Adevărul despre DOPAMINĂ cu Dr. Anna Lembke

If you get a rat addicted to cocaine by putting them in a, in a cage to press a lever for cocaine, rats love cocaine, they will typically press that lever till exhaustion or death. If before the rat dies, uh, you take the cocaine away, eventually they'll stop pressing the lever. It can take a while, but they'll stop pressing it. But if you then expose that animal to a very painful foot shock, the first thing the animal will do is to run back and start pressing the lever. In other words, stressors become a major trigger. For our lizard brain, or rat brain if you will, to want to go back to whatever those early learned behaviors are for alleviating pain or alleviating suffering or escaping whatever the situation is.

We can say there's no pleasure without pain.

And because life is hard. Life is hard, and when life gets hard, we have this overlearned behavior to want to go back to whatever That maladaptive coping strategy is.

Do you have an addiction nowadays? Amulete salut, doctor Mikhaila. Ici avons un épisode extraordinaire, un carré évolutif qui vous remet des pré-dépendances. D'accord, te confrontes quoi dépendance? Tes fauteuils seraient moins connus pour nous la capote pendant que c'est possible ça, on a une solution. D'accord, crées que nous avons une dépendance? Que que je suis maïbine? Seraient moins connus pendant que invitées-nous quelques carrés pour bes castes. Sustenez que fier carré avons Un drog deles. Aí se vedem da que queira sair este, se da que entredevor ne putem descobrir a droga, si putem seguire sim instrumente para combater este lucro. Invitada minha de Astas e este Dr. Ana Lemke, este a conduzir clínica de adicção da Stanford. Um martir, um júriu de Los Angeles agressivo mete a si YouTube, que afim negligente, ela foi a primeira mártir em um processo e armou ainda o urca para a cena impacte-se. București. Este autor a acestăi cartă generatia dopamina. Este o cartă în care descrie crizi vă patiënti cu care avut de afacă, binancele care și au data acordul pentru acest lucru. Cis teu o cartă din care am vesi forte multe lucru despre acest equilibru entre dependența, dorința asta de dopamina, și dureri. Acest equilibru Treboje se existe hasta parece fie mantra a cestek kart. Si karta jeste publicata la litera jeste do a publicare i o kartek excelente pekare tes fotesc se teo procuri. Podcastul boabede conosce tereste sprigini de Unicredit Bank, šile mutsumesc pe a cestekale i šipendifaptokas sprigin a cestekale iniziativa educatica. Iniziativa educativa, mčeškuze. Doktor Ana, welcome.

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

Yeah, thank you. Thank you so much for, for taking your time and coming to our podcast. How are you?

I'm good.

What are you doing lately in your practice and in everyday life?

Well, in my practice, I'm continuing to see patients. We have an addiction medicine dual diagnosis clinic, so we see patients who are struggling with addiction and also very often other co-occurring mental illnesses, depression, anxiety, OCD, schizophrenia. I also teach medical students and residents, and our clinic is largely run by our fellows and residents who are in training but are spending an additional year with us to learn specifically how to screen and intervene for patients with addiction. Because unfortunately, most doctors still don't have a good understanding of how to do that. So that is the sort of focus of my professional life. I also write, I do research. So it's the classic 3-legged stool of academic medicine: teaching, seeing patients, and doing research.

I've been watching your materials, I've read your book, I saw your podcast with Huberman, I saw your podcast with Diary of a CEO. And nobody asked you, and I want to ask you this question, how did you get into studying addiction?

It's a great question. When I first started in psychiatry, I was specifically avoiding patients with addiction, and that's for a number of reasons. First, I didn't learn very much in medical school about how to help patients with addiction, so I didn't have Any tools in my toolbox. Number 2, my father, who was a surgeon, was a high-functioning alcoholic, meaning that he could still do his work and be fine for months at a time, but then he would go on binge drinking episodes and disappear from our life and our— and also his professional life. And as a result, I had a certain degree of what we call negative countertransference. Mm-hmm. toward patients with addiction. I'm sure you're familiar with the term negative countertransference, but it just means when we have our own emotional baggage associated with a certain type of patient that interferes with our ability to give that patient the kind of care that they deserve. Mm-hmm. So I had this thinking about patients with addiction, false thinking, which is that patients with addiction can never get better, that it's a— a willpower problem rather than thinking about it as a mental illness. So ironically, even though I had training in mental illness, even though I'm a psychiatrist, I didn't want to see patients with addiction. But then I had a patient who continued not to get better. I was doing psychotherapy, I was prescribing medications, and yet she didn't improve. And one day her brother called to let me know that she had been in a rollover car accident, meaning that the car had rolled over several times and she had almost died. And I said, that's terrible. You know, what happened? What were the circumstances of the accident? And he said, well, she's been using again. Mm-hmm. And I didn't even really understand the sentence. I said, well, using what? And he said, she's been using heroin again. Isn't that what you've been treating her for? And that's when I realized, oh my goodness, I'm actually harming patients Because I'm avoiding the topic of addiction because I had never once asked her about drug and alcohol use.

Did you feel it as a sort of professional failure in that case with that patient that you didn't ask her? And that it— was that the moment that taught you to outgrow the repulsion against addiction and really go into that?

That's right. Yeah, I realized that I had failed her as a psychiatrist and that in avoiding the topic of addiction and pretending it wasn't there or not even asking about it, I was doing my patients harm. Hmm. So I vowed at that moment that I would learn everything I could about addiction. This was still very early in my career. This was the late 1990s. So I switched the focus of my work and I really focused on addiction. I started researching, writing, and my best teachers of all were actually my patients themselves. Once I started asking patients about addiction, they were eager and willing to talk about it. So this funny idea that patients won't tell us about their addictions is really not true. They're eager to have a safe space where they can talk about it, and once we, as their physicians, open that door, Mm-hmm. You know, they're very happy to be able to talk about what is really the central problem in their lives, because it turns out that if you have a patient with addiction who's also struggling with depression, anxiety, or other mental health harms, if you ignore the addiction and just prescribe your antidepressants and your mood stabilizers, they're not going to get better. Because their addictive process overwhelms any treatment that we have to offer. On the other hand, if we ask them about their addiction, we help them get into recovery, they get better, their families get better, everybody around them benefits, but also their depression, their anxiety, their other mental health problems get better also. And many times What we discover is they don't even have those other mental health problems. They don't actually have bipolar disorder, right? Or they don't actually really struggle with depression, that it's the addiction itself that is driving and creating those problems. So, so it's very rewarding work because people get a lot— when they get better, they get a lot better.

Yeah. And I, I think you, you were kind of lucky Like that, that was an unfortunate event, but the fact that you had to face something you didn't like, yeah, you had to face a patient with addiction, uh, and going to this work. And in your book, you, uh, you, you start with a quote. I don't, I, I don't remember the quote exactly, but it says that we don't really like addicts, yeah, because they remind me or about who

Yeah. So that's a lovely quote from one of my colleagues, Kent Dunnington. He's actually not a physician. He's a philosopher and theologian. But I quote him in the book. And I think that's the quote you're referring to. Yeah, that's the quote. Yeah, yeah. And the quote is roughly that addicts are modern-day prophets because they show us who we really are. And I love that quote. I love that quote, and it's a very apt quote for my book Dopamine Nation, because in the modern world, many of us, if not all of us, are struggling with some form of compulsive overconsumption. So to think about people with addiction as being over there and not like us is not true, right? Mm-hmm. Addiction occurs on a spectrum. We all have the same ancient brain reward pathway. We all are vulnerable to compulsive overconsumption. And so the problem of addiction is a growing problem and one that we all need to pay attention to.

Do you have an addiction nowadays?

I mean, don't we all?

Yeah, exactly. That is the second question. How can we know what addiction is? we have? How can we— because a lot of people, they don't really realize they have a problem with that.

That's right. So what is the definition of addiction? Addiction is the continued compulsive use of a substance or a behavior despite harm to self and/or others. Sometimes we're aware of that harm, but very often we're not because denial is a big part of the disease of addiction, that we're not very good self-observers, and we tend to overestimate the benefits and underestimate the harms of our substance use or our behaviors, whether it's gambling or sex or digital media or what have you. But essentially, the definition of addiction, how we diagnose it, is based on the 4 Cs: out-of-control use, Compulsive use, craving, and continued use despite consequences. That last one being the most important one. When we cross over into consequences, like with many mental illnesses, that's when, you know, we've, we've moved into meeting criteria for being diagnosed with having an addiction. But it is a spectrum disorder, so you can be mild, moderate, or severely addicted. You can also be like, pre-addicted, so kind of having some problematic use but maybe not necessarily meeting threshold criteria. And the truth of the matter is that if you go to see 10 different psychiatrists, you might come up with 10 different opinions. People on the most severe end of the spectrum will probably almost always get the diagnosis, but on the milder end of the spectrum, psychiatrists might disagree. I would also add that we have a lot of good science now showing what is happening in the brain as people become addicted, but we do not base our diagnosis on a brain scan or a blood test. Uh-huh. The state of the science is just simply not there. We still base it on what we call phenomenology, that is, patterns of behavior that repeat themselves across Individuals, geographies, cultures, time periods?

Yeah. So like, this is the hard part, that addiction is a spectrum and you don't really know, like, where, where you are on that spectrum and when it becomes a problem, when you have to stop it, or when it's just a pleasure that you can continue doing. For example, a very hardworking doctor that comes home and every night he drinks 3 glasses of wine. Is that a problem? Is that an addiction? How can you know?

Well, I'm glad you used alcohol as the example because we probably have more data for alcohol than for any other substance. If that were a patient of mine, I would try to find out how many drinks he has in a given week.

Yeah.

Because we have good data showing that if as an adult male you drink more than 14 standard drinks in a week or more than 4 in any given occasion, an occasion being one day, then you have greatly increased risk of all-cause morbidity and mortality.

Yeah.

So things like pancreatitis, liver cancer, accident, death, that all goes up the more that we drink. And it goes up very quickly after 14 standard drinks in a week. Having said that, although quantity and frequency are important, we never diagnose addiction based on quantity and frequency alone.

Okay.

Okay. Does that make sense?

Yeah, because you can, like, maybe you can, you know, this is, uh, these are the side effects, and you say okay, and you just drink because you like it, right? And you don't have the diagnosis of addiction,

right? So it's, it, it's, it's, it is a judgment call often, because we know that if people drink a lot, they're very likely to meet the criteria for addiction.

Okay.

But we don't base it on quantity and frequency because in the Diagnostic and Statistical Manual, they were looking for a unified definition that could encompass all different substances and behaviors. Mm-hmm. And there was also the recognition that somebody could— that some rare individuals might be able to drink quite a bit and still not have out-of-control use, compulsive use, craving, and consequences. So they made that distinction. So when we're diagnosing addiction, we care about how much you're using and how often, and in fact, we start there— Mm-hmm. When we're asking about the problem, but at the end of the day, what we're looking for is, what are the problems in your life associated with your use? Are you having difficulty cutting back? Is there a whole lot of mental real estate occupied with using? Are you developing tolerance? That is, do you need more over time to get the same effect? When you try to stop, do you experience withdrawal, the standard withdrawal syndrome with alcohol? So we're looking for physiologic dependence and we're looking for these 4 Cs.

Does work count? I mean, can you be addicted to work?

So workaholism or work addiction is not in the Diagnostic and Statistical Manual of Mental Disorders, so it's not officially recognized. But I think culturally, we are seeing more and more people who have a compulsive attachment to work and have harm in their lives as a result— broken relationships, regrets later on that they didn't spend more time cultivating other parts of themselves, not getting enough sleep. So, you know, it's a little bit harder with work because we as a culture and as a society We value work. We normalize working hard. Our cultural workaholics are our cultural heroes also. Young people want to be like Elon Musk and Mark Zuckerberg and people like that.

Yeah, like work hard, never sleep.

Right. Also in sports too, this idea that we should try to maximize effort even if we're destroying our bodies in the process. We typically don't diagnose those as addictions because we as a culture have overvalued those, I would say.

You think we should have this diagnosis of work addiction?

I mean, I'm not sure.

Yeah, me neither. I mean, when you said the 4 Cs, I found myself in work. I feel like I have a compulsive need to work even in free time. I, um, um, like, I, I don't have control. I feel, feel like I don't, I don't think that it, uh, impacts me negatively. Yeah, but a lot of addicts say that, right? Like, a lot of addicts say, yeah, I, it's okay for me, but my wife would like me to work a bit less.

Mm-hmm. Yeah.

So am I an addict or how? Because if that is a problem, you need the sort of treatment, right? But you need to have a diagnosis first. And if you don't have it, right?

It sounds like your work is mostly highly adaptive for you and also a big part of your identity and not significantly adversely impacting your relationships, which is really important. It sounds like your wife is a little bit disgruntled, but basically okay with your— Yeah. So it sounds like healthy and adaptive channeling of your life's energies.

Okay.

So I would never sit here and say that, you know, we should apply the addiction lens to everything that we look at. On the other hand, I think consumption of social media and digital media more broadly is a good example of a behavior that we've broadly normalized in our society, and we are only now beginning to recognize can actually be a diagnosable addiction, for example, social media addiction, which is not yet in the DSM, so not yet in the Diagnostic and Statistical Manual.

Will it be?

I'm quite confident it will be within the next 10 years or so because it's now being broadly recognized by teenagers themselves, by parents, by teachers, by healthcare providers, especially frontline psychiatrists, and other mental health care providers that a subset of individuals, and mostly we're worried about kids, becomes compulsively engaged with the internet, with social media, and other forms of digital media to the point where they're not sleeping, they're not exercising their bodies, they're not going to school or actively participating in school when they go there, They're getting more depressed, more anxious, in some cases suicidal. So the entire phenomenology that we see with drug and alcohol addiction, we now are seeing with a subset of individuals, including young people, on their devices. So as a society, we are closing in on a consensus that social media addiction is real. or digital media addiction is real. And I just want to qualify that further by saying that most people who use these devices and digital media will not become addicted to digital media, just like most people who drink alcohol won't become addicted to alcohol. The vast majority will be able to manage their consumption, but there will be a subset of uniquely vulnerable individuals who, once exposed to a given drug, will have a very strong vulnerability or propensity to get addicted to that drug.

Yeah. And it's like you say in your book that the more available is a drug, the more you will use that. And the availability of social media brain rot kind of content is scary, right? Because you don't have to buy it. Imagine you will have unlimited cigarettes in your pocket. They appear all the time. You have them unlimited. You just have to pull them in and That's kind of scary.

Right. And, you know, I think it's appropriate to analogize cigarettes and digital media, some forms of digital media. You know, some people would protest that by saying, well, but cigarettes can give you lung cancer and there's no benefit to cigarettes, whereas social media, there are lots of benefits. And I think that's very important argument to make. On the other hand, what I would say to push back against that argument is that there are many platforms online that have some potential for benefit. For example, the purported benefit of social media is to connect humans, right? Yeah. That's why it's called social media, to enhance our ability to make relationships with other people, and relationships with other people are key to human survival. It's a fundamental human need. But what people need to recognize about addictive social media platforms is that they may create the illusion of human connection—

Mm-hmm.

—when in fact what they actually do is interfere with real human connection. So, When you have a product that claims to do one thing, but by and large does its opposite through the engineering of an addictive product, that's when I think it's appropriate to say, hey, social media, it turns out, is a lot more like cigarettes than we thought.

You've been a witness in in the court against Meta and YouTube, right?

That's right. Yeah.

You think this is one of the key directions that we have to control this kind of social media addiction? What can be done there? I mean, yeah, we see a lot of people watching their phones all day. Yeah. How can that be solved in the future?

Well, I think it's important to highlight that the social media trial trials in the United States against Meta, but also other large social media companies, are really focused on harm to children.

Okay.

So 18 and under. And the reason I think that's important is because, you know, living in a liberal democratic society, we largely believe that consenting informed adults are free to decide what they want to do in terms of

Yeah.

You know, consuming addictive substances. So we don't let, you know, minors buy cigarettes or buy alcohol. We don't let them wander into a casino and gamble. And the idea is that we're now dealing with fundamentally addictive social media products, so digital drugs, and we want to protect kids, so 18 and under. So these trials are all about that. And as you probably read, There have been a number of trials so far. I testified in California and also in New Mexico. I was also part of other trials, and we won those trials against Meta. And they were jury trials, and there were penalties in the hundreds of millions that Meta had to pay. As those trials went on and it became increasingly clear that juries were deciding against Meta,

Yeah.

They settled for a very large amount of money, $12 to $18 billion. But it wasn't just a financial settlement. They also agreed to change their product for kids. And the agreement was that they would change the most addictive design features. So we talked about access being a big risk factor for addiction. Part of the settlement is that Meta will create more guardrails so that very young children under the age of 13 can't access Instagram and other Meta platforms. So that's a very important change. They're going to limit the actual amount of time that kids can spend on the platforms. Previously, they were doing things like interjecting take-a-break kinds of screens, which don't work.

Yeah.

Right. So instead, because of this litigation, they are now going to just cut kids off after 2 hours. And later, if other social media platforms join them, they're going to actually cut kids off after 1 hour on the platform.

But it's like cutting kids— like, let's make kids-friendly cigarette packs. Yeah. Just with 5 cigarettes per day for kids. Yeah. Isn't that the same?

Yes. Yeah. Well, it's not a bad analogy, but I would say you have to start somewhere. Yeah. You have to start somewhere. And, you know, I think that's a really important point is that this is a brand new societal problem, unprecedented in the history of the world, these digital drugs, right? So as societies around the world are struggling to figure out what to do, especially when you have, you know, a drug which is so embedded into our everyday lives. But I think starting somewhere makes sense. As you know, in Australia, they've banned social media entirely for kids under the age of 16. Now, we don't know if that's going to work or not, but I applaud their attempts to try something. In the United States, in the UK, many European countries, they're getting smartphones out of schools so kids aren't distracted by the slot machine in their pockets. And in the United States, we're asking companies to create guardrails by making it harder for kids underage to access the platforms, by limiting the actual amount of time, by changing the algorithm, for example. So instead of the algorithmic feed that optimizes to increase watch time, the companies will have to provide a chronological feed. Meaning that young users will only get messages or reels from people that they follow or from friends. Yeah. Not the random chronological feed. Yeah.

What do you think about TikTok?

Yeah, so TikTok is another defendant in these trials. And in the case in California, TikTok settled before the jury came out with their verdict. And there will be many other trials going forward against TikTok. Now, this litigation is just a vehicle to try to get TikTok to make a safer product and be a more responsible corporate entity. But again, it's just one vehicle. Probably we'll need top-down legislation as well.

You talk in your book about the drug of choice. And you also talk about your addiction, and that was really mind-blowing because you talk about your addiction to books. Yeah, like a specific kind of books, like the vampire love novels. Right,

right. Romance novels and erotica. Yes, yes.

And that you've been addicted to your Kindle.

That's right.

I mean, I never thought about this being an addiction.

Right.

It's just somebody that reads a lot, right?

Right. Well, yes. I mean, I think— so first of all, let me say that I wouldn't want to trivialize my patients' life-threatening addiction to things like alcohol and heroin by comparing it to my quite mild addiction to romance novels. On the other hand, what I was trying to do with that was to humanize the problem. And also highlight that even behaviors that we typically think of as healthy, like reading, has now been druggified by making it more accessible, more potently reinforcing, more novel, and by creating easy access through things like the Kindle or other digital devices, which means that 24/7, wherever we are, whatever we're doing, we can access these digital drugs in ways that we just couldn't before, and again highlighting how much access increases our risk of addiction. It's one thing to have limited access for a certain time of day, it's another thing to have access 24/7. Mm-hmm. So yes, so I got addicted to romance novels. It was midlife, it started with the Twilight Saga, which seemed innocent enough, but somehow just really captured my imagination, and slowly over a Over a number of months to years, I just found myself reading more and more romance novels. I got a Kindle, and then I could read anonymously. Nobody could see what I was reading. And then I found myself reading late into the night. I'd be tired the next day. So that's an example of consequences as a result of that behavior. But also importantly, I had a narrowing of my interests, which is another thing that happens with addiction. It hijacks our brain's reward pathway. Other more modest rewards become less salient or less reinforcing, and all we want to do is just get through other tasks so we can get to our drug of choice and just be immersed in that world. Also, I experienced tolerance, which is finding that I needed more and more potent forms over time to get the same effect. So I progressed from Twilight, which is a vampire series written for teenagers, to a point where I was reading very graphic erotica involving, you know, sex, graphic sex scenes that I really wasn't like, wouldn't have been interested in before, but found myself there, which is very often the case in clinical care. Hmm. When we're treating patients with sex addiction, they will find themselves, for example, watching a type of pornography that originally they would've said, well, I'm not even really interested in this type of thing. But because they developed tolerance to sort of the vanilla pornography that they started with, they need more and more deviant forms to get the same effect. And that can lead some people down to places that are even illegal, right? Now they're looking at child pornography, or they're hiring escorts in a setting where that's illegal, or what have you. So that's a very common trajectory with addiction, is that in order to feed the beast, so to speak, we find ourselves going outside of our moral compass or engaging in illegal activity in order to get our more potent drug.

So I think it is very important for us to understand what happens beneath, what is the mechanism of this addiction. in order to be able to understand it and to outstand or fight against it. So can you explain at this point what happens in the brain when we find the drug of choice and then we are searching for this pleasure and we go for more and more? What happens actually?

What happens in our brains is that we go through a process called neuroadaptation where we adjust to whatever the reward is such that over time it becomes less rewarding. And ultimately we can end up in a reward deficit state where now we need more and more not to get high but just to kind of be normal. And one of the ways I like to teach about that is to use a metaphor of a balance To represent how we process pleasure and pain. So imagine that in your brain's reward pathway, there was something like a teeter-totter, like in a kid's playground, and that represents how we process pleasure and pain. When we experience pleasure, it tips one way, and pain, it tips the other.

It's just like that in here.

Yep, just like that, right?

Yeah, so we just start to play with pain, with pleasure.

Right.

And it's joyful, and that's it. We don't see what happens next.

That's right. Yeah, it starts innocently enough, right, with reading the Twilight Saga or what have you, or just enjoying some beers with friends or whatever it is. And our pleasure-pain balance tilts to the side of pleasure. But there are certain rules governing that balance, and the first and most The most important rule is that the balance wants to remain level with the ground. It wants to return to that level position. That's what neuroscientists call homeostasis.

But why? I mean, why don't we stay in the pleasure all the time? Why do you have to come back?

Well, you have to come back because you have to have a supple pleasure-pain system that can easily and quickly respond to changes in the environment. So this system evolved for a world of scarcity and ever-present danger, where we would have to work very hard to get a little bit of pleasure. And also, we have to be able to respond to a lion chasing us, right? So it has to be a supple system, and it has to be sensitive to external stimuli. So that means with any deviation to the pleasure side, we have to get back into balance pretty quickly so that we can go on to whatever's Next, and get the goods that we need to survive in a dangerous environment. And so our brains will work very hard to restore a level balance, and they do that through this process of neuroadaptation. And I like to imagine that as these little neuroadaptation gremlins hopping on the pain side of the balance to bring it level again. Mm-hmm. And essentially, they represent things like downregulating postsynaptic dopamine receptors, In response to a dopamine surge. Dopamine is our reward neurotransmitter. But the gremlins like it on the balance, so they don't get off as soon as it's level. They stay on until we're tilted an equal and opposite amount to the side of pain. That is the hangover, the comedown, or just that moment of craving, wanting to watch one more TikTok video, have one more glass of wine, or what have you. Now, if we wait long enough and we don't use, The gremlins get the message their job is done, they hop off, and homeostasis is restored. But if we continue to consume our drug of choice over days to weeks to months to years, those gremlins start to multiply. They get bigger and stronger, and eventually they're camped out on the pain side of the balance. And now we've entered addicted brain. We've reset our hedonic or joy threshold. threshold. Now we need more of our drug in more potent forms to get the same effect, or just to level the balance and feel normal. And importantly, when we're not using, we're walking around with the balance tilted to the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, depression, and craving. And that's really important to recognize because It means that other more modest rewards that we now put on the pleasure side of the balance will not be effective, because we've changed our hedonic set point, and we will need a whole lot more reward, again, just to level the balance and feel normal. And importantly, we may experience symptoms of depression and anxiety, and feel like we're self-medicating that, and that we need our drug— Wow. To treat that, But in fact, our drug created that problem in the first place. And what we really need to do is abstain from our drug for long enough for those gremlins to hop off the pain side of the balance so that homeostasis can be restored, and we can recapture our ability to take pleasure in other more modest rewards.

So we can say there's no pleasure without pain?

Well, you could say that, yes. I mean, there certainly are more complex forms of joy that aren't necessarily followed by pain. I mean, this is an oversimplification. As George Box has said, all models are wrong, but some are useful. Mm-hmm. And I would say this model is useful for understanding the process of neuroadaptation, but it is an oversimplification. For example, We can experience pleasure and pain simultaneously, like when we're eating spicy food. Mm-hmm. So it's not that they're always in opposition, but this opponent process mechanism is a nice way to capture the ways in which pleasure and pain are relative to each other, and also the ways in which, if we're continuing to consume a highly reinforcing substance or behavior, we can reset our hedonic or pain threshold such that we need more and more pleasure to feel any pleasure at all. And when we're not using, we're miserable.

Yeah. So that's the problem when we just look for pleasure, pleasure, pleasure, and we, we start to numb the pain all of the time. So you think we have to normalize pain a little bit in the world we live now?

Yeah. I mean, I think in this drugified world where everything has become more potently reinforcing, more accessible, more novel. We really are all more vulnerable to the problem of addiction, which means that our ancient wiring is mismatched for this modern ecosystem. And in order to reset our balance and be in a, in a healthier equilibrium, we have to consume pleasure more modestly and also intentionally lean into what I'll call right-sized pain. And this is the whole branch of science known as hormesis. Mm-hmm. So hormesis is a Greek term. It means to set in motion, and it's essentially a branch of science showing that when you expose an organism to mild to moderate doses of painful stimuli, you make that organism more resilient. For example, exercise. So we know that exercise Yeah. But we also know it's really good for us and makes us feel good afterwards, sometimes even during. So how does that work? Well, essentially, the body senses injury, and in response to injury, starts to upregulate feel-good neurotransmitters like dopamine, but also our endogenous opioids, our endogenous cannabinoids, serotonin, norepinephrine, So going back to that pleasure-pain balance, we know that when we press on the pleasure side, those gremlins go on the pain side, and we can end up in this reward deficit state, which is addiction. But it's also true that if we intentionally press on the pain side, for example with exercise or ice-cold water immersion, those gremlins will go on the pleasure side, and we can get our dopamine indirectly by paying for it upfront, and that turns out to be a better way to get our dopamine because we evolved to get our dopamine that way. We didn't evolve to have instant— instantaneous access to these high-potency pleasures. We evolved to have to work first and get our pleasure second. But the other thing too is that when we get our dopamine indirectly by working for it or exposing ourselves to painful stimuli upfront, Mm-hmm. What we see is instead of a spike of dopamine followed by dopamine freefall and this dopamine deficit state before going back to the level position, assuming we still can go back to the level position and aren't stuck in that dopamine deficit state, which is what happens in addiction, when we expose ourselves to painful stimuli, we don't get the spike of dopamine, we get a gradual rise in dopamine, and then it remains elevated for hours after we stop the painful stimulus. So even after we stop running, feel-good neurotransmitters like dopamine, serotonin, endogenous opioids, they remain elevated for hours afterwards before going back down to the level position. We don't go into that dopamine deficit state, which is what drives compulsive reuse.

But still, why— what I mean, uh, that's true for small addictions, right? But can that be used in, like, in big addictions? Because I was thinking about Jacob. Yeah, you have this— the first chapter of your book is about Jacob. We won't go into details because we, like, need a lot of time to go into these details, but he was like a masturbation machine problem. Mhm. And, uh, he, uh, he was telling in the beginning of the chapter that he was trying to abstain. Yeah, he was when he was young, and that was creating pain. I mean, why abstinence a lot of times creates pain, but you still get back to your addiction? You don't reset your balance with pleasure and pain. You still want more, more, more despite the pain that abstinence brings back.

Okay, so let's talk about that because the timeline really matters here. So you can imagine, going back to this pleasure-pain balance, you've accumulated all these gremlins on the pain side of your balance, right? Yeah. You're using all these drugs on the pleasure side. When you abstain and you take away from the pleasure side, that balance is going to go crashing down to the side of pain, and you will experience pain initially.

Yeah.

And the first 10 to 14 days are acute withdrawal, very painful. But if you can just get through those first 10 to 14 days without using, the gremlins hop off the pain side of the balance, and homeostasis is restored. And 80% of folks who can abstain for 4 weeks feel better. And I'll just give you— and I know you're asking about the long-term, and I'll get to the long-term, but I think it's important to point out sort of that you've got that acute, withdrawal, right? And then you've got, for 80% of folks, feeling a lot better. Now, this doesn't mean their addiction is cured, but in terms of how they subjectively feel, if they can abstain for 3 to 4 weeks, again, 80% of folks report feeling much better than they did when they were using. There's a very important experiment that was done by Brown and Shuket showing that if you take a cohort of adult males who meet criteria for alcohol addiction, but also meet criteria for major depressive disorder, and you put them in a psychiatric hospital where they have no access to alcohol, but they also don't get any treatment for depression, so no antidepressants, no therapy, nothing.

Okay.

After 4 weeks, 80% of those individuals will no longer meet criteria for major depression. So simply by abstaining from alcohol for 4 weeks, their depressive symptoms resolve entirely. Now, in the first 2 weeks, they feel worse, and many of them feel suicidal, which is why they're in a psychiatric hospital when they do it. But when they get to 4 weeks, they feel better than they have in a very long time, and that's because they've restored some degree of homeostasis, right? Yeah. And they've also gotten their frontal lobes back online. We're much better at really honestly being able to evaluate the true impact of our addictive behaviors on our lives once we get out of that vortex of the addiction cycle. So in 4 weeks, people will often look back and say, I can't— I don't even recognize that person who I was in my addiction. That's not even me. Okay, but now let's take from the 4 weeks going forward, which I think is where your question is. Mm-hmm. was getting at. Why do people relapse?

Yeah.

Right? Like, they feel so much— 80% anyway feel better. You know, they're doing so much better, they feel better, their families are happy, they're more productive, everything's better. Like, what— why would they ever go back to using that drug of choice? Well, addiction is a chronic relapsing and remitting disease, and once those addiction networks are created, they probably never entirely go away. Like a bonfire, we can get them down to just a few burning embers, but we probably can't ever put them out entirely, such that the craving can persist for months to years to even a lifetime. So there's a, you know, a very famous, potentially apocryphal story about the founder of Alcoholics Anonymous, Bill Wilson, who apparently, you know, he had abstained from alcohol for decades, and apparently on his deathbed said, I still crave alcohol every day. Yeah. So, and we do see that. Now, typically craving gets a lot better the longer the person can abstain, but some people will report craving never goes away. And that's probably because, again, those neural networks, once created, are there forever. We can quiet them down, but they don't entirely go away. Plus, you have differences in innate, sort of DNA-driven vulnerability to addiction. Mm-hmm. Like, we don't all come into this world with the same degree of vulnerability. Some people are just wired for addiction more than others, right? So, and then you have life circumstances that will drive people back to addictive use. One of my favorite animal experiments is if you get a rat addicted to cocaine by putting them in a cage to press a lever for cocaine— rats love cocaine— they will typically press that lever till exhaustion or death. If before the rat dies, you take the cocaine away, eventually they'll stop pressing the lever. It can take a while, but they'll stop pressing it, and they'll kind of go and do whatever else there might be to do. In the cage that they're in, but they'll forget about the lever. But if you then expose that animal to a very painful foot shock, the first thing the animal will do is to run back and start pressing the lever. In other words, stressors become a major trigger for our lizard brain, or rat brain if you will, to want to go back to whatever those early learned behaviors are for alleviating pain or alleviating suffering or escaping whatever the situation is. So, you know, you've got your 4 months of abstinence, you're feeling so much better, but then you've got the lifetime. And the lifetime ahead of that remains challenging for people with severe addiction because, again, those neural networks never entirely die, because innately their DNA may predispose them to addiction. And because life is hard. Life is hard, and when life gets hard, we have this overlearned behavior to wanna go back to whatever that maladaptive coping strategy is. The other thing I always say about the gremlins is once those gremlins are created, they might hop off the balance and allow us to restore homeostasis, but they never entirely go away. They're waiting at the bottom of the balance, eager to hop on again. Mm-hmm. And we tend to forget about them. So we have very vivid memories for the initial stimuli of pleasure and pain. Like, if you look back at your childhood, most of us will remember intense pleasures and intense pains. That lays down hardcore memories, because from an evolutionary perspective, we need to know where to find the good things and how to avoid the bad things, right? But we have very poor memory for the gremlins. So very poor memory for what comes after that initial stimulus. And that's where things like Alcoholics Anonymous or other 12-step groups can act like an extended hippocampus to help remind us about the gremlins. We have a shared narrative where we're telling our story of my life in addiction, what happened, how I got into recovery, and how much better it is now. And those stories make the rounds. And they serve to remind us about what the gremlins can actually do if we're not careful.

That's kind of a scary story because a lot of people think that they can get into an addiction or to bad behavior with substance abuse, but then they can quit. And as you say in the story in the book, and as you just said, for example, people that use cocaine, they develop this neural network that are wired for the cocaine use that will never go away. Those networks will stay there for life, right?

I mean, that's what we think, and that's what the research shows, and that's also what our clinical experience shows, that people who develop a very severe addiction will most, in most instances, struggle lifelong with triggers that can set them up for craving, that can put them at risk for relapse. Having said that, there are millions and millions of people all over the world who get into decades-long, and in many instances, lifetime-long sustained recovery from severe addiction. Mm-hmm. So there's lots of reason to be hopeful. We often don't hear from those people, but you— we all know somebody, or maybe not even realize we know somebody who is in recovery from a very severe addiction. There are many, many stories of hope. And yes, it can be very hard, but I've seen very— people with very severe addictions at every stage of life, even in their 70s and 80s, get into recovery, and recovery is always worth it.

So, but it's still a continuous fight, yeah, with, uh, uh, with the craving?

It varies person to person. In my clinical experience, the longer someone can go without using, the faster they will get to that place where they're not craving. But there are some individuals, and this is sometimes called the protracted abstinence syndrome, who even after year you know, many months or 2 or 3 years of abstinence will still be struggling. You know, it's possible that some individuals lose the neuroplasticity to restore homeostasis, which is why, for example, for people with very severe opioid addiction, we will use opioids to treat opioid addiction. When you give somebody with opioid addiction a medication like buprenorphine or methadone maintenance, They don't get high off of that. What happens is you allow them to restore homeostasis, so they're not constantly fighting the craving, and so it allows them to use their energy and creativity to work on other aspects of recovery. So that's— and those are some of the, you know, most evidence-based treatments that we have for opioid addiction. So, you know, there's a spectrum of the disease process, and there's also a spectrum of recovery. Not everybody's the same.

What do you think about food addiction and the use of GLP-1 medication that somehow acts on the addiction centers in the brain?

Yeah, so GLP-1s are an exciting new tool that we have to combat addiction. As you know, they were first approved to treat diabetes and also help obese people lose weight, but now they're being explored to treat all kinds of addictions. There's good evidence to show that they're helpful for food addiction, for alcohol addiction, and even evidence in nicotine addiction and opioid addiction. They're also being explored in some behavioral addictions like sex addiction and gambling addiction, and there's a lot of reason to be hopeful Because what we're seeing with alcohol addiction in particular is that for some individuals, they can be really miraculously helpful. We prescribe them in our clinic to individuals who have tried everything.

For what?

For alcohol addiction.

Okay.

Yeah, who have not been able to get into recovery and who with the GLP-1 are able to get into sustained recovery.

So you prescribe GLP-1 for alcohol addiction?

Yes, we do.

And does it work?

In some people it does, yeah. So I think what's interesting about addiction, which is also true for other mental illnesses, is that you need a wide variety of tools because there's so much inter-individual variability. And one patient may respond to one intervention but not another. And we're seeing the same thing with GLP-1. So we have some patients for whom the GLP-1s are not at all helpful, and also they may not tolerate them because there are quite a few side effects. And then we have other patients for whom they help where nothing else did. So we are seeing a range of responses, but we're definitely seeing some people really be helped by them.

You know, I'm curious about something. We all know people been addicted with something and they have, they have this willpower, you know, the people that say, okay, I'm enough with that, no matter if that's alcohol, smoking, eating a lot, drug use. And they will say, okay, I'm enough. I'm not this person anymore.

Right.

And they stay on track without help, without therapy, without medication. They get lean and fit. They never drink. They never smoke. And by the other hand, we have people that cannot do that. And we judge them saying that they don't have willpower. What is the difference between these people? Did you, I mean, did you see in your practice, like, these people that have this willpower to have something in common?

So this phenomenon of what's often referred to as natural recovery is well documented. There are definitely individuals who meet DSM criteria for addiction who spontaneously get into recovery on their own. Yeah. Without seeing a doctor, without going to a 12-step group, without taking medication. They're just able to get to a point in their lives and they say, enough is enough, and they stop. But most people with very severe addictions are not able to do that. They need help. Or if they are able to exert their willpower to stop, it doesn't last. So they're able to do it maybe for a month or 2, but at some point they tell themselves, oh, it's okay for me to go back using. And then maybe it's okay for a while, they're able to use in moderation, but eventually they will slip back into those addictive patterns. So I would say natural recovery is something that is going to be possible for a minority.

Yeah.

A small minority of people who are, you know, who have a significant addiction problem. Um, but it, it does definitely happen. Um, and, you know, and it, and it is real. I, I've sort of given up on trying to predict who is going to be able to get into recovery and who isn't.

Are you doing that? Yeah. In your—

I used to. Okay. Because I used to think that you could kind of tell.

Yeah.

But, but actually, I don't think that's true anymore. You know, I've had patients who seem to have, like, all of the things in place that you think would make it possible for them to get into recovery, uh, you know, good friends, a good job, socioeconomic stability, um, all kinds of resources at their fingertips, and yet who cannot stop using. I mean, I've had people who have very, you know, the opposite. have really hard lives, and yet somehow are able to find the capacity to get into recovery. So I mean, in general, if you look at the literature, you know, the risk factors for addiction can be summarized as nature, nurture, and neighborhood. Nature is, do you have a biological parent or grandparent with addiction? Right. Did you get a genetic load that makes you more vulnerable? Do you have a co-occurring mental illness that makes you more vulnerable to addiction? In terms of nurture, did you have trauma growing up? Did you have unstable caregivers? Were you physically, mentally, or sexually abused? Those are risk factors for addiction. And then neighborhood, are you poor? Are you unemployed? Those are risk factors for addiction. Do you live in an environment where you have easy access to drugs? That's a big risk factor for addiction, as we've talked about. So these are known risk factors, and yet on an individual basis, I can just say it's hard to predict that some— sometimes people who have all those risk factors get into recovery. Other people who have none of those risk factors can't get into recovery without help.

Although you say in the book that we already know that, like, rich countries are having poor mental health. Yeah. So maybe being rich is a risk factor as well, right?

Well, you know, I live and work in Silicon Valley in California, one of the richest places in the world, and we've always thought of poverty as being one of the biggest risk factors for addiction, and it is a big risk factor for addiction. Yeah. But I think extreme wealth is also a big risk factor for addiction, especially when it's inherited wealth, so not something that somebody earned through their own Striving behaviors, their workaholism, if you will, but it's the wealth inherited by their children, which I think looks like that may also be a big risk factor for addiction because it gives, simply said, just more access to drugs.

And maybe more than that, because also in your book you say that we inherit, beside the wealth, we inherit this extreme safety. Yeah, I mean, kids are so safe and they can do whatever they want, and that turns to be again a problem, right?

Yeah, it's a big problem. I also think we don't talk enough about boredom as a risk factor. You know, if you don't really have any kind of purposeful engagement, no task that you have to do either to survive or or to give you meaning and purpose, I think it makes people much more vulnerable to the problem of addiction.

Yeah. I mean, I think it's from your book, you said that you need boredom to make space for new ideas to come. Yeah. That's right. Because if you're not bored, you simply don't have that space anymore to think about yourself and to have new ideas. And yeah, we talk about the phones because the phone is is the enemy of boredom. And actually, boredom is kind of painful, right? I mean, I don't like to be bored.

Right. Boredom is painful. It opens the doorway to all kinds of existential questions like, why am I here? And what is my life purpose? And we have so many ways now to distract ourselves from those deeper questions, which I think is not good because we're not asking those questions and we should be.

So we have to add boredom to the hermetic pain, right? We have to exercise boredom the same way we exercise in the gym.

Yeah. And you would know better than I, but I think there are some young people now who are actually doing videos of themselves just sort of sitting quietly and doing nothing. Of course, they are taping themselves doing it. So there's always this meta Cognitive component to everything now. But yes.

Yeah, but we have like, well, this is the business of the future. This is the wellness business of the future. You will have the gym and the boredom, like the boredom rooms. Hey, what are you doing today at 2? Oh, sorry, I cannot come. I'm going to the boredom room where I'm going to stay for 1 hour and do nothing. They lock my phone and I just have to watch the walls.

You joke, but versions of this exist where people literally will pay money to be in an environment that prevents them from doing much of anything or accessing digital media because, given access, we're very much slaves to these temptations. Yeah,

the boredom clinics.

Boredom clinics.

Yeah.

Low overhead, low overhead for the entrepreneurs out there who are thinking— I mean, it doesn't take much.

I'm a boredom doctor. I prescribe no phone.

Right. Well, the great thing about prescribing no phone, though, is that initially folks will experience quite intense withdrawal. You know, we talked about anxiety, irritability, depression, craving being the universal symptoms withdrawal. But when they get to the other side of that, because we treat digital media addiction with the same kinds of dopamine fasting or abstinence trials as we do drug and alcohol addiction, when they get to the end of those 4 weeks, many individuals will no longer be bored. The point being that these frictionless, easy pleasures create a sense of easy boredom because they change our hedonic or joy threshold. Such that we can't be satisfied with simple things. But if we can wean ourselves from these digital drugs, we reset our reward pathways, and then all of a sudden we do have a capacity for some degree of boredom or just sitting in the quiet.

So can you maybe propose a simple or complex protocol for phone addiction? Because I think this is the most prevalent addiction nowadays in the spectrum also, of course. But we all use our phones a lot.

Yeah. You know, I'm hesitant to do a sort of one-size-fits-all. In my book and in the interactive workbook, I do talk about abstaining from a platform that we do too much and regret using for 4 weeks. Again, the same model that 2 weeks is not sufficient because we're just going through acute withdrawal, that we really need to abstain for 3 to to 4 weeks in order to reset reward pathways and get the benefits of abstinence. But it's very hard to just sort of, you know, do a blanket, like, most people cannot not be on their devices because they're required to for work, for school, to be able to just interact in modern society. You know, I have had adolescent patients who were so severely addicted that, you know, I recommended that their families take all devices away a period of time, and that can be effective in that setting. But for an adult who's struggling with compulsive overconsumption, what I usually recommend is they choose the platform or type of behavior— maybe it's online pornography, maybe it's online shopping, maybe it's gaming, maybe it's social media— and they delete those apps and abstain from that specific subset of behavior for 4 weeks. While otherwise still using their phone as a tool, not as a drug. And one way to think about this in order to frame it is, in the period of digital abstinence, what we're trying to avoid doing is avoiding using the phone to entertain ourselves and avoiding using the phone to change the way we feel. So those 2 things, to do a digital detox from— Our devices, try to go 4 weeks without using it to change the way you feel or to entertain yourself. So that means you have to find other forms of entertainment, like meeting up with friends in real life or listening to a vinyl record or using old-fashioned devices that won't give you access to the internet. And then specifically, the not using our devices to change the way we This is a really hard one, because we might even be checking email to change the way we feel, right? And we don't usually think of email as addictive, but I'm bored, let me see if anything good came in.

Yeah, there's where the dopamine comes, because you expect something.

Right, so you have to be very thoughtful about, you know, how we're using the device, but this is still the recommendation, taking a break for 4 weeks from that specific type of behavior and from trying to use these devices and platforms to change the way we feel or to entertain ourselves.

Yeah, but first you need to realize that this is an addiction, yeah, and that it harms you somehow. And you have a patient described in your book that had a shopping addiction. And I think a lot of people don't realize they have a shopping addiction, right?

Yeah, or they do, but they don't know how to stop. Yeah, the patient I describe in the book, Like most of us, he shopped online, and initially he told himself it was things that he needed.

Yeah.

But he got to a point where he was in severe credit card debt, buying things online he didn't need, finding himself getting into this pattern where he would crave the searching part of it. So it's not just getting the object, it's also the ritual of searching for it. The anticipation of its coming. But then as soon as it would arrive and he would open the box, he would instantly be deflated. Like, there would be no joy there anymore. So then he would go online again, and he got to the point where he was ordering things he absolutely knew he didn't need, like keychains and mugs, just so he could have something to look forward to. He knew it was being sent and he could open it. And he ended up with many rooms full of useless items. So for him, the intervention was to delete all of the shopping apps, to unlink all of his payment sources from those apps, and to not use credit cards or Venmo or buy anything online for 4 weeks to try to get him out of that addiction vortex and to be able to give him more perspective on how he wanted to change his relationship with shopping going forward. So again, I would emphasize that these sort of digital detox months or abstinence trials are not like treatment for addiction. What they are are experiments.

Yeah.

Allowing us the opportunity in some cases to just see if we're addicted in the first place, to see if we can do it, and also what the impact is on our psyche, because I think people really underestimate how much these addictive loops may be making us more depressed and more anxious. And it's not until we really get away from them that we realize how much better we feel when we're not engaging on these digital platforms.

What would you do if you would be, let's say, a Romanian parent of an adolescent that is using social media Extensively. If what how would you approach that? Because the adolescent doesn't think it's it's a problem, and actually in Romania we are like it's in a survey Romania showed to be the first country in Europe as a problematic social media use in adolescence. Twenty-two percent of adolescents in Romania have this problematic social media use.

Yes, I'm familiar with some of those data showing that Romania is a leader in terms of adolescent addictive or problematic use of social media. What I tell parents is, number one, try not to give a very young child a personal device.

Yeah.

So any child under the age of 13 should not have their own smartphone, smartwatch, iPad, That kids at that age just don't have the neurocognitive development to be able to navigate what is ultimately a highly addictive platform and product.

So at first you would ban them? Yeah,

for younger children, for sure. And remember, I always tell parents too, you know, you can make a decision as a parent which turns out not to be a good one, and when you realize it's not a good one, you can change course, especially if the child is still under the age of 13 when we still have some reasonable amount of control over what they're doing. So if you have a younger child under the age of 13 and they have a personal device, I would recommend explaining to the child why you're taking it away and then taking it away. Now, once kids get into their teenage years, it's much more difficult because even if we don't provide them with a device, they will go out and procure their own.

Yeah.

Our own children did that. So I know that from personal experience. Yeah. So we didn't give our children any devices, but when they were 16 and they started high school, they basically needed to have laptops to participate in school because, yeah, everything was going online. And then our daughter said that she needed a smartphone in order to be socially connected. We didn't agree with that, so she just went out and got her own. But the important thing at that point is to have a lot of open discussions about what appropriate use looks like. So talk about what I'll call a digital etiquette. Mm-hmm. When is it appropriate to be on your phone? When is it not appropriate? For example, when you have guests come over, it's not appropriate to be on the phone. Mealtime, it's not appropriate to be on the phone. In your bedroom, in your bed, when you should be sleeping, it's not appropriate to be on the phone. So talking about that openly as a family, as well as talking about how different difficult it is. Now, for the subset of parents— it's going to be about 10%— who have a child who develops an actual addiction to their device, I would recommend you seek professional medical treatment because that is a situation that is extremely difficult, if not impossible, for parents to navigate on their own. That, that child has likely developed a more severe mental health problem They most likely have co-occurring psychiatric disorders like depression or bipolar illness or who knows what. And I recommend getting support and having your child be seen by a mental healthcare provider.

And that should be a psychiatrist specialized in addiction or?

It should definitely be somebody who has expertise in addiction, ideally somebody who has expertise in digital media addiction in adolescents. But it doesn't need to be a psychiatrist. You know, there are all kinds of people with all kinds of degrees who are very skilled in this arena, even people who might self-designate as, you know, life coaches, social workers, many psychologists. So there are lots of good folks out there who can do this work. The key is to make sure you go see somebody who holds themselves out as having expertise in the domain of— Yeah. addiction. If you just go see a psychiatrist who doesn't have expertise in that area, they may actually miss the problem of addiction or underdiagnose it.

I think we need a lot of professionals nowadays specializing in addiction.

Yes, I think that's right. We have— the workforce doesn't match the need, that's for sure.

Yeah. Uh, well, another, like, big addiction we have in Romania is gambling. So, uh, in, um, 2 years ago, it seemed that Romanian people lost 19 billion lei in gambling. It's almost €200 or let's say $200 per inhabitant.

Right.

It's much more than other European countries. And the online gambling overtaken the slot halls. So we have slot halls that are banned. But the online gambling is not banned. And if you would see it, I mean, you can see in Bucharest, we have a lot of outdoor ads for gambling.

Yeah.

And what they say, they say, play responsibly, play just for fun. What the fuck? How can that be possible in a country with with with with this big problem? What what can you do? Like before the government steps in, and there's a lot of advocacy in stepping in, and they say they won't step in because there's a lot of profit coming to the budget.

Yeah.

But it's like having profit selling heroin or cocaine. You can open like cocaine shops. They have a lot of profit, right? And before they step in and do something about that, what can people do? Because play responsibly, just play for fun. You take the app and you play the slot and you lose all your money,

right? Yeah. This is a big and growing problem all around the world, especially sports betting, but also these new Polymarket, Kalshi.

Yeah.

Which have gamblified everything, right? So you can now bet on almost everything. And it's also the parley market. It's also an unfair market because now you have insiders who actually can manipulate that betting or have insider knowledge.

Oh, yeah.

Which means that the average gambler is even more likely to lose to the house. Yeah. It's a ginormous problem. It gets directly to this issue of access. When you have in your hand the equivalent of a slot machine wherever you go, very, very hard to use it responsibly, especially if you happen to be one of those people who is vulnerable to becoming a pathological gambler. And again, it's probably— I mean, right now we think of it as about 10% of the population, but with increased access, it may be as high as 25% of the population And when people develop a severe gambling addiction, it is life-threatening. I mean, I know, I know we don't think of people as like overdosing on gambling like we do, uh, the way that they can overdose on fentanyl.

Yeah.

But, but people can destroy their lives, lose the people they love, lose their jobs, end up suicidal, and, uh, just completely devastated. So this is a very serious illness. It is a serious Mental illness, and we need to take it seriously as a society. And I really appreciate, you know, your insight regarding a government that says, well, you know, we don't want to curb this because it's bringing in so much money. It's like, okay, that's short-term games, short-term gains, long-term losses, because you're basically gambling away your humans, right? Uh-huh. Why not invest in the humans that can become productive members of society in the long run. And you'll do that by insulating them from too much access to gambling. So we really need to curb the access, which means we need to not only provide guardrails for kids for online gambling, but we also need to use things like AI. to figure out who are the pathological gamblers. And then what's happening now is the companies are doing that already.

Okay.

And then actually targeting those individuals to get them to gamble more.

Yeah, exactly. Like the algorithm knows who is willing to play more. They send notifications, stuff like that. Give you free money for slots.

Yes, exactly. And the opposite needs to happen. Once those companies identify who are the at-risk gamblers, they should be required by law to limit those individuals from the platforms or create other sources of friction, or for that matter, other sources of support for them to get the help they need so that they don't lose everything.

I have a hard question for you.

Okay.

If you would be like the highest official in Romania, You would be the law.

Scary thought.

Yeah, exactly.

Just because I don't think I should be the highest official of anything.

But let's imagine, just imagine, because you're the professional working with addiction and you can ban only one of those 3. You can ban the gambling and the slot machine and stuff like that. You can ban this vape smoking and you can ban The social media use. Which one of them you would choose? Only one choice.

Well, I would say that social media is gamblified, so it's hard to say that. So to me, those are very equivalent, but I would probably go for the gambling. Yeah, anything that's been gamblified, especially for kids.

Because this one has the biggest impact. Yeah, on the people.

I think ultimately in the long run it's going to have the most destructive potential. Yeah.

Yeah, I hope that Romanian officials will learn things from, uh, from this. I mean, I, I don't think that Romanian officials are watching our podcast. Maybe. At least the people that are watching should put more pressure on that.

Actually, what you didn't include in that list, which would be Way on top for me is pornography. Pornography and other platforms that encourage the problem of compulsive sexual behavior. That's a huge, huge problem and very underrecognized.

Would you ban that or?

I mean, again, banning, I mean, regulating.

Yeah, there are countries that you cannot access porn on the internet.

Is it really? I mean, is there really any place anymore that you can't access? It's hard for me to believe that.

I mean, I think you can go with like special devices with VPN and stuff like that. I have some, a game in the end if you want to play a game.

Sure.

So I have, there's like, I will say the phrase.

Okay.

And you finish it with a word or with a sentence. It's

like a Rorschach test or something? Yeah.

So my drug of choice today is—

And then I have to answer it? Yeah. Okay.

Yeah. My drug of choice today is—

Celebrity gossip shows.

Oh my God.

Really? Yeah. My husband knows that.

So you binge on them or you control that?

I mean, where one ends and the other begins is hard to say. I try to limit my use to no more than about 3 days a week, no more than about 2 hours at a time. If I can stay in that window, then I think it falls squarely within entertainment and recreation and not something that I would regret later.

Okay, so 3 days a week. That seems—

3 days a week, a couple hours, kind of like watching a movie or something like that. Yeah.

Okay. The last time I was truly bored was?

Last night in the hotel room, because I'm jet-lagged and I couldn't sleep. So when all the Romanians were sleeping, I was wide awake. And I mean, was I bored? You know, there's an interesting— I often think that boredom merges with sort of unhappy ruminations. So it was some combination of bored And ruminating, which is a very unpleasant state. And that was last night.

Okay. And you didn't use any social media and stuff like

that? No. I mean, I don't— I'm not on social media. You're not? No. Oh, no. I wouldn't be able to handle being on social media. But

we are on social media now.

I know. Well, good for you. You can handle it. I know I wouldn't be able to.

Do you think I'm kind of a— if, like, if the social media is the drug, am I the drug dealer?

Could be. Yeah, I think you're pretty close. I actually don't don't know what what you're. I I I wouldn't really want to diagnose you without doing a full workup, but we could do that some other time if you want. Yeah.

Okay, the patient who changed how I practice taught me that.

I mean, I've had so many patients who have changed me and my life and my practice. I mentioned. the young woman early on who was in the rollover car accident. Yeah. Jacob, who you mentioned, who opens the book, who had a very severe sex addiction. He changed me because when I met him, I had— I was both— so he developed a sex addiction and ultimately built his own masturbation machine using a variety of technologies. He's an engineer. And he had a very big impact on me because he was the impetus for me to write Dopamine Nation because I realized that I wasn't that different than him, that actually my, you know, that romance novels are in some ways just socially sanctioned pornography for women and that I had my own kind of compulsive patterns around that. So I saw myself in

him. Yeah. The biggest myth about dopamine is?

I mean, a recurring myth about dopamine is that it's about pleasure when in truth it's about reinforcement, and dopamine will be released in response to any stimulus that our brain recognizes as potentially important for survival. So it's not really about pleasure, it's about, uh, this is something that you should approach, explore, and exploit. Um, and so it's more of a survival neurotransmitter and the ultimate gain function modulator, meaning that it is the neurotransmitter that sort of Whatever you're doing now, do more of it. If some is good, more is better.

Yeah, that was the game.

Great. Okay, that wasn't too bad. That wasn't too bad.

Yeah, well, I want to thank you for your time. And I think that the thing that we learn in the book and thinking about addiction is that we have a lot of addiction we don't know about. And the first thing I love also, the acronym you use in the book for the dopamine detox, when you say you have to collect the data. So you have to know how often you use, the thing you use, you need to objectify it or—

Or the objective, figure out what you're hoping to get from using. Most people want to use to have fun or to solve a problem. So try to think about why do you use?

Yeah. And then find a problem. Yes, D-O-P-A-M-I-N-E, dopamine. Right. So data, objective, then you need to find a problem. It causes you a problem, right? Like, for example, if you use a phone, why you use it? Well, to avoid boredom. You already know boredom is good. So, uh, and yeah, data. Yeah. Uh, objective is to, um, to, to have fun. And like, is there any problem it causes you? I think that the time you waste on the phone is one of the problems. You can do a lot of things with that time.

That's right. We often call that opportunity costs, right? All the things you're not doing because you're spending so much time on your phone.

And then you have to practice this abstinence and be mindful.

Right. Yeah. And what a great chance to practice your mindfulness skills, which is the ability to observe yourself without judgment, your thoughts and feelings without judgment. When you can't reach for your phone, you're sort of left with that. And it's good to strengthen those mental muscles.

And then there comes the introspection. Dopamine from introspection that you check how you feel, you think about that, and then comes the next level.

Right. So after the 30-day dopamine fast, which is what the Mm-hmm. This acronym provides a framework for, then hopefully, you know, like you're out of the vortex of addiction, and you can more objectively assess the true impact of that behavior on your life and decide what you wanna do next. Do you wanna continue to abstain, or do you wanna go back to using? Frankly, most people wanna go back to using, but they almost always wanna use differently. They wanna use less. And then you can make a very detailed plan for what that will look like. How much? How often? What are your red flags suggesting you might be returning back to your old patterns?

And then the last letter is E. It's experiment,

right? And so then whatever plan you decide on, then you can go back out in the world and see how it goes. And if it goes well, great. And if you find you're slipping back into old patterns, you can do another reward reset, another 30 days of abstinence, or you can just try to implement more self-control. self-binding strategies by creating more barriers between yourself and your drug of choice.

You wrote this book about 5 or 6 years ago?

That's right. In 2021, it came out. Yeah,

so it's 5 years ago. What would you change if you would write it again today?

I mean, AI didn't exist, or at least not in the large language models that are available directly to users. I would probably have more on specifically social media and large language models. That's one thing I would change.

What do you mean by that?

Oh, I would just— I would talk— I mean, if I could do an update to the book, I would include some of these newer technologies like chatbots. Yeah. And then the unique nature of that. I mean, beyond that, I really I probably wouldn't change very much because I didn't think anybody would read the book, and it's sold over 1.5 million copies worldwide and been translated into 35 languages. So it did much better than I ever expected. So I probably wouldn't change very much.

Yeah. And if you have one last message for the Romanian public, you go on the stage tomorrow, right? Yeah. What are you going to be talking about?

I'm going to be talking about the dopamine acronym. I'm going to be doing a workshop in the morning. I'll walk folks through that acronym. And then I'm going to give a keynote address where I'll talk about some of the major concepts in Dopamine Nation, like what we discussed today. And then I'll be on a panel that's specifically addressing the problem of how to reconcile the profit motive, because this is a business conference, you know, that corporations have with the increasingly addictive nature of the products that we're consuming. And the fact that a vulnerable subset of individuals are getting addicted to these various new technologies and what we as a society can and should do about that.

That's great. I can't wait to see you tomorrow on the stage.

Oh, great. Well, I'll look forward to seeing you too.

Yeah. And I wish you a pleasant discovery of Romania if you stay a few days. I hope You will enjoy it here.

Yes, thank you. It's been wonderful so far. Lovely people and a beautiful setting. So it's very nice to be here.

Yeah. And thank you so much again for coming. Actually, it's so funny because I sent you an email because I was planning to come to Stanford in the end of the year. And you said, yeah, but why Stanford? I come to Bucharest. Right. It was amazing.

Yeah.

And I have such a big dopamine rush then because I like Oh my God, Dr. Anna Lembke accepted to come to the podcast that I forgot to reply to you. You said, yeah, I'm coming to your podcast, and I forgot to reply. Isn't that funny? Yeah, I remembered in like a week and I, oh my God, so sorry. So thank you again for replying back.

Yes, no problem.

And for coming for this podcast.

Well, great. It's so much nicer to do these things in person and you have a beautiful Studio and a great team, so it's nice to be here.

Yeah, thank you so much. Yeah. Muțumesc și ecarem asponaici. Sper că acest podcast să se fie util. Miean moțierte meste util, amțiți care este definiția dependenții și lucuri de pecare. O să observe că le fac compulsiv, o să începse verific dacă entră de vorsum compulsiv, dacă am crează probleme, dacă numă potă pțina de le faci și ată existe și Modalități să brincare po să încegeș să ieste din acest cerc vicios. Care ta sa? Or care din o atribuie soibă, un specialțin în condefaptul că treiim un trun mediatu de adictiv, și toți vedem un jour vreasa fie vundut pentru profit, și toți avem un jour a propă toți avem un jour ieste gundit pentru afi adictiv. Ce că care cele să înprintre ultimele resortur care aurumăs ne adictive, de zacă vrei Se te desenvoltes, por assim dizer, se fazes um lucro útil para cujo que tem bonas tateias, este, e se que no caso não é apurado dependência, quer dizer, poderia ser um asfalto de lucro. Muito obrigado por terem ouvido. Atenção, muito obrigado ao Unicredit Bank pelo facto de estarem a ouvir o podcast do Babo e da Econoaster. Tchau, pecorando!