 2013ish. And then fentanyl, a highly potent and lethal opioid, got introduced into the drug supply, and that's really where we still are now. Where even though prescription opioid related deaths have decreased, fentanyl related deaths are still on the rise.

[00:24:45] And this is truly, truly devastating because we've got people who are seriously addicted to opioids who are seeking out fentanyl and you know, the sort of effect of fentanyl and the lethality of fentanyl are very closely linked. It's hard to use just the right amount to get the feeling you want without also killing yourself. 

[00:25:04] Russ Altman: Yeah.

[00:25:05] Anna Lembke: But on top of that, we have fake pills out there that are laced with fentanyl and we've got people dying from a single pill, um, you know, who aren't even addicted necessarily. But just sort of, you know, got an exposure, really what some people now are referring to as poisonings rather than a quote unquote overdose. And this,

[00:25:25] Russ Altman: Are those, if I could just to clarify, 

[00:25:26] Anna Lembke: Yeah.

[00:25:26] Russ Altman: For the ones that are like, is it that those doses of fentanyl would have been okay for an experienced user who has developed a huge tolerance. But if this is a no, a novel user, a first time or second time, and that that dose is way inappropriate for them and it's therefore killing them? 

[00:25:41] Anna Lembke: Yes, yeah.

[00:25:41] Russ Altman: Or would that, would that, Okay.

[00:25:43] Anna Lembke: Yes. And yes, I mean, you can have enough fentanyl that even for an experienced user, it would be lethal. 

[00:25:49] Russ Altman: Yeah. 

[00:25:49] Anna Lembke: But what we're talking about mainly with these counterfeit pills, especially young people and experimentation is that they think they're taking a Percocet, right? That they've taken before that they got it from a doctor or whatever. But in fact, it's not a Percocet, it's got fentanyl in it, even a small amount. 

[00:26:03] Russ Altman: Wow. 

[00:26:04] Anna Lembke: And they sort of, you know, it slows the heart rate, slows breathing, uh, they fall asleep, heart stops and they don't wake up again. 

[00:26:11] Russ Altman: So it, so is it fair to say that this is still a problem of addiction, uh, because now we're talking about these kind of surprise doses that are much too high and drugs that you're not really even expecting to get any fentanyl.

[00:26:25] Anna Lembke: It's still a problem.

[00:26:26] Russ Altman: It starts, yeah. 

[00:26:27] Anna Lembke: Yeah. It's still a problem of addiction. It really, it really is. I mean, this is a scourge of addiction and overdose deaths, but it's also a problem of access. One of the biggest risk factors for addiction is simple access to a drug of choice. If you have more access, more people use it, more people get addicted, more people die from it. There are more harms. So especially for that vulnerable subset, you know, who's vulnerable to addiction or has other mental health issues. So um, you know, this is a huge addiction problem. But it's also a huge supply chain problem. 

[00:27:01] Russ Altman: So yes, good. I wanted to clarify that. So do the principles that you outlined for, um, uh, treating addiction in the first half of our conversation, do they all still apply? I, of course, we've all, we all know about the medications that are available. 

[00:27:14] Anna Lembke: Right.

[00:27:14] Russ Altman: And I, in reviewing your CV, you've published a lot on like, what's the right schedule for taking drugs over time and how long should it go and,

[00:27:23] Anna Lembke: Right, right.

[00:27:23] Russ Altman: But, um, so I know that there's a medical component to it. But are the other principles still perfectly applicable in terms of these dopamine issues and looking for other sources and all that? Or does it change? 

[00:27:34] Anna Lembke: Yeah. I mean, the brain chemistry, the basic brain chemistry of this dopamine deficit state applies to opioids as well. A difference in treatment though, is what we found is that many people with severe opioid addiction actually can't stop. Um, so the other suggestion of sort of we'll just do a dopamine fast, stop for thirty days, um, isn't really practically possible for people, some people with severe opioid use disorder.

[00:27:58] We don't know why that is, but we speculate that essentially their brains may not be plastic enough to return to that baseline level of dopamine homeostasis. Which means that they're always in that dopamine deficit state no matter how long they stop using, which is a really terrible, painful state, which is why we use opioids to treat opioid addiction, right?

[00:28:19] That's kind of counterintuitive, but that's what methadone is. That's what buprenorphine is. These are opioids that have a very long half-life, much longer than heroin, for example, or fentanyl. So you get people out of that constant cycle of intoxication withdrawal, drugs taking, intoxicating withdrawal.

[00:28:31] You get them in a steady state that allows them to be able to get their brains back online to be able to engage in other recovery work. So that's, you know, that's why we use those medications. It's not that people are getting high on them. It's that it's allowing them to restore homeostasis and kind of move on with their lives.

[00:28:53] Russ Altman: Great. And then in the final just few seconds, um, what's your sense of the outlook here? Are, is there, are there reasons for, I don't want to be Pollyanna, are there reasons to be optimistic here or are we still only now still discovering the depth of this problem? 

[00:29:07] Anna Lembke: If we're going to talk about the future of everything. 

[00:29:10] Russ Altman: Yes.

[00:29:11] Anna Lembke: I think we're looking at I think that addiction is the modern plague and we are going to be dealing with addiction to all kinds of things including digital media for the next hundreds if not thousands of years as one of the major problems that humans will face.

[00:29:25] But I am optimistic that we will figure it out because we are highly adaptive creatures and we are good problem solvers on, already now you've got people actively engaged in the discussion of like, you know, what about social media? What about video games? What about the drugification of our food supply?

[00:29:42] You know, conceptualizing these things as essentially hijacking our reward pathways, uh, depriving us or depleting our agency and our autonomy and in essence, our freedom, and then what are we going to do about it? So I'm optimistic. 

[00:29:57] Russ Altman: Thanks to Anna Lembke. That was The Future of Addiction. Thanks for tuning into this episode. We have more than 250 episodes in our archive. So you have instant access to a broad range of discussions on an amazing variety of topics. If you're enjoying the show or if you've benefited from it, please consider rating and reviewing it. A five would be nice and it will help give us some feedback. You can connect with me on X or Twitter @RBAltman and you can connect with Stanford Engineering @StanfordENG.