Dopamine Nation: Finding Balance in the Age of Indulgence

Highlights

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dowel

Note: New word

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Whether it’s sugar or shopping, voyeuring or vaping, social media posts or The Washington Post, we all engage in behaviors we wish we didn’t, or to an extent we regret. This book offers practical solutions for how to manage compulsive overconsumption in a world where consumption has become the all-encompassing motive of our lives.

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The term double life is as familiar to me as ST segment elevation is to the cardiologist, stage IV is to the oncologist, and hemoglobin A1C is to the endocrinologist. It refers to the addicted person’s secret engagement with drugs, alcohol, or other compulsive behaviors, hidden from view, even in some cases from their own.

Page 444

In 2016, I gave a presentation on drug and alcohol problems to faculty and staff at the Stanford student mental health clinic. It had been some months since I’d been to that part of campus. I arrived early and, while I waited in the front lobby to meet my contact, my attention was drawn to a wall of brochures for the taking. There were four brochures in all, each with some variation of the word happiness in the title: The Habit of Happiness, Sleep Your Way to Happiness, Happiness Within Reach, and 7 Days to a Happier You. Inside each brochure were prescriptions for achieving happiness: “List 50 things that make you happy,” “Look at yourself in the mirror [and] list things you love about yourself in your journal,” and “Produce a stream of positive emotions.” Perhaps most telling of all: “Optimize timing and variety of happiness strategies. Be intentional about when and how often. For acts of kindness: Self-experiment to determine whether performing many good deeds in one day or one act each day is most effective for you.” These brochures illustrate how the pursuit of personal happiness has become a modern maxim, crowding out other definitions of the “good life.” Even acts of kindness toward others are framed as a strategy for personal happiness. Altruism, no longer merely a good in itself, has become a vehicle for our own “well-being.” Philip Rieff, a mid-twentieth-century psychologist and philosopher, foresaw this trend in The Triumph of the Therapeutic: Uses of Faith After Freud: “Religious man was born to be saved; psychological man is born to be pleased.” Messages exhorting us to pursue happiness are not limited to the realm of psychology. Modern religion too promotes a theology of self-awareness, self-expression, and self-realization as the highest good. In his book Bad Religion, writer and religious scholar Ross Douthat describes our New Age “God Within” theology as “a faith that’s at once cosmopolitan and comforting, promising all the pleasures of exoticism … without any of the pain … a mystical pantheism, in which God is an experience rather than a person… . It’s startling how little moral exhortation there is in the pages of the God Within literature. There are frequent calls to ‘compassion’ and ‘kindness,’ but little guidance for people facing actual dilemmas. And what guidance there is often amounts to ‘if it feels good, do it.’”

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My patient Kevin, nineteen years old, was brought to see me by his parents in 2018. Their concerns were the following: He wouldn’t go to school, couldn’t keep a job, and wouldn’t follow any of the household rules. His parents were as imperfect as the rest of us, but they were trying hard to help him. There was no evidence of abuse or neglect. The problem was they seemed unable to put any constraints on him. They worried that by making demands, they would “stress him out” or “traumatize him.” Perceiving children as psychologically fragile is a quintessentially modern concept. In ancient times, children were considered miniature adults, fully formed from birth. For most of Western civilization, children were regarded as innately evil. The job of parents and caregivers was to enforce extreme discipline in order to socialize them to live in the world. It was entirely acceptable to use corporal punishment and fear tactics to get a child to behave. No longer. Today, many parents I see are terrified of doing or saying something that will leave their child with an emotional scar, thereby setting them up, so the thinking goes, for emotional suffering and even mental illness in later life. This notion can be traced to Freud, whose groundbreaking psychoanalytic contribution was that early childhood experiences, even those long forgotten or outside of conscious awareness, can cause lasting psychological damage. Unfortunately, Freud’s insight that early childhood trauma can influence adult psychopathology has morphed into the conviction that any and every challenging experience primes us for the psychotherapy couch. Our efforts to insulate our children from adverse psychological experiences play out not just in the home but also in school. At the primary school level, every child receives some equivalent of the “Star of the Week” award—not for any particular accomplishment but in alphabetical order. Every child is taught to be on the lookout for bullies lest they become bystanders instead of upstanders. At the university level, faculty and students talk about triggers and safe spaces. That parenting and education are informed by developmental psychology and empathy is a positive evolution. We should acknowledge every person’s worth independent of achievement, stop physical and emotional brutality on the schoolyard and everywhere else, and create safe spaces to think, learn, and discuss. But I worry that we have both oversanitized and over-pathologized childhood, raising our children in the equivalent of a padded cell, with no way to injure themselves but also no means to ready themselves for the world. By protecting our children from adversity, have we made them deathly afraid of it? By bolstering their self-esteem with false praise and a lack of real-world consequences, have we made them less tolerant, more entitled, and ignorant of their own character defects? By giving in to their every desire, have we encouraged a new age of hedonism? Kevin shared his…

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Beyond extreme examples of running from pain, we’ve lost the ability to tolerate even minor forms of discomfort. We’re constantly seeking to distract ourselves from the present moment, to be entertained.

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As Aldous Huxley said in Brave New World Revisited, “the development of a vast mass communications industry, concerned in the main neither with the true nor the false, but with the unreal, the more or less totally irrelevant … failed to take into account man’s almost infinite appetite for distractions.”

Note: It’s terrifying how accurate he was

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In session with her I suggested she try walking to class without listening to anything and just letting her own thoughts bubble to the surface. She looked at me both incredulous and afraid. “Why would I do that?” she asked, openmouthed. “Well,” I ventured, “it’s a way of becoming familiar with yourself. Of letting your experience unfold without trying to control it or run away from it. All that distracting yourself with devices may be contributing to your depression and anxiety. It’s pretty exhausting avoiding yourself all the time. I wonder if experiencing yourself in a different way might give you access to new thoughts and feelings, and help you feel more connected to yourself, to others, and to the world.” She thought about that for a moment. “But it’s so boring,” she said. “Yes, that’s true,” I said. “Boredom is not just boring. It can also be terrifying. It forces us to come face-to-face with bigger questions of meaning and purpose. But boredom is also an opportunity for discovery and invention. It creates the space necessary for a new thought to form, without which we’re endlessly reacting to stimuli around us, rather than allowing ourselves to be within our lived experience.”

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We’re all running from pain. Some of us take pills. Some of us couch surf while binge-watching Netflix. Some of us read romance novels. We’ll do almost anything to distract ourselves from ourselves. Yet all this trying to insulate ourselves from pain seems only to have made our pain worse.

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I became acutely aware of this effect of high-dopamine addictive substances on the brain’s reward pathway in the early 2000s, when I started seeing more patients coming in to clinic on high-dose, long-term opioid therapy (think OxyContin, Vicodin, morphine, fentanyl) for chronic pain. Despite prolonged and high-dose opioid medications, their pain had only gotten worse over time. Why? Because exposure to opioids had caused their brain to reset its pleasure-pain balance to the side of pain. Now their original pain was worse, and they had new pain in parts of their body that used to be pain free. This phenomenon, widely observed and verified by animal studies, has come to be called opioid-induced hyperalgesia. Algesia, from the Greek word algesis, means sensitivity to pain. What’s more, when these patients tapered off opioids, many of them experienced improvements in pain.

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As Dr. Volkow and her colleagues wrote, “The decreases in DA D2 receptors in the drug abusers, coupled to the decreases in DA release, would result in a decreased sensitivity of reward circuits to stimulation by natural rewards.” Once this happens, nothing feels good anymore.

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In the approximately two years in which I compulsively consumed romance novels, I eventually reached a place where I could not find a book I enjoyed. It was as if I had burned out my novel-reading pleasure center, and no book could revive it. The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind. Reading had always been my primary source of pleasure and escape, so it was a shock and a grief when it stopped working. Even then it was hard to abandon. My patients with addiction describe how they get to a point where their drug stops working for them. They get no high at all anymore. Yet if they don’t take their drug, they feel miserable. The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia, and dysphoria.

Note: Me and video games circa 2013-14

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Right after the conditioned cue, brain dopamine firing decreases not just to baseline levels (the brain has a tonic level of dopamine firing even in the absence of rewards), but below baseline levels. This transient dopamine mini-deficit state is what motivates us to seek out our reward. Dopamine levels below baseline drive craving. Craving translates into purposeful activity to obtain the drug.

Note: That’s a powerful nugget of knowledge. Dopamine is lower than basal rate just after the cue.

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Studies indicate that dopamine release as a result of gambling links to the unpredictability of the reward delivery, as much as to the final (often monetary) reward itself. The motivation to gamble is based largely on the inability to predict the reward occurrence, rather than on financial gain. In a 2010 study, Jakob Linnet and his colleagues measured the dopamine release in people addicted to gambling and in healthy controls while winning and losing money. There were no distinct differences between the two groups when they won money; however, when compared to the control group, the pathological gamblers showed a marked increase in dopamine levels when they lost money. The amount of dopamine released in the reward pathway was at its highest when the probability of losing and winning was nearly identical (50 percent)—representing maximum uncertainty. Gambling disorder highlights the subtle distinction between reward anticipation (dopamine release prior to reward) and reward response (dopamine release after or during reward). My patients with gambling addiction have told me that while playing, a part of them wants to lose. The more they lose, the stronger the urge to continue gambling, and the stronger the rush when they win— a phenomenon described as “loss chasing.” I suspect something similar is going on with social media apps, where the response of others is so capricious and unpredictable that the uncertainty of getting a “like” or some equivalent is as reinforcing as the “like” itself.

Note: That’s fascinating. I didn’t know the thrill of gambling is linked to the uncertainty.

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In my clinical work I see people who struggle with severe addiction slipping right back into compulsive use with a single exposure, even after years of abstinence. This may occur because of persistent sensitization to the drug of choice, the distant echoes of earlier drug use.

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Here’s some good news. My colleague Edie Sullivan, a world expert on alcohol’s effects on the brain, has studied the process of recovery from addiction and discovered that although some brain changes due to addiction are irreversible, it is possible to detour around these damaged areas by creating new neural networks. This means that although the brain changes are permanent, we can find new synaptic pathways to create healthy behaviors.

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Science teaches us that every pleasure exacts a price, and the pain that follows is longer lasting and more intense than the pleasure that gave rise to it. With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases. By imprinting instant and permanent memory, we are unable to forget the lessons of pleasure and pain even when we want to: hippocampal tattoos to last a lifetime.

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First, most of us are unable to see the full extent of the consequences of our drug use while we’re still using. High-dopamine substances and behaviors cloud our ability to accurately assess cause and effect. As the neuroscientist Daniel Friedman, who studies the foraging practices of red harvester ants, once remarked to me, “The world is sensory rich and causal poor.” That is to say, we know the doughnut tastes good in the moment, but we are less aware that eating a doughnut every day for a month adds five pounds to our waistline. Second, young people, even heavy users, are more immune to the negative consequences of use. As one high school teacher remarked to me, “Some of my best students smoke pot every day.” As we age, however, the unintended consequences of chronic use multiply. Most of my patients who come in voluntarily for treatment are middle-aged. They seek me out because they’ve reached a tipping point where the downsides of their use outweigh the upsides. As they say in AA, “I’m sick and tired of being sick and tired.” My teenage patients, by contrast, are neither sick nor tired. Even so, getting teenagers to see some negative consequences of their use while they’re still using, even if it’s only that other people don’t like it, can be a point of leverage for getting them to stop. And stopping, even just for a period of time, is essential for getting them to see true cause and effect.

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A minority of patients (about 20 percent) don’t feel better after the dopamine fast. That’s important data too, because it tells me that the drug wasn’t the main driver of the psychiatric symptom and that the patient likely has a co-occurring psychiatric disorder that will require its own treatment.

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The n of DOPAMINE stands for next steps. This is where I ask my patients what they want to do after their month of abstinence. The vast majority of my patients who are able to abstain for a month and experience the benefits of abstinence nonetheless want to go back to using their drug. But they want to use differently than they were using before. The overarching theme is that they want to use less. An ongoing controversy in the field of addiction medicine is whether people who have been using drugs in an addictive way can return to moderate, nonrisky use. For decades the wisdom of Alcoholics Anonymous dictated that abstinence is the only option for people with addiction. But emerging evidence suggests that some people who have met criteria for addiction in the past, especially those with less severe forms of addiction, can return to using their drug of choice in a controlled way. In my clinical experience, this has been true.

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The key to creating effective self-binding is first to acknowledge the loss of voluntariness we experience when under the spell of a powerful compulsion, and to bind ourselves while we still possess the capacity for voluntary choice. If we wait until we feel the compulsion to use, the reflexive pull of seeking pleasure and/or avoiding pain is nearly impossible to resist. In the throes of desire, there’s no deciding. But by creating tangible barriers between ourselves and our drug of choice, we press the pause button between desire and action.

Note: I read this while on the plane to Venice. I’ve left my personal phone at home. Only carrying my work phone with most of the apps disabled.

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The medication naltrexone is used to treat alcohol and opioid addiction, and is being used for a variety of other addictions as well, from gambling to overeating to shopping. Naltrexone blocks the opioid receptor, which in turn diminishes the reinforcing effects of different types of rewarding behavior. I’ve had patients report a near or complete cessation of alcohol craving with naltrexone. For patients who have struggled for decades with this problem, the ability to not drink at all, or to drink in moderation like “normal people,” comes as a revelation. Because naltrexone blocks our endogenous opioid system, people have reasonably wondered if it might induce depression. There’s no reliable evidence of that, but I do occasionally see patients who report a flatlining of pleasure with naltrexone. One patient said to me, “Naltrexone helps me not drink alcohol, but I don’t enjoy bacon as much as I used to, or hot showers, and I can’t get a runner’s high.” We worked around this by having him take naltrexone half an hour before entering a risky drinking situation, such as a happy hour. This naltrexone-as-needed approach allowed him to drink in moderation and also enjoy bacon again.

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We talked to a thirty-eight-year-old man who described how prior to coming to New Hospital for treatment, he had received the “addiction surgery.” The addiction surgery involved insertion of a long-acting naltrexone implant to block the effects of heroin. “In 2007,” he said, “I went to Wuhan province for the surgery. My parents made me go, and they paid for it. I don’t know for sure what the surgeons did, but I can tell you it didn’t work. After the surgery, I kept shooting up heroin. I couldn’t get the feeling anymore, but I did it anyway because shooting up was my habit. For the next six months I shot up every day with no feeling. I did not think about stopping because I still had money to buy it. After six months, the feeling came back. So I’m here now, hoping they’ll have something new and better for me.” This anecdote illustrates that pharmacotherapy alone, without insight, understanding, and the will to change behavior, is unlikely to be successful.

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Taking disulfiram daily is an effective deterrent for those who are trying to abstain from alcohol, especially for people who wake up in the morning determined not to drink but by the evening have lost their resolve. It turns out that willpower is not an infinite human resource. It’s more like exercising a muscle, and it can get tired the more we use it.

Note: Citing debunked science. I think if a person thinks their self control is limited, it is.

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In today’s dopamine-rich ecosystem, we’ve all become primed for immediate gratification. We want to buy something, and the next day it shows up on our doorstep. We want to know something, and the next second the answer appears on our screen. Are we losing the knack of puzzling things out, or being frustrated while we search for the answer, or having to wait for the things we want?

Note: I felt this with video games in 2014. I felt that playing so much Dota was conditioning me to be able to put effort only for short periods of time - 45 minutes or so. I would try single player games and quit at the first sign of frustration. When I realised this I decided to grind through the next game no matter how hard it got. I remember feeling so much pride and accomplishment when I finished Mark of the Ninja. It proved to me that I hadn’t lost the ability to persist. It was still there if I was willing to dig deep.

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The neuroscientist Samuel McClure and his colleagues examined what parts of the brain are involved in choosing immediate versus delayed rewards. They found that when participants chose immediate rewards, emotion-and reward-processing parts of the brain lit up. When participants delayed their reward, the prefrontal cortex— the part of the brain involved in planning and abstract thinking—became active. The implication here is that we are all now vulnerable to prefrontal cortical atrophy as our reward pathway has become the dominant driver of our lives. Ingestion of high-dopamine goods is not the only variable that influences delay discounting. For example, those who grow up in resource-poor environments and are primed with mortality cues are more likely to value immediate rewards over delayed rewards compared to those who are similarly primed and grow up in resource-rich environments. Young Brazilians living in favelas (slums) discount future rewards more than age-matched university students. Is it any wonder that poverty is a risk factor for addiction, especially in a world of easy access to cheap dopamine?

Note: I remember reading a lot around this. I vaguely remember reading the account of a guy who grew up poor finding it difficult to budget.

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In the spring of 2011, Chris got caught by police stealing ice cream while intoxicated. He was offered jail or rehab. He chose rehab. On April 1, 2011, in rehab, Chris was started on a medication called buprenorphine, better known by the trade name Suboxone. Chris credits buprenorphine with saving his life.

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Michael’s accidental discovery of the benefits of ice-cold water immersion is an example of how pressing on the pain side of the balance can lead to its opposite— pleasure. Unlike pressing on the pleasure side, the dopamine that comes from pain is indirect and potentially more enduring. So how does it work? Pain leads to pleasure by triggering the body’s own regulating homeostatic mechanisms. In this case, the initial pain stimulus is followed by gremlins hopping on the pleasure side of the balance. The pleasure we feel is our body’s natural and reflexive physiological response to pain. Martin Luther’s mortification of the flesh through fasting and self-flagellation may have gotten him a little bit high, even if it was for religious reasons. With intermittent exposure to pain, our natural hedonic set point gets weighted to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time.

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Dopamine’s importance to motor circuits has been reported for every animal phylum in which it has been investigated. The nematode C. elegans, a worm and one of the simplest laboratory animals, releases dopamine in response to environmental stimuli signaling the local abundance of food. Dopamine’s ancient role in physical movement relates to its role in motivation: To obtain the object of our desire, we need to go get it.

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Invisible incentives are now woven into the fabric of white-collar work, from the prospect of bonuses and stock options to the promise of promotion. Even in fields like medicine, health care providers see more patients, write more prescriptions, and perform more procedures, because they’re incentivized to do so. I get a monthly report on my productivity, as measured by how much I’ve billed on behalf of my institution. By contrast, blue-collar jobs are increasingly mechanized and divorced from the meaning of the work itself. Working under the employ of distant beneficiaries, there’s limited autonomy, modest financial gain, and little sense of common mission. Piecemeal assembly-line work fragments the sense of accomplishment and minimizes contact with the end-product consumer, both of which are central to internal motivation. The result is a “work-hard/play-hard” mentality in which compulsive overconsumption becomes the reward at the end of a day of drudgery. It’s no wonder, then, that those with less than a high school education in low-paying jobs are working less than ever, whereas highly educated wage earners are working more. By 2002, the top-paid 20 percent were twice as likely to work long hours as the lowest-paid 20 percent, and that trend continues. Economists speculate that this change is due to higher rewards for those at the top of the economic food chain.

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Just as it is possible to have a scarcity mindset amidst plenty, it is also possible to have a plenty mindset amidst scarcity. The feeling of plenty comes from a source beyond the material world. Believing in or working toward something outside ourselves, and fostering a life rich in human connectedness and meaning, can function as social glue by giving us a plenty mindset even in the midst of abject poverty. Finding connectedness and meaning requires radical honesty.

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When it comes to compulsive overconsumption, shame is an inherently tricky concept. It can be the vehicle for perpetuating the behavior as well as the impetus for stopping it. So how do we reconcile this paradox? First, let’s talk about what shame is. The psychological literature today identifies shame as an emotion distinct from guilt. The thinking goes like this: Shame makes us feel bad about ourselves as people, whereas guilt makes us feel bad about our actions while preserving a positive sense of self. Shame is a maladaptive emotion. Guilt is an adaptive emotion. My problem with the shame-guilt dichotomy is that experientially, shame and guilt are identical. Intellectually, I may be able to parse out self-loathing from “being a good person who did something wrong,” but in that moment of feeling shame-guilt, a gut punch of an emotion, the feeling is identical: regret mixed with fear of punishment and the terror of abandonment. The regret is for having been found out and may or may not include regret for the behavior itself. The terror of abandonment, its own form of punishment, is especially potent. It is the terror of being cast out, shunned, no longer part of the herd. Yet the shame-guilt dichotomy is tapping into something real. I believe the difference is not how we experience the emotion, but how others respond to our transgression. If others respond by rejecting, condemning, or shunning us, we enter the cycle of what I call destructive shame. Destructive shame deepens the emotional experience of shame and sets us up to perpetuate the behavior that led to feeling shame in the first place. If others respond by holding us closer and providing clear guidance for redemption/recovery, we enter the cycle of prosocial shame. Prosocial shame mitigates the emotional experience of shame and helps us stop or reduce the shameful behavior.

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We tend to think of shame as a negative, especially at a time when shaming— fat shaming, slut shaming, body shaming, and so on— is such a loaded word and is (rightly) associated with bullying. In our increasingly digital world, social media shaming and its correlate “cancel culture” have become a new form of shunning, a modern twist on the most destructive aspects of shame. Even when no one else is pointing the finger at us, we’re all too ready to point it at ourselves. Social media propels our tendency toward self-shame by inviting so much invidious distinction. We’re now comparing ourselves not just to our classmates, neighbors, and coworkers, but to the whole world, making it all too easy to convince ourselves that we should have done more, or gotten more, or just lived differently. To deem our lives “successful,” we now feel we must achieve the mythic heights of Steve Jobs and Mark Zuckerberg or, like the Theranos corporation’s Elizabeth Holmes, a latter-day Icarus, go down in flames trying. But the lived experience of my patients suggests that prosocial shame can have positive, healthy effects by smoothing some of narcissism’s rougher edges, tying us more closely to our supportive social networks, and curbing our addictive tendencies.

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Malcom McLean was not one to pass up an opportunity for profit. Now, an obvious one awaited. He had six ships, three large and three small, sailing between the U.S. West Coast and Vietnam. Westbound, they were loaded nearly full with military freight. East-bound, they carried little but empty containers. The rates paid by the U.S. government for the westbound haul covered all costs for the entire voyage. If Sea-Land could find freight to carry from the Pacific back to the United States, the revenue would be almost entirely profit. Thinking the situation through, McLean had another of his brainstorms: why not stop in Japan? Japan was the world’s fastest-growing economy during the 1960s: between 1960 and 1973, its industrial output quadrupled. Already the second-largest source of U.S. imports, by the late 1960s Japan was quickly moving up the ladder from apparel and transistor radios to stereo systems, cars, and industrial equipment.

Note: Japan was already rising before the container and the Vietnam war

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But if my mother was an environmentalist at heart, I don’t remember her ever applying the label to herself. I think it’s because she’d spent most of her career working in Indonesia, where the dangers of pollution paled in comparison to more immediate risks—like hunger. For millions of struggling villagers who lived in developing countries, the addition of a coal-fired electrical generator or a new, smoke-belching factory often represented their best chance for more income and relief from backbreaking toil. To them, worrying about maintaining pristine landscapes and exotic wildlife was a luxury only Westerners could afford.

Note: True that. Hunger trumps everything else

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