Anna Lembke's "Dopamine Nation"
The rolling disaster that is the opioid epidemic has kept the concept of addiction in the news in recent years and is perhaps leading to a more nuanced understanding of addiction in our country. My sister recently recommended a Huberman Lab podcast interview with Dr. Anna Lembke on the science and treatment of addiction. I found the conversation fascinating and immediately added Lembke's book, Dopamine Nation: Finding Balance in the Age of Indulgence, to my summer reading list. Lembke is the medical director of Stanford Addiction Medicine and still treats patients in her clinical practice. In her book, she blends her patients' experiences with research findings on addiction, crafting a relatively concise volume that I found to be a compelling read.
Lembke explains that pain and pleasure are processed in the same area of our brains. Homeostasis, that biological imperative you might remember from high school biology, is very much a factor in how we experience these sensations. Our body metes out essential neurotransmitters (e.g., dopamine) in accordance with a sort of scale that our brains are forever trying to balance. This "opponent-process theory" dictates that we respond to an extreme dose of dopamine– say from eating chocolate while watching porn– with a corresponding dip in dopamine (Lembke notes that this mechanism is at play in other body systems too, most fascinatingly in our visual system). Over time, our baseline or "set point" level of dopamine can be altered, meaning that more and more extreme stimuli are needed to tip our scales in the direction of pleasure. These neuroadaptations are at the heart of addiction and they can lead to conditions such as withdrawal, anhedonia (an inability to feel pleasure), and even hyperalgesia (increased sensitivity to pain).
Some of the scientific phenomena Lembke describes were totally new to me. For example, when an environmental cue signals the potential for a pleasurable experience (e.g., the ringing of Pavlov's bell or a glimpse of our smart phone on our desk), we get a hit of dopamine followed by a mini-dip below our baseline level. This generates a form of pain– a desire to obtain the anticipated reward. If the anticipated reward doesn't materialize, we feel an even deeper plunge below baseline. This pattern helps describe "loss chasing" by pathological gamblers, in which losing money fuels a desire to gamble more so they can experience a larger dopamine crest when they finally win. Unpredictable rewards are an especially potent fuel for this cycle, a lesson that social media has learned well.
One reason this book caught my attention is my recent interest in attention, a topic that Johann Hari investigates in his book Stolen Focus. Some of the tools that are used to hijack our attention rely on the dopamine responses enumerated in Dopamine Nation. I had heard the term "surveillance capitalism" to describe our use of the internet and social media, but a historian Lembke cites uses a term that was new to me: "limbic capitalism." Our economy is increasingly reliant on the manipulation of our biological pleasure/pain systems. Those systems, which served our ancestors admirably for thousands of years, are vulnerable to manipulation in an environment awash in plenty.
A challenge in treating addiction is resetting the dopamine system. Lembke describes the process that clinicians use to do this. Some of the strategies she explores could be useful to anyone trying to rebalance their own pleasure/pain scales, even if our addictions aren't yet serious enough to land us in her clinic. I highly recommend this book because it contains fascinating stories of addiction, compelling science, and some practical strategies for navigating our own relationships with pleasure and pain.