With Pleasure Comes Pain -Our Addiction to Dopamine- with Dr.Lembke | Empowering Neurologist EP131

We essentially get to that place where, you know, we experience the pleasure. We have this opponent process reaction tilted to the side of pain, which remember is going to happen every time we have a huge surge in dopamine. And then as soon as we have that, we're going to have craving.

Well, hello everyone. Again, welcome to The Empowering Neurologist. I'm Dr. David Perlmutter. You know, so much of our lives is consumed by activities that are designed to bring us pleasure and at the same time offset the various pains, the various challenges that we may face, to the extent that at times these pursuits become self-enforcing, to the extent that we might actually become addicted to various types of activities that we engage because they bring us the sense of pleasure. The problem is that with time, some of those activities become even increased to the point that they interfere with our lives. It is interesting to note that the very same area of the brain is involved in both this pain response and this pleasure response, with the seeking of the pleasure being fueled by a neurotransmitter called dopamine, hence the name of Anna Lembke's new book, Dopamine Nation, which explores this balance, how it can get us into trouble, and more importantly, how we can bring balance, restore balance to our lives based upon understanding what's going on and then doing something about it. So I'm looking forward to our time together. Let's jump right in. But first, let me tell you a little bit about our guest today, Dr. Anna Lembke. Dr. Anna Lembke is a professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, and she is the chief of the Stanford Addiction Medicine Clinic. In 2016, she published Drug Dealer, M.D.: How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to Stop, Johns Hopkins University Press, 2016, as I mentioned. And that was highlighted in the New York Times as one of the top 5 books to read to understand the opioid epidemic. Dr. Lemke recently appeared on the Netflix documentary, The Social Dilemma, an unvarnished look at the impact of social media on our lives. Her book that we talk about today is called Dopamine Nation: Finding Balance in the Age of Indulgence, and that will be out in August of 2021. This is a book that explores how to moderate our compulsive overconsumption, including what we do in the digital world, In a World Where Feeling Good Is the Highest Good. Well, Dr. Lemke, welcome to our program.

Thank you for having me. I'm really excited to be here.

This is a really, really interesting book. I mean, it really calls out, I think, you know, what some of the biggest problems in America today, and it's not because of our lack of things, it's really because of our overabundance. And you made a very interesting point right off the bat of the book that You know, we're getting more and more leisure time, and it's been said, idle mind is the devil's plaything. And I think the biggest thing that you bring to bear, you actually talk about this throughout the book, is you created this model, a metaphor if you will, of understanding the balance that's, I think, constantly underlying all of our decisions, and it has to do with pain versus pleasure. Actually created a kind of like a teeter-totter between pain and pleasure. So why don't you just, if you could, walk us through that as an entrée into how we ultimately really try to cater to our pleasure centers, and yet ultimately that makes us more at risk for pain?

Sure. So one of the most interesting findings in neuroscience in the last 75 years Is that the same parts of the brain that process pain also process pleasure and that they actually work like a balance or a teeter-totter in a kid's playground. So when I experience pleasure, my balance tips slightly to the side of pleasure, and when I experience pain, it tips to the side of pain. So they're opposite sides. So for example, if I eat a piece of chocolate— I really like chocolate— I get a little, you know, tip to the side of pleasure and a release of dopamine, the pleasure Pleasure neurotransmitter in my brain's reward pathway. But one of the important rules governing that balance is that it wants to stay level. So it wants to preserve what neuroscientists call homeostasis. So as soon as I have that pleasurable experience, there's like a little gremlin that hops on the pain side of my balance to bring it level again. But the gremlins really like it there, so they stay on until I'm tipped in equal and opposite amount to the side of pain. And that's the aftereffect or the comedown, or in my case, that moment of wanting a second piece of chocolate. Now, if I wait long enough, the gremlin hops off and homeostasis or a neutral balance is reasserted. In addiction, essentially that balance goes awry.

How, how does it go awry? I mean, let's just say that we keep catering to The good feelings we get, or we think we get, when we eat the piece of chocolate or we're gambling online or we're ordering products that we're not going to use from Amazon and we get that hit when it arrives. You talked about somebody in your book that did that. How does it ultimately go awry when we face addiction?

Well, the second rule governing that balance is that with repeated exposure exposure to the same or similar rewarding stimulus, the initial response or deviation from neutrality gets weaker and shorter in duration, and that after-response on the pain side gets stronger and longer. So what that means essentially is that those neuroadaptive gremlins, they remember from our previous exposure to pleasure. And over time, if we continue to expose ourselves, whether it's video games or pornography or cocaine or, you know, Netflix binges that eventually—

I'm guilty.

Right, we've all got something, right? That eventually we develop tolerance to that stimulating thing, but really more importantly, and this is really the key, that if we keep indulging, then more and more gremlins hop on the pain side of the balance until we're essentially at war with those gremlins and it Tips way over to the side of pain. So even when we stop using, we, we stay tilted to the side of pain. We're in what's called a dopamine deficit state, which is to say by ingesting all this dopamine from these potent drugs, our brains have to accommodate that by downregulating our own dopamine transmission, downregulating our own production of dopamine, our own dopamine receptors. So we're essentially in the equivalent of a— Clinical depression, right? So then nothing else is enjoyable, right? For me, it's only eating chocolate is enjoyable, and nothing else gives me pleasure. And I'm incredibly focused on that. And when I'm not eating chocolate, I'm essentially in this dopamine deficit state. So that's really the key point: that all of this abundance and all of this dopamine is actually making us more unhappy because of this opponent process mechanism and this dopamine deficit. state that's generated by this kind of overconsumption.

Well, I think you characterize it as you were talking about social media, saying that the smartphone is our modern-day hypodermic needle. That's a great quote. I had to highlight that one. In this dopamine deficit situation that then arises when we suddenly cut ourselves off from whatever it is, I think the woman's name was Sarah in your book, a Korean Sophie, Sophie. Sophie, right, okay. And she was reluctant to not listen to her earbuds or her iPhone or whatever it was walking to class. And she said, well, then what am I going to do? And asked you how long it would take then. And I think you really quickly responded, 4 weeks. So what is happening during that 4-week period of time?

So essentially what happens is that once we've, um, you know, got our pleasure-pain balance kind of chronically set to the side of pain, the solution for that is to abstain, to stop ingesting whatever it is that we've got that complicated, overindulging, compulsive relationship with. And that means that initially we're going to have to expose ourselves to more pain because it takes About 4 weeks for those neuroadaptive gremlins to hop off and for the balance to reassert homeostasis. And the reason it takes 4 weeks, or the way we know that it takes 4 weeks, is that there have been studies actually looking at the brains of people with addiction, serious addictions, and noticing that that dopamine deficit state persists into the 2nd and 3rd week after abstaining. We also have studies looking at, for example, people with severe alcohol addiction who also present with clinical depression. And then we have found that— there's a study that shows if those individuals enter a hospital and get no treatment at all for their depression but just abstain from alcohol for a month, that by the end of the month, 80% of those individuals no longer meet criteria for major depression. So just by abstaining from alcohol, their mood improves. And again, that's these neuroadaptive gremlins hopping off the pain side. That's our brains beginning to regenerate our own dopamine and our own dopamine receptors and reassert homeostasis. And homeostasis is this place where we can then begin to have access to more modest pleasures or, you know, what we talk about as natural rewards because we're not Bombarding our reward pathway with these sort of various drugs in all their forms.

Well, similarly though, can we not increase the sensitivity of the pleasure centers by exposing ourselves to things that are painful? I mean, you talked about how that was used beginning in the 1960s in terms of people experiencing pain. Actually, you have a quote in there from Hippocrates from what, several thousand years BC, talking about how diverting our attention, or, and even more appropriately these days in terms of receptor sensitivity, how does augmenting pain might prove helpful for us?

Right. So that's exactly sort of the heart of the book. If we know that pressing on our pain side ultimately resets our hedonic or joy pathways to the side of pain, then it raises the really compelling question, well, if we press on the pain side first, will the gremlins hop on the pleasure side and actually give us more access to pleasure?

I love the metaphor. It's so good.

It's so like, it's visual, right? It's tangible. You can kind of make— it takes really complicated neuroscience, and for me, it makes it make sense. But, but the answer to that is, you know, yes, we can. And We can use pain to get more dopamine. So, and this is, there's a whole science of hormesis showing that if you expose animals to toxic stimuli, mild, very mild doses of radiation, starvation, you know, spinning fruit flies in a centrifuge, that actually you will make them live longer and be more resilient. Obviously, if you overdo it, you'll kill the animal. So there's this like sweet spot in between. But these sorts of toxic exposures or challenging situations, or, you know, the obvious example with human beings is just exercise. Like exercise is immediately toxic to cells. That's been shown over and over again. And yet those small doses of physiologic toxicity or behavioral biochemical challenges actually are very healthy for us. And the reason is that we're— by pressing on our pain side, we're resetting our pathways to the side of pleasure. Likewise, very interesting work showing that if you suffer from a pain condition, that applying a little bit of pain, like in the form of acupuncture, can cause the release of our own endogenous endorphins, our own opioids, in order to relieve that pain So pain is not only a way to get pleasure, pain is also potentially a way to relieve pain.

Well, one of the interesting points that you brought up that I wasn't aware of, and I thought was really intriguing vis-à-vis our discussion on low-level stress or hormesis, was that while the— either it was Hiroshima or Nagasaki— killed people near the area of explosion, that those people in the surrounding environment who had a low-level exposure to actual radiation ended up having increased longevity. And one explanation that you described in the book was that their DNA repair mechanisms may have been amplified. And we've, on this program, discussed the whole notion of hormesis quite a bit. We actually had Wim Hof on the show talking about ice water immersion, and you discuss him in the book as well. So it's really a question of— it's the reason we lift weights, for example, because we're traumatizing muscle and then it rebuilds itself. back to where it was and a little bit more. So you're right, it is that sweet spot. There is quite a bit of commentary in the book about, you know, just the overall incredible explosion of antidepressant drugs, anxiolytic drugs, sleep medications, uppers for learning and studying in America. And maybe just a brief overview as to why that's happening. Maybe in contradistinction to other countries that are perhaps less affluent and people have less time to devote to their pleasure-seeking.

Yeah, I mean, one of the really concerning trends in modern medicine, modern psychiatry, is the huge increase in the number of people who take some kind of antidepressant or anxiolytic on a daily basis. I think it's 1 in 4 American adults takes an antidepressant. The use of antidepressants is increasing in countries across the world. Of course, the United States is leading the charge. I think Iceland is number 2. In general, people who live in rich nations are more likely to take antidepressants than individuals who live in poor nations. So it's this amazing paradox, like the more we have, the richer we are, the more abundance, the more miserable we seem to be And again, I think the pleasure-pain balance is one way to understand that. The other huge concern I have about the explosive use, you know, in terms of the use of these psychotropic medications is that if you look within rich nations, it's poor people who are most likely to be taking some type of psychiatric medication, including poor children. And I think that's really disturbing and we really need to look at that. Because on some level we need to ask ourselves, are we using psychiatric medications as a form of social control?

Well, you, in speaking about children in the book, you talk about how we're kind of afraid to put children in their place and discipline, let's say, which is really brand new. That I think the quote in the book was something about how children used to be looked upon as being just small adults. And that parents just seem so overwhelmingly consumed with not really with minimizing the traumas of the world and really sheltering our children. And that might have a really significant detrimental long-term effect on them in terms of being able to cope with the challenges of our modern world.

Yes, I mean, I think what's happened is that we're sort of raising our kids in the equivalent of a padded We've both over-sanitized their experience and at the same time, ironically, over-pathologized. So we're really quick to diagnose kids with all kinds of conditions, and yet we're wanting to protect them from having any kind of adverse event or challenging experience for fear that they're going to end up on the psychotherapy couch as adults. When in truth, having these kinds of challenges early on is exactly Exactly what kids need to build up the resilience to, you know, be functional adults.

And it really seems it's an outgrowth then of Freud telling us that really all of our actions as adults are motivated and colored by our childhood experiences. And I think that really tempered, you know, the way we treat, especially these days. I mean, you know, I'm not saying we should be spanking our kids, believe me. But I can assure you, in my day, even in school, your teachers could spank you if they wanted. I can attest to that. And, you know, there's a question about sparing the rod. But I think there is really a tendency for us to try to do everything we can, both in our own lives and in raising children, to really do everything we can to Make it as pleasurable as possible and reduce the entire experiences that may be painful, even grief and sorrow, which are important parts of the human experience, which ultimately, I think, round us out.

I absolutely agree. And we've really, we've sort of, like my generation of parents, we've been taught that we need to be Friends with our kids, you know, and that we we have to you know in order to have a secure attachment, we have to you know constantly be on good terms. And as a mother of teenagers, I can tell you number one that is impossible to achieve, and number two probably not good for kids. You know, they need to have structure and limits and boundaries. They need to be on occasion shamed for their behavior. So this idea that you know as parents, you know it's all going to be. feel good and, you know, we're going to be beloved and that's how we're going to know we're good parents. No, you know, if you're being a good parent, there are going to be periods of time in raising your children when they won't like you, and that's, that's good.

Wow, this is very, very powerful information because I think, you know, the biggest threat that we have as, as parents is that they won't love us if we blank, if we don't allow them to stay at their friend's house, whatever it may be. And it won't, you know, we're trying to make all the decisions. We're trying to really insulate them from the word you use is pain, as we try to insulate ourselves from pain. And yet we're hearing now the upside of pain, as you well describe in the book, and not necessarily physical, but emotional type pain.

Yes, absolutely. Yeah. I mean, so for example, exposure therapy is really underutilized for things like anxiety disorders. But I talk about one patient in the book who had terrible social phobia, was treated with antidepressants and stimulants. It just led to him being more isolated, less functional. And finally, he got a very talented therapist who works on our team who treated him with exposure therapy. So she said, your job is to go out to Starbucks. And not use your app ordering coffee, but order at the counter, talk to the barista. This was pre-COVID, you know, and, and then kind of we'll process it. And he was terrified to do this. He had become a virtual shut-in, but he went and he did it, and he sort of spilled his coffee as he was grabbing it, and that made it all the worse, right? He was like, oh no, panic attack. So he went back and told her, he said, next time— She said, next time you go and order I want you to spill it on.

Oh my gosh.

Yeah, so this idea of like sort of escalating doses, you know, in order to like build up your resilience. And again, pleasure-pain balance, you know, you want to kind of do it in small doses so that your brain can adjust and say, okay, I can, I can tolerate that. And like the sense of confidence and competence that can come from that experience is just really important.

akin to the microdosing of antigenic challenge for peanut allergies, which is du jour now.

It's exactly that.

Which I actually spoke to with one of your colleagues at Stanford. You talk in the book, and I think our listeners and viewers will get good information here that they can consider leveraging, and that is the self-binding idea chronologically, geographically, And through recontextualizing the various things that a person might have issues with. So maybe let's talk about what that means, self-binding or restriction as it were, and then we'll look at the 3 types.

Yeah, so basically what my book recommends is that you look at what is that substance or behavior that you use in a compulsive way that you recognize is ultimately making you Less contented, less functional person, or is somehow orthogonal to your values. Take that out of your life for 4 weeks. Why 4 weeks? Because again, this is probably the minimum amount of time it takes to restore normal homeostasis so you can have access to more modest pleasures and also have access to that thing that you gave up. And so it will be pleasurable again, right? So you lose some of your tolerance around And then when you go back to using it, because the truth is that most of us are not severely addicted, we're a little bit addicted, and most of us don't want to cut out our drug of choice forever from our lives, whatever that drug may be. So then the idea is when you incorporate it back in after this dopamine fast or this abstinence month, you need to be really intentional about creating barriers or self-binding strategies between yourself and your drug of choice so that when you use it again, you don't progress to that point where you've got your pleasure-pain balance tilted to the side of pain. And so I sort of categorize these self-binding strategies broadly as physical barriers or space strategies where we actually physically remove the drug from ourselves, making it harder to access. Like if it's potato chips, you don't buy potato Yeah. You don't have them in the house. Then I talk about using time as a way to create self-binding. So this is like, examples are like intermittent fasting or knowing that you're only going to use your drug of choice after you've completed a set goal or only on this day of the week and only for this much time. So you use time as a construct to be able to set yourself limits. Self-bind. And then the last category is this categorical category. So you might decide, you know what, this video game is crack cocaine for me. I cannot play this video game. I'm gonna remove it from my life. But I can play this, that video game, right? Or I'm gonna take off Snapchat because once I start using Snapchat, I just can't control myself. But, you know, Facebook is maybe okay for me. So kind of deciding what are your safe drugs, so to speak, and what aren't. So those are the types of sort of self-binding strategies. And the key here is that we have to be intentional and do it in advance because once we get into the throes of compulsion, it's very, very hard to resist that draw. We essentially get to that place where we experience the pleasure, we have this opponent process reaction tilted to the side of pain, which remember is gonna happen every time we We have a huge surge in dopamine. And then as soon as we have that, we're going to have craving. And that craving is going to drive the compulsion to use. So we, that's where we have to put the barrier in so that when we experience the craving, it's harder to get our drug, a little bit more time to pass, and then the gremlins hop off and we have a level balance.

But doesn't that leave open the opportunity then for recidivism?

Oh, absolutely. I mean, I do talk about that. If you have a severe addiction and you go back to— so I have many patients with severe addictions to things like alcohol and drugs, and whenever I do this experiment, the vast majority come back and say, I feel so much better, my life is better, I can't believe I was using in that way. And I say, well, what would you like to do? Would you like to continue to abstain, or do you want to go back to Almost universally, they wanna go back to using, right? So that's not what I would want for them, but that's what they choose. And some are successful, more than you might think. Many are not. Sometimes going back to using plummets them immediately back into their addictive disease, and they might have to go through that cycle a couple times before they realize, really, I can't have this in my life. But the reason, David, that talking about moderation and self-binding is so important Right. And I think that's really important, is not just for the severely addicted person struggling with alcohol who's wondering if they can moderate it. It's for the person with food addiction who can't abstain from food, right? You can't eliminate food. That's not compatible with life. So you have to find a way to use it in a more adaptive way. Or frankly, you know, our smartphones. It's not really possible at this point to be a functioning adult participating in the world and not use a smartphone. And yet many of us have smartphone addictions. So we have to figure out how to take that device and make it less potent, use it in a more restricted way that's more in balance and harmony with the kind of life we're wanting to lead.

It seems— we wrote about this in our last book, Brainwashed— that for many people, I mean, talking about drug addiction, alcohol addiction is one thing, but the addiction that you just brought up to technology and how marketing is so— how it so conspires to leverage the exact pathways that you are talking about to make us act, behave, and make certain choices in a certain way. And I think the term in the book was limbic capitalism, whereby the deck is so stacked against us in terms of us being able to make rational choices now. There's such— we are so compelled based upon what the inputs are that it seems challenging that we can even help ourselves. You mentioned, I think in the book you're talking about how people decide the lateral move or the self-binding might be going gluten-free or Atkins or keto or paleo. But even as it relates to gluten-free, how the world manipulates that now with all of the new so-called gluten-free foods that are really high in highly processed carbohydrates, with high levels of sugar, and really are bad food choices. But because we hang our hat on gluten-free or whatever it may be, we are cajoled into making really bad choices that, interestingly, as it relates to the food choices, those types of food choices enhance inflammation. And inflammation does tend to sever our connection to the prefrontal cortex and therefore jeopardizes our ability to make more informed informed longer-term types of decisions. So it seems that term limbic capitalism really rang for me.

Yes, that's actually David Courtwright's term, and he's written a wonderful book, you know, on similar themes. And it is, it's, you know, it's amazing the way in which we have drugified everything, you know, from children's books To, you know, shopping, to, I mean, just about anything you can think of, to gluten-free foods. You know, they're now drugified. They're made more potent. They're more novel. They're ubiquitous. The quantity is endless. And just as we can, you know, implement some kind of self-binding strategy, the world sort of conspires to get around that. And tempt us yet again. You know, for example, you know, again, you know, the internet is just pernicious in this regard, you know, especially for people struggling with, you know, more severe addictions. They're constantly being invited back in, right? You can't go online and not see this thing or that thing that the technology and the AI has determined that you like and is sort of following you around, you know, knocking on your door. Remember me? Remember me? So it's very, very hard to avoid, but not impossible, not impossible. And that's what my book talks about, really holding up people with severe addiction in recovery as modern-day prophets for the rest of us.

We brought out in our discussion something called the test of time as it relates to using digital media. T, how much time are you going to dedicate on the front end to the task? I, do you remain intentional? Watching for those pop-ups that you just talked about. M, are you mindful during the experience? And finally, E, once it's said and done, was it enriching? You walk away saying, am I better now that it happened? Or what did I just do with the past 15 minutes that turned into 4 hours? A lot of your book talks about drugs, uppers, downers, stimulants, sedatives. And antidepressants. And yet the interesting case of Chris. Chris, who ultimately came to see you and asked for Suboxone and tried to do his very best, seemingly a bright guy from your description. But at the end of the day, it appears that you came to the realization that that chemical seems to work for him. And thus, that's how he continued. Can you just take us through that vignette a little bit? Because I think it was really interesting because it shows there is a time and a place for modern-day pharmaceuticals.

Yes. Thank you, David, for bringing that up because I certainly don't want people to leave our conversation thinking that I am anti-psychiatric medication in all instances. That's not at all what I think. And that's why the example of Chris was so important. So this is a young man who developed a severe opioid addiction, including ultimately started with prescription opioids and then progressed to heroin. And if you think about the pleasure-pain balance, the idea once your balance gets tipped to the side of pain and your hedonic set point is sort of on that side, the idea is that if we abstain for long enough, Those neuroadaptation gremlins will hop off and that balance will be reasserted. But it is also possible, David, that for some people that balance is broken and that it's essentially no matter how long they abstain, they will be walking around with a balance tipped to the side of pain, irritability, and anxiety.

You really need to walk us through that one more time. What you just said is so incredibly important.

Okay. So, you know, basically Chris tried to abstain, right? So he had his balance tipped and he tried so hard multiple times, right? And the idea again with abstaining is that with long enough time, our dopamine transmission will uptick again, right? We'll start to make our own dopamine and our own dopamine receptors. The gremlins will hop off and we'll have a level balance and we'll have access to, you know, just natural rewards. But But what Chris found was no matter how long he abstained, his balance didn't correct itself. That for reasons we do not understand, he now lacked the capacity to reassert homeostasis or a level balance. He was in a chronic dopamine deficit state, probably caused by the exposure to opioids. You know, who knows? But the bottom line is he just was never gonna have a level balance. And so does that mean we ask him to live a life walking around irritable, anxious, depressed, not able to sleep? I mean, that's totally inhumane. So that is why he is now successfully treated with an opioid that is FDA-approved to treat opioid addiction, and it's called buprenorphine. But what it basically does is it doesn't get him high. Yeah. Just goes on the pleasure side of his balance and reasserts homeostasis so that he feels normal again. And he will absolutely talk about it in that way. It's like when he takes this medicine, it doesn't get him high at all. It basically just allows him to, in his own words, feel normal and kind of go on with his life. And so that's why I think it's, it's really interesting and important to remember that these tools do have their time and place and can be lifesaving for some people as they were for Chris.

I think that's, of anything we've talked about, I'm gonna say that was the most valuable because it really characterizes the notion of individuality, of personalized precision medicine. And in this case, whether it is a structural issue or probably a biochemical receptor desensitivity issue, that you were able to appreciate that and rather than point a finger, accepted it and realized that while it is a drug, it seems to be helpful in this case and you're going to go for it and allowed this young man to get on with his life. I mean, you can, from the narrative, you can clearly see that he was struggling day in and day out and he seemed like a bright guy. Mm-hmm. And yet he needed you to tinker or to maintain. I think he came to you asking for the medication because he had been on it in the past. He needed you to work with that. And it was really quite a beautiful moment in the book when you said, yeah, that's what we'll do.

Yeah. Oh, well, thank you. That's really good to hear. You know, you're one of my first readers. And so it's interesting and gratifying to hear kind of what stood out for you and what was meaningful. So thank you.

Well, I hope this isn't a curveball, but I just want to go outside the book for just a moment because I think you're the person to ask this question to. And that is, as you and I are having this conversation, we are hopefully seeing we're over the peak of COVID at least, and things are looking like they're going in the right direction. But having said that, over the past year or two since this whole thing began and got ramped up, What has your world been like in terms of professionally? In other words, what have you been seeing?

Yeah, so it's a great question. When I've been asked this question over the last year, it's often been asked with the assumption that my patients must be doing really badly. And in fact, I would say I would say half or more of my patients have experienced quarantine as a result of COVID as a huge improvement in their lives. Wow. So let me explain, because I think it's not what kind of you'll read in the media, but it's really what, you know, if you talk to healthcare professionals, you know, they'll acknowledge is that, you know, the world is kind of a crazy place. And the pace of the world is just almost more than our brains have the capacity to withstand. And with quarantine, it just slowed everything down. And for people who are struggling in particular with addiction, it meant they weren't constantly being bombarded with triggers to use, you know, going shopping, going down the liquor aisle, or going to parties and being offered a drink or watching other people, you know, have a good time using. All of these things were eliminated. Many of my patients found that their work stress went way down 'cause they weren't commuting. People endorsing having time with family, like gratifying and rich time, because again, there weren't all these other temptations. There was just what we had here. And I think this idea of like, Really, I think, you know, quarantine was a kind of global moment of self-binding, right? We were all forced to contract and decrease consumption. And I think, you know, as tragic as COVID has been, and of course the loss of life and the loss of jobs has been devastating, there is definitely this silver lining, this kind of pause to rethink the way we've been living our lives. Having said that, I certainly have had patients who have died from drug overdose in this period, patients who have relapsed, patients who have, you know, become addicted during quarantine because they're at home and they've, you know, got nothing to do but drink alcohol or smoke cannabis. But I would have to say that that is in the minority. The majority of my patients have used this time as a moment for renewed wellness?

Metaphorically, I think of the early on, the images from Delhi before and during of the skies clearing, suddenly a blue sky because cars were shut down, the transportation in the city was shut down. And it reminds me again of Sophie's story where she, I think she said, she She'd stopped using her digital devices walking to and from class. And she said, I noticed the trees. So you're right. It's a shift. But some people make lemonade out of the lemons and others are bothered by the sour taste. I want to thank you so much, first, for sharing time with us today. And second, certainly more importantly, For all that you're doing. You're doing some amazing work. And I've— I talked about in the introduction all the various committees that you're on and founded and are continuing to service. So I appreciate it very much.

Well, thank you. And right back at you.

Great. We'll talk soon. That was an interesting discussion and super cool that there are people like Dr. Lemke out there doing the work that they do. so dedicated day in and day out and really being able to leverage some leading-edge tools, including pharmacotherapy when it is necessary, as we learned. It's an interesting setup that she describes where there's this balance between pain and pleasure, how we tend to cater to pain very minimally, trying to offset it, but really looking to live our lives to the extent that It is as pain-free and pleasurable as possible, but understanding how that can get away from us and create issues. I'm Dr. David Perlmutter. Thank you for joining us today on The Empowering Neurologist, and we will be back soon.