Ann Mossop: Welcome to the UNSW Centre for Ideas podcast. A place to hear ideas from the world's leading thinkers and UNSW Sydney's brightest minds. I'm Ann Mossop, director of the UNSW Centre for Ideas. This podcast was recorded on the lands of the Bidjigal and Gadigal people. We pay our respects to their elders past and present, whose sovereignty was never ceded. The conversation you're about to hear, Addicted to Dopamine, is between Dr. Anna Lembke, psychiatrist and author of, Dopamine Nation: Finding Balance in the Age of Indulgence, with journalist Sana Qadar, and was recorded live. I hope you enjoy the conversation.

Sana Qadar: Thank you Ann, it is a pleasure to dive into tonight's discussion. We're going to be hearing from Dr. Anna Lembke. She is a professor of psychiatry at Stanford University School of Medicine, and chief of the Stanford Addiction Medicine dual diagnosis clinic. She is also a New York Times bestselling author. Her latest book, Dopamine Nation, is all about how we can find balance in an age of unprecedented indulgence. Now, unless you live under a rock with no phone, no bad eating, or drinking habits, no vices at all, this book is highly relevant to pretty much all of us. Dr. Lembke, thank you for being here.

Anna Lembke: Thank you for inviting me.

Sana Qadar: Now, you're pretty brave in this book, in that, you explore your own experiences of addiction, not just the experiences of your patients. Could you start by talking about your experience of addiction and how it grew?

Anna Lembke: Well, it's always a little embarrassing as these things are. But in my early 40s, I did develop a kind of compulsive attachment, which I think you could fairly call a mild addiction to romance novels. So it started with the Twilight Saga, you might think of The Twilight Saga as my gateway drug. And then I got a Kindle, which was akin to my hypodermic syringe. And it escalated from there over the course of about two years, to what I consider to be a kind of socially sanctioned addiction to erotica, or, you know, pornography for women, if I could phrase it like that. To the point where I was habitually staying up very late at night, reading romance novels. As soon as I would finish one book, in fact, before I would actually finish it, once I got three quarters of the way through to the climax, I wouldn't even finish it, I would already be on Amazon looking for the next book. To the point where I was often groggy in the morning, exhausted on my way to work, not fully able to be present for my patients, or my children or my husband. Several nadir's in the course of my compulsive behaviours, were, at one point, I did bring a book to work and found myself in the 10 minutes between patients, just wanting to escape and read that book. Once I went to a social event with another family, and found a room where I could read in the middle of the social event. 

So these are all things that are, you know, slightly embarrassing to talk about, especially since I'm a psychiatrist who treats addiction. But I really didn't see it unfolding. As the, kind of, you know, harmful behaviour that it ultimately became, which really is a hallmark of addiction that we don't really see it as it's happening. Or if we do see it, we don't see the extent of the harm that we're causing to ourselves and or others. So that's kind of my story. I do reveal that in the book. I reveal it reluctantly, because of course, it's very shameful, especially since I, as a physician, I'm supposed to have it all together. And obviously, you know, we're all human. But I did want to draw a parallel between, you know, my relatively mild compulsive consumption of erotica, and the more significant cases of sex addiction that I do talk about in the book. In a way to normalize it and also to speak to the ways in which our modern world has created this environment where we're all vulnerable to these kinds of addictive behaviors.

Sana Qadar: Yeah, it takes a lot of guts to, sort of, admit something like that. Was it a difficult decision to try to be so candid about it?

Anna Lembke: You know, it was. I'll tell you, in the, like, the month before the book actually came out, I think I was having a continuous panic attack. 

Sana Qadar: Wow.

Anna Lembke: But I really felt I owed it to my patients who had been willing to share their stories in order to help others. And of course, every one of my patients, I got informed consent to share their stories, they were so generous in their willingness to do that. So I didn't feel that I could be… it felt hypocritical to not talk about some of my own difficulties and my own aha moments that really haven't formed my ideas and my thinking on this topic. And I can say, the response has been deeply gratifying, just the number of people who have said, the fact that you shared, you know, your own struggles was really meaningful to me or to them, yeah.

Sana Qadar: That's lovely. Long before your brush with addiction, what interested you in wanting to go into psychiatry and addiction medicine in particular?

Anna Lembke: Oh, yeah, very good question. So again, to be completely transparent, I first went into psychiatry, saying, I will treat anybody who wants to come see me, except those people with addiction, who need to go somewhere else.

Sana Qadar: Oh wow.

Anna Lembke: You know, to get their problems sorted out, and then they can come back and see me. And there are a couple of factors going on there. One is that in our medical training, for most of the last 200 years, doctors actually received very little training about addiction. We have not been socialised or educated to think of addiction as a medical disorder, we think of it primarily as a social problem, a moral problem, a character defect. It's really only in the last 20 years that there's been a significant shift, at least in the United States, with regards to addiction being a brain disease. And that shift has largely been brought about by the opioid epidemic. And the layers of that are many, and the racial biases in that are also interesting to discuss. So part of it was that I was very ignorant about addiction, of course. When I look back, and I think about… I would never send a bipolar patient who was manic away and say, you know, take care of your mania, and then come back and see me. So it was a very strange thing, in retrospect, to do. The other thing is, you know, the addiction runs in my family, and so there's that kind of countertransference, negative countertransference, where I was uncomfortable, because I had never really been able to sort out some of the things that had happened in my own childhood, where I hadn't wanted to look closely at that. 

But to answer your question, in a roundabout way, you know, ultimately, I realised that I was actually harming my patients by ignoring their addiction. And when I, in fact, began to ask my patients about their substance use problems and other addictions, they were so eager to talk about it. And they got so much better because we were talking about it. So, since then, it's been, you know, two decades of, you know, very gratifying and rewarding work, to work with this population. When people with addiction get into recovery, not only are their lives better, but the ripple effect is just enormous. People with co-occurring disorders who have addictions, their co-occurring disorders get so much better when we start paying attention to the addiction. So if they have schizophrenia, or bipolar disorder, depression, anxiety, those disorders will really not get better if we're ignoring the addiction. And then I guess, I would say, the last piece that addiction medicine is maybe the final bastion of medicine, where we can still talk about spirituality, and spiritual issues. And that has always been a big draw for me.

Sana Qadar: Okay, well, let's talk about what we've learned in the last two decades about what's going on in the brain exactly, when we are becoming addicted. First of all, what role does dopamine play in all of this?

Anna Lembke: Dopamine is a neurotransmitter in the human brain. And that means that it's the molecule that bridges the gap between neurons that is important for fine tuning those electrical circuits that make up our brain circuits, that make us who we are. So neurons are the long spindly cells that send these electrical currents, but they don't actually touch end to end, there's a little gap between them called the synapse, and so neurotransmitters bridge that gap. And dopamine is one of those neurotransmitters. 

The last 100 years or so of neuroscientific research has seen a veritable explosion in research around dopamine. And what we have learned is that dopamine is the neurotransmitter that is fundamental to the experience of pleasure, reward and motivation. And there's a dedicated circuit in the brain for pleasure, reward and motivation that we call the reward circuit. Dopamine is not the only neurotransmitter involved in pleasure, reward and motivation and hence addiction, but it is the final common pathway for all reinforcing substances and behaviours.

Sana Qadar: And so what changes are occurring in the brain? What's going on as we are slipping into addiction?

Anna Lembke: So to understand that, it's first essential to understand that pleasure and pain are co-located in the brain. And by that I mean that the same parts of the brain that process pleasure, also process pain, and they work like opposite sides of a balance. So if you imagine that in your brain, there's a teeter totter, like in a child's playground, when we experience pleasure, it tips one way, when we experience pain, it tips the other. And there are certain rules governing that balance. And the first rule is that with any deviation from neutrality, our brains will work very hard to restore a level balance, or what neuroscientists call homeostasis. So let's say, for example, I eat a piece of chocolate, I get a release of dopamine in my reward pathway, my balance tilts slightly to the side of pleasure. No sooner has that happened, then my brain goes to work to try to restore that balance, this is called neuroadaptation. I like to imagine that as these little neuroadaptation gremlins hopping on the pain side of the bounce to bring it level again. But the gremlins really like it on the balance, so they don't get off as soon as it's level, they stay on until it's tilted an equal and opposite amount to the side of pain. That's the come down, the after effect, the hangover, in my case, that moment of wanting one more piece of chocolate. Now, if we wait long enough, the gremlins hop off and homeostasis is restored. But there's of course, a natural tendency when that balance is tilted to the side of pain to grab for another one. Which is why for example, as I'm eating that first piece of chocolate, I'm already thinking about having another one, it's because my balance has tilted slightly to the side of pain, or I'm watching a YouTube video, and I'm halfway through the video, I'm already thinking about what can I watch after this? So in other words, homeostasis is one of the most important driving physiologic mechanisms really governing all living organisms. And for every pleasure, we pay a price. And that price is a transient experience of pain, and I use pain very broadly. Now to understand what happens when people become addicted, you need to understand the second rule of the balance. And the second rule of the balance is that with repeated exposure to the same or similar reinforcing stimulus, that initial response to pleasure gets weaker and shorter, but that after response to pain gets stronger and longer. In other words, the gremlins multiply, they get bigger and stronger. And pretty soon, I've got enough gremlins on the pain side of my balance to fill this whole room. And that is the addicted brain. We've essentially changed our hedonic or joy setpoint for experiencing pleasure and pain, such that we're walking around with a balance, weighted to the side of pain, so that we need more of our drug and more potent forms, not to get high, but just to level the balance and feel normal. When we're not using, our balance is tilted to the side of pain, and we're experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, dysphoria, craving, inattention, and we lose the ability to take joy in more modest rewards, right? So after I've eaten that much chocolate over that many days, I've got that many gremlins. Now when I reach for that single piece of chocolate, I eat it, it doesn't do anything for me. So that inability to take pleasure in more modest, natural rewards, and an intense narrowing of our focus on obtaining large amounts of that drug, again, just to restore homeostasis.

Sana Qadar: I mean, this feels almost like a cruel trick of human nature. If you put aside addiction for a moment, the fact that like, if I want chocolate, I will feel pain after that. Why does that happen? Is this a protective mechanism? What's going on here?

Anna Lembke: Another great question. So we can only speculate. But if you think about it, from an evolutionary perspective, this pleasure, pain balance makes perfect sense. Why? Because we evolved in a world of scarcity, and ever present danger. And the only way that we could survive in this world of scarcity is to be continual seekers, never satisfied with what we have, always looking for more. And what better way to make us keep looking than to make sure for every pleasure we pay a price, that price is pain, that drives us to look for more bison, more mates, more water in the desert, more berry bushes, you know, whatever it is.

Sana Qadar: Right, so this is where our brains have led us astray in the current world we live in, because you write about how increasing abundance has led to an increase in addiction. And there's just so much more to be addicted to now, I want to throw in an audience question here. This is from Laryssa Fadunich-Hoffman, she asks, is addiction a new phenomenon and does it differ from age old concepts like hedonism?

Anna Lembke: Hmm, okay, interesting. So since there have been humans, there has been addiction. If you look back at the oldest Sumerian records, 1000s and 1000s of years ago, you can find evidence of humans using various substances intemperately, or using them not in moderation. So it's very clear that since there have been substances, since there have been humans, there has been a problem of addiction. But that is a growing problem in the modern world. So what we see is more people developing addictions, more people in this kind of pre-addicted state or dealing with mild forms of compulsive overconsumption. We see addiction in demographic groups that previously were relatively immune to addiction that would include women and older people. So for example, if you look at rates of alcohol addiction, for the most of the last 1000 years, it was five to one men to women. For the millennials, we're looking at rates that are one to one for alcohol use disorder. We have new drugs that never existed before. So that means that we have people who maybe were immune to traditional drugs, who might now very well get very addicted to social media. So we live in an addictogenic environment, and this mismatch between our primitive wiring and the modern ecosystem has made, I think, addiction really, you know, akin to the modern plague.

Sana Qadar: An addictogenic environment. I haven't heard that term before. I'm gonna remember that one. I wanted to touch on one type of addiction that you haven't mentioned there, which is gambling, which is a particularly big problem here in Australia, because there are poker machines in almost all the pubs, which I found especially bizarre when I moved here from Canada. But you write that pathological gambling has only recently been classified as an addictive disorder in the DSM. Why is that?

Anna Lembke: Well, I mean, you know, it took a long time to just get addiction recognized as a mental illness, despite the very strong neuroscientific evidence of physiologic brain changes, both as a result of addiction, and innately inherited vulnerabilities, therefore, and now what we have is a lot of controversy around whether or not people can actually get addicted to a behaviour. You know, does addiction have to involve ingesting a substance? And I would argue very strongly that, no, it doesn't. That the kind of natural history of the disease of addiction that we see when people get addicted to drugs and alcohol is identical to what we see phenomenologically when people get addicted to gambling, sex and pornography, gaming, food, it all looks exactly the same. Which is to say, that people start out using, for one of two reasons, either to have fun or to solve a problem. And that problem can range from depression, anxiety and attention to loneliness, boredom, and everything in between. If the drug, whether it's a behaviour or substance, works for them, they will return to it, because of course, we are reflexively wired through our dopaminergic system to do that. And with repeated exposures over time, they'll invest more and more energy, more and more resources, until eventually their brain will come to replace the drug or misidentify the drug as fundamental to their survival, because they need the drug to restore a homeostatic balance or a level balance. And once you get to that point, then you have continued compulsive use, despite harm to self, and or others, which is the fundamental definition of addiction. And when you talk about your experience in Australia of, you know, these kinds of poker games available everywhere, one of the biggest risk factors for addiction is simple access to that drug. If you live in an environment where drugs are readily accessible, you're more likely to try them and more likely to get addicted to them. And again, just this recurring theme, we are now living in a world where through innovation technology, our supply chain, COVID disruption notwithstanding, and the internet and our, you know, devices, really at the touch of a finger, we have access to all kinds of reinforcing substances and behaviours.

Sana Qadar: Yeah, an important point. And just on gambling as well, in terms of the dopamine hit you get from gambling, as opposed to taking a drug, how does that differ? Because, you know, if you pull the lever of a poker machine, you're not guaranteed a win. Whereas if you take a snort of cocaine or whatever, you're guaranteed to, you know, high, at least in the early stages of an addiction.

Anna Lembke: Yes. Okay. So let me get to the second part first. So in the early stages of any addiction, you get the high and that's what reinforces the behaviour and has you coming back. But depending upon, you know, how quickly it happens, almost inevitably for everybody, as those gremlins accumulate on the pain side of the balance, people aren't using because it feels good anymore, right? They're using because they're in pain. So even people who are using drugs, you know, as they become addicted, they're not enjoying that process anymore. But they're compelled to repeat it as a part of this drive to restore homeostasis. But what you're alluding to, is a very interesting phenomenon that we have observed specifically with gambling, which is called loss chasing. And what this refers to is how very addicted gamblers will talk about, they can get to a point where they don't actually want to win. Because if they win, then the narrative would go, they have to stop playing, because they told themselves, I'm just in here until I win, and once I win, I'll stop. But in fact, what they're going for is not the monetary win, but to be in the altered state of the game, in which they can experience forgetting and non being, which is what all of us crave on some level. So this loss chasing is a level at which gamblers actually want to lose, because losing allows them to extend their time in the game. Because the self narrative is, oh well, now I can't get out because I've got to win back what I lost. Interesting studies looking at dopamine levels in the brains of addicted gamblers, and comparing those dopamine levels to healthy controls. What you see is a rise initially in dopamine levels with winning, both in healthy controls, and in addicted gamblers. The big difference, though, is what happens with losing, you can see an increase in dopamine levels in addicted gamblers, even when they're losing. And the most dopamine release is not with winning, it's when the odds of winning and the odds of losing are 50%. So at that optimal point of risk is when addicted gamblers get the most dopamine. 

Sana Qadar: Wow, does that make gambling totally unique? Among all the things that we can be addicted to? Is that the only kind of addiction where we see that dynamic play out?

Anna Lembke: I don't think so. I mean, in fact, you know, the consumption of digital content might mimic gambling, best of all. So if you think about our engagement in social media, or gaming disorder, you know, the gamification or gamblification of video games, or the gamblification of social media, has many of those same qualities, for example, we post something on the internet, we get this great response, we want to keep posting or keep watching. And then we get a negative response, and then the narrative is, well, now I have to stay on until I get my likes back up. Or now I have to play another level until I get my ranking up. Or once I get my ranking up, I have to keep my ranking up. I couldn't possibly quit. Now I'm number one. Right? And I hear this all the time, from young people, especially those addicted to video games, saying that the rankings are really a very pernicious part of their compulsive overuse. That what drives them initially to stay in, for sometimes days at a time ,is to get the ranking up, but then what keeps them there is that they feel they can lose their ranking. So it's this funny, numerification or giving these numbers, or this placement, compared to other people, a kind of monetization, or quantification, that dopamine seems very, very sensitive to.

Sana Qadar: How much of an explosion Have you seen in addiction to gaming or social media? Sort of the digital sphere in the last 10,15 years? You know, like when did it first start to come on your radar?

Anna Lembke: The big shift that I saw was in 2001, 2002, with the advent of the smartphone. What the smartphone meant was that all of a sudden, there was 24/7 mobile access to these behavioural digital drugs. And it started sort of a trickle, first with many adult males with pornography addiction, saying that, hey, I've looked at pornography for the last 20 years, but once the internet came along, and then especially my smartphone, it got out of control for me and I developed this full blown harmful addiction. And then I feel like it was really about 2010, 2015 that we started to see the beginning of people, especially young men, addicted to video games with a real increase in the last two or three years of young people. Again, mostly young men addicted to video games.

Sana Qadar: We'll get into solutions and you know what we can try to do to stave off that kind of thing in a moment. But addiction really changes the brain over time as well, doesn't it? In terms of making it much more easy to relapse, much more likely to relapse, even after long periods of abstinence. Can you talk about the longer term changes that happen in the brain?

Anna Lembke: Yeah, so this is based on both animal studies, as well as our clinical experience. I'll start with the animal studies. So there's a very famous experiment showing that if you inject a rat with cocaine over seven successive days, what you will see is that the rat goes from hanging out on the side of the cage, to jogging in the middle of the cage to eventually in this running frenzy all around the cage, if you then stop those cocaine injections for a year, which is about equivalent to a rat lifetime, and then you re-inject that rat with cocaine, what you'll see is the rat is immediately in a running frenzy, akin to day seven of cocaine injections at the beginning of its life. And so that has a lot of implications, it suggests that there's some kind of permanent echo, permanent brain change, and that even with sustained abstinence, that can be reactivated with exposure to the drug. And this mirror is exactly what we see clinically, people who get into recovery from their drug of choice, who have these totally positively transformed lives, and then either are exposed to their drug of choice, let's say alcohol or whatever it is, or exposed to another drug like an opioid, and then immediately are plummeted in no time at all, back into the very depths of their addiction, again, all of that suggesting there's some kind of latent permanent brain change that can be reactivated. Whenever I say that, though, I always want to emphasise that that doesn't mean that this is hopeless. You know, the brain continues to preserve plasticity throughout life. Neurogenesis continues throughout life. There are things we can do to promote neurogenesis or the growth of new neurons. And even if there are these damaged areas, what we know from the work of people like [Edith] Sullivan, my colleague here at Stanford, is that, with recovery, what we do is we create new circuits that reroute around those damaged areas.

Sana Qadar: All right, just on the issue of, or the question of dopamine, and the role it plays in addiction. I want to throw an audience question in here. Ellen Barker from Melbourne asks, are all forms of addiction ultimately addiction to dopamine?

Anna Lembke: Great. So the answer, Ellen is yes, the final common pathway for all addictive substances and behaviours seems to be dopamine and its release. And then it's neuroadaptation or this dopamine deficit state, that arises with repeated use in this specific circuit of the brain consisting of the nucleus accumbens, the ventral tegmental area, and the prefrontal cortex. So there is this kind of sense in which we can use dopamine as a kind of common currency to measure this phenomenon. But I would say that we usually don't talk about it as being addicted to dopamine, because dopamine is really just the signal. For example, if I gave you a spoonful of dopamine, it would have zero effect on you because dopamine doesn't pass the blood brain barrier.

Sana Qadar: One other question on neurotransmitters, this one from UNSW alumni, David Joyce, are there maladaptive sides to other neuro chemicals such as oxytocin or serotonin?

Anna Lembke: Ah, well, the nature of the brain is a drive toward homeostasis. So any kind of modulation we have in any neurotransmitter system, that's a deviation from our baseline homeostasis, the brain will work hard to get back to homeostasis. So the implication here is, for example, when we prescribe antidepressants that work on the serotonin system, there probably is, although we don't typically think of antidepressants as addictive, there probably is a level of neuro adaptation over time, very slowly, to those antidepressants, such that, and I see this clinically, some individuals may find over time their entered antidepressant stops working, or they need more of the antidepressant, to get the same effect. And there's a very small literature emerging now, suggesting that something called tachyphylaxis can take place, where it's possible that for some people, the use of antidepressants long term may actually make depression worse. So again, this idea whether we're using an anxiolytic and working on the benzodiazepine and GABA system, or serotonin reuptake inhibitors, working on the serotonin system, that the brain adapts over time and can, like, in a sense, over adapt, and that we ended up getting, sort of, the opposite of what we were hoping for.

Sana Qadar: Okay, coming back to dopamine and addiction. You mentioned briefly, just a moment ago how, through recovery, the brain can be retrained, which is very hopeful and good to know. But even though we do live in a world of abundance, over abundance and dopamine, I want to talk about what this means for children in particular, because we've had quite a few audience questions on this. So I'll throw a few of those at you. First, here's one from Karen Bana, who is currently staff at UNSW. Are there different effects or responses to dopamine for children, compared to adults, and are some people more predisposed to addiction than others?

Anna Lembke: Okay, so part of the reason that we are so adamant that we need to try to protect our children from addictive drugs and behaviours is because their brains really are different. And one of the central differences is that, when we are born, and up until about age five, we have more neurons than we're ever going to have in our whole lives. And what happens from about age five through to age 25, is there's a pruning process where our brains slowly cut back the neurons we're not using. And myelinate, basically grease the wheels of the neurons that we use most often. And what that means is, in that crucial time of development, we are essentially building the infrastructure that we will be left with for the rest of our adult life. And if we're building an infrastructure around a maladaptive coping strategy, that is really not good, because it means it's going to be harder to create the scaffolding later, or get rid of that scaffolding that became so robust through, you know, childhood and adolescence. To answer the second part of the question, yes, indeed, some people are more predisposed to addiction than others. For example, we do know from family studies, that if you have a biological parent or grandparent with an alcohol addiction, you are at increased risk of developing an alcohol addiction yourself, even if raised from birth, outside of that alcohol using home, in a home that's otherwise a resilient and healthy kind of setting. So this does tell us that there are innate differences in vulnerability to addiction, I think we can all attest to that, in our own lives. The kind of personality which we used to call the addictive personality, we now just call it the disease of addiction or the vulnerability to addiction. You know, it varies from person to person, there are some people who we feel like could get addicted to anything and other people for whom it seems like that's not their particular vulnerability in life. But again, you know, the risk, the innate or inherited risk of addiction is about 50% of the risk, there's a whole other set of risk factors that doesn't have to do with that inherited vulnerability. It has to do with how you're raised, it has to do with the environment you live in. It has to do with access to the drugs, we've been talking about access as a major risk factor. Furthermore, it's not going to be one gene, it's going to be a complex polygenic phenomenon.

Sana Qadar: Very complex. Okay, this is a question I think a lot of parents and a lot of caregivers and teachers are going to wonder about, this is from Linda Rodin from Sydney, who is UNSW alumni. She asks, as an educator, the addictive nature of online usage concerns me. We have noticed a marked decline in student's abilities to concentrate in a sustained manner on tasks such as reading. Are there strategies educators can introduce to reduce the amount of time students choose to spend online. And given everything you've said about, like, accessibility and the fact that phones are everywhere. I wonder if there's anything that can be done to address this? But yeah, what do you think?

Anna Lembke: There is so much we can do! And I love that question, because we need to come together collectively and address this very significant problem that we're all struggling with. And we cannot expect our brains to be able to, without support and self binding strategies, temper our use, which leads to this distractibility. To say that another way, we have to create tech free spaces, to allow and encourage our students to get the kinds of mental musculature going again, that will allow them to have sustained attention. And we can do that by creating classroom tech free spaces, and screen free, tech free activities. It is very, very hard to resist these digital drugs, when they are right in front of us and when they are available. So we have to create environments where we say that everybody at the same time is going to put away their devices, get a pen and paper and have a sustained period of having their own creative thoughts, responding to whatever the prompt is, thinking. What happens now is, as soon as we get to a rough point or a frustration point, or a point, when we don't know the answer, we immediately deviate from that by distracting ourselves with our devices, going on the internet, finding an answer entertaining ourselves in some way. And what we need to recapture is the ability to sit with that frustration tolerance, to wait for the answer of how to move forward to spontaneously bubble up to the surface, and to create those kinds of non-reactive thinking spaces that, really, are required to problem solve, especially for hard problems.

Sana Qadar: Forget kids, that's my problem now, I go to my phone the second I’m frustrated with a work task or whatever.

Anna Lembke: We all deal with that. But I think part of it is just the awareness, you know, saying, oh, oh, like I meant to spend the next hour, you know, concentrating and focusing on this project, and five minutes into it, I found myself going to my phone. So what I need to do is turn off my phone, put it in another room. And when I hit that first speed bump, say, oh, I'm having the urge to distract myself with some kind of digital drug, so that I don't have to sit here with this uncertainty, in this frustration. But if we force ourselves to do that, really interesting stuff can come out and we we will find solutions that we're not otherwise going to find.

Sana Qadar: In your own life, how do you try and equip your kids to navigate our dopamine drenched world?

Anna Lembke: Well, my husband and I took a pretty extreme view, our kids were born starting in the early 2000s. And we created essentially a completely tech free bubble, within Silicon Valley. Not only did we not have computers in the home, well, we didn't even have WiFi to our house, and my husband and I did not have smartphones. And we did that for about the first 15 years of our kids' lives. But we all had very sophisticated computer, and internet systems at work. So we would go to work. But essentially, we made home this kind of tech free bubble, I must say I'm very grateful that we did that. I feel like that enhanced our quality of life and allowed us to enjoy parenting together in ways that would have been very difficult with the devices. This is no judgement on any parent out there. Not at all. This is just what we kind of accidentally, honestly, decided to do. As soon as our daughter entered high school, she came back after the first day and said I need a computer, or I'm not going to be able to do homework. That turned out to be 100% true. She came back the next, the second day and said I need a smartphone or I'm not going to be cool. And we said yes to the computer, no to the smartphone. A week later, she had bought her own smartphone, was funding it with her own allowance, and she was off and running. And so my advice to parents is, as long as you still have control over your children, which in my experience is until around age 13, if you're lucky, try to very much limit their exposure to devices and screens, monitor their use, limit their use, quantity and frequency matter. And talk a lot about this problem and talk a lot about the pros and cons of this incredible technology. But protect them as much as possible and encourage them to develop coping strategies and ways of socialising and entertaining themselves and dealing with boredom that don't involve a screen. Because once they get to be teenagers, really all bets are off, they will get devices even if you don't get them for them, and then they'll have to navigate that. But you know, our older children who now are on their phones, and you know, quite a bit, and listen to podcasts all the time and on. So I mean, you know, probably not that different from other teenagers and other young people. But nonetheless, I feel like that early time did create a kind of bedrock or foundation for them to be thoughtful in their use, and to at least be fighting the good fight, let me say and recognizing that, that the pull of these digital products is enormous, and that we must be thoughtful about the kinds of relationships that we want to have with these devices. 

Sana Qadar: That's incredible, you were able to do that. I have to admit I feel slightly panicked about my household and my toddler in it, and I have to ransack the place. Get rid of all the screens and the Wi Fi. Oh my goodness.

Anna Lembke: Yeah. So I don't mean to make you feel that way because I'm sure, you know, you are more normal than we were. And so it's not it's not a matter of judgement, but I will say, you know, even if you can't get rid of, you know, all of the screens, try really hard to, as a family, have designated tech free rooms, have designated tech free times, for example mealtime is an example of that. You might think about a digital Sabbath, especially when your children are younger. This would be one day per week when the family intentionally leaves all technology and devices behind, and goes out in nature, cooks, cleans closets. So, some kind of recognition that this wonderful technology does have a dark side and that we do need to take breaks from it in order to kind of let those gremlins hop off and restore some baseline dopamine homeostasis.

Sana Qadar: Good advice. Okay, I want to touch quickly on shame and radical honesty, which you write about in the book. So when it comes to treating addiction, there are drug treatments, there's talk therapy, self binding strategies, all of which you go into in the book, but you also write about how things like pro social shame and radical honesty can play a role in helping us avoid overconsumption. Can you explain what those are and how that works when it comes to overconsumption?

Anna Lembke: Sure, so just very briefly, what I wanted to do when talking about shame, was to highlight the double edged nature of shame. So shame about the way that we're consuming these various substances and behaviours is certainly a well known factor in terms of exacerbating or continuing the behaviour. We feel shame about what we've consumed, as I did about, you know, erotica. And then because I don't want to feel shame, I keep doing the behaviour, and I consume more. But it's very important to acknowledge that shame can also be a way that motivates us to change that behaviour, right? If we didn't feel shame about the behaviour, we wouldn't care to, want to change it. And so this idea of prosocial shame, or shame being actually a positive emotion, it's a very potent emotion. Shame is what allows us as a, you know, human communities to decide what is okay behaviour and what isn't. And so naturally, you know, we feel shame. And we should feel shame when we, when we deviate from, you know, those consensus norms. So I just think it's really important to acknowledge, especially as we think about parenting, you know, there's always this fear of sort of shaming our children because, God, are they going to end up on, you know, psychiatrist's couch for some kind of mental complex. But I think it's important to acknowledge that, you know, there is appropriate shame, and when our kids have done something wrong, or when we've done something wrong, it's very important to acknowledge that wrongdoing, you know, not in a way that would shun or ostracise, but say, you are in the fold, and you know, you can get stuff wrong, you know, feel shame, apologise, and then make amends or move forward. So that's the shame piece. And of course, tied into that is the honesty piece. Because if we're not being honest with ourselves and others about what we're doing, there's no opportunity to experience shame. And then there's no opportunity to make amends and change our behaviour. And one of the most interesting things that I've learned over 20 years of seeing patients get into recovery from addiction, is them talking about how important telling the truth is to their recovery. And what's interesting is, it's not just that they have to tell the truth about their drug use, they find they have to tell the truth about everything, large and small, in order to stay in recovery. So I got really curious about that, like, what is it about what I call radical truth telling, that is so important to allowing us to manage our compulsive overconsumption? And I talked about, you know, the very various levels at which it might work. But just very briefly, when we're truly honest, especially about our shortcomings, the way we've been selfish, or the way we've lied. We think that people are going to go running screaming from us, but in fact, what happens is that it draws people closer, as they recognize their own brokenness and shared humanity. And when that happens, we get a little pop of dopamine, you know, in that shared moment of intimacy, which then itself can become a feed forward cycle, to maintain that honesty, to not transgress, to not engage in those shameful behaviours.

Sana Qadar: How did radical honesty and pro social shame help you overcome your addiction?

Anna Lembke: Oh, okay, good question. So, this gets to the importance of telling somebody else. So what happened was, I was teaching a class to a group of young psychiatrists, and I had them pair off where one would be the patient and one would be the provider. And the provider had to ask the patient about a behaviour that they wanted to change. There was an odd number of people so I was the patient for one of the young students. And he said do you have a behaviour you want to change? And I said, yes I want to change my reading habit. Now. I did not go into detail about what my reading habit was. It just said I want to change my reading habit. And, you know, [he said] why do you want to change your reading habit? Well, I'm staying up late at night, you know. Anyway, it's fascinating once we put into words, especially if we tell another human being what we're actually doing, it becomes real to us in a way that it's not when it's just pinging around and the dark recesses of our unconscious. And what I found was, once I told him that I couldn't unsee it, right? So it didn't immediately stop the behaviour. But now when I was reading, I was like, oh, I'm reading, I'm doing that thing that I told him, I wanted to change. And that was the beginning of me getting enough, kind of, objectivity and ability to reflect to say, hh, I really do want to change that behaviour. Now, how am I going to do it?

Sana Qadar: And how has that worked within your own family as well, to try and you know, keep your children from becoming too addicted to, you know, devices or whatever else? Like how do you work radical honesty and pro social shame into your family life?

Anna Lembke: Well, it starts with us, the parents, acknowledging our own character defects, acknowledging our own foibles, our own mistakes. In the book, I talk about how my kids got a bunch of chocolate Easter bunnies, and I kept nibbling away at the chocolate Easter bunnies. I would think, oh it’s just a little bit, it’s just a little bit, no one will notice. My kids had forgotten about the chocolate. And then, you know, like a week after Easter, they're like, I'm gonna like, well, where’s my chocolate? And what happened to my Easter Bunny? And I'm like, I don't know! Who ate it? I don't know who ate it. You know, and I just lied. It was horrible. I had these adorable little children. And I lied about eating their chocolate. And they were like, are you sure you didn't eat it? I didn't eat it! And then they started accusing each other. And I had to sit on that for two or three days. And then I had to like, you know, I had to come and I had to tell the truth. And I had to apologise and say, I ate your chocolate. They were horrified. They're like, Mom, not only did you eat our chocolate, but you lied about it. And I was like, it's true. I did. But I think those kinds of behaviours, kind of set, set the tone. I don't… you're a mother, but I don't know if you've done things like that, and then like… I've done so many things with my kids that like I then had to go, I have to go apologise like two or three… It's amazing how hard it is to like, be honest about stuff like that. And it's so painful to apologise. But it's really important. Because it models for them that we're not perfect, that we make mistakes, you can make mistakes. The key is that you need to apologise and make amends. And you know, try to be a better person.

Sana Qadar: Yeah, my kid’s two, so I'm not there yet, but we will get there, and I shall remember that. Did you have to be radically honest with your family about your romance novel addiction? And where are you with that now, has that been curbed and kicked? Or do you still sort of get pangs of desire to read romance novels now.

Anna Lembke: So really interesting. What happened there was, I did what I recommend to my patients. And in my book, I gave up romance novels for a month in order to get the gremlins off, reset reward pathways. And then I decided okay, it was much harder than I thought it would be, I went into withdrawal. And then after a month, I felt much better. And then I thought, okay, I'm gonna go back to reading in moderation. The first book, I got out, I binged all weekend long. So exactly what my patients talk about. It's really interesting for me to observe that in myself. I was like, okay, I can't moderate, like this is really a problem. So then I committed to giving it up for a year, I was able to give it up for a year. What happens to me with romance novels, what happens to many of my patients, I will have what's called euphoric recall, where I will remember some of the initial feelings that I had, basically just escaping, you know, not thinking, not being in my body, with reading romance novels, and then when I read them, they don't work. So it's kind of like I've burned out those neurotransmitters or my gremlins, my romance reading novel gremlins, you know, they're gonna they're just so eager to jump back on the balance, even if I just start to get a little bit of a pleasure, the price is enormous. It doesn't get me any longer to where I want to go. So slowly over time, I essentially don't read romance novels at all because they don't work. And this is exactly what the people that I.. have got. Now, I read a lot of mystery novels. But I've also, you know, I also tried to try to read other categories that are more challenging, that are more resistant to this kind of escapist fantasy thing that I tend to look for.

Sana Qadar: Did that experience change how you relate to patients? Has it changed you as a doctor?

Anna Lembke: Oh, yeah, absolutely. I mean, I think I can relate much more to my patients with addiction than I could before. Absolutely. The insidious nature, the way it kind of creeps up on you how hard it is to stop. This problem of, persistent problem, even a decade hence of euphoric recall. The kind of grief, you know, that you experience when your drug doesn't work anymore. And you asked about my family and yeah, my whole family knows about this and yeah, you know, I think it's just, it's humbling, but you know, we're all we're all human beings, so all struggling.

Sana Qadar: Yeah, absolutely. All right, final question then, this one comes from UNSW alumni Ed Bereton. What are the top three things we can do to avoid dopamine addiction? So for those of us listening who might be worried about certain behaviours, what are your takeaway messages? What are the top three things we can do?

Anna Lembke: So the first recommendation is actually abstinence for long enough for your brain to reset, baseline dopamine firing, or baseline homeostasis. In my experience for people who have actually become addicted, that's 30 days, on average, to reset reward pathways. The first two weeks feel awful because we're in withdrawal. But by weeks three and four, we feel better. If you're someone who doesn't feel like you've developed an addiction, then maybe it doesn't take a month, maybe it just takes a week, maybe it just takes 24 hours. But I highly recommend an actual period of abstinence away from the device, even if just to mindfully observe what happens to us as we go into these subtle symptoms of withdrawal. Once we've reset dopamine reward pathways, what I recommend is creating self binding strategies to create metacognitive and literal barriers between ourselves and our drug of choice. So with digital content, that might be things like, I'm deciding, I'm just going to use my phone or my devices or be online during these discrete hours of the day. But I'm not going to be on before 9am Or after 5pm, or whatever works for your job and your lifestyle. Or it might be having discrete places where, again, you don't have technology in those rooms, right? Or in those kinds of spaces. Or it might be something as simple as deleting apps or deleting alerts. Remember, alerts can also trigger dopamine and the dopamine deficit state that creates the craving. So all of those things can make a big, big difference in our lives. And then the third thing I recommend is doing things that are hard. So if you think about these gremlins, when you press on the pleasure side of the balance they have on the pain side of the balance. But when we press on the pain side of the balance, with things like exercise, ice cold water, or effortful engagement in a difficult task, those gremlins actually hop on the pain side of the balance. And there's the potential to reset reward pathways to the side of pleasure. So often when my patients say well, what should I do if I get a craving for cannabis? Should I eat a cookie or watch a movie? Well, you know, my suspicion is, that probably won't work. Because you've already, you know, limited your ability to get pleasure from pleasurable substances more broadly, you might paradoxically, go for a jog or do 50 push ups or clean out your closet. So in fact, press on the pain side of the balance to get those gremlins to switch sides and reset reward pathways.

Sana Qadar: Perfect. I said that was the final question. But final, final question. 

Anna Lembke: Okay. 

Sana Qadar: What's the danger if we as a society don't start to address our propensity for overconsumption? You know, if we don't start to make a change, what do you worry, we are heading towards?

Anna Lembke: Yeah, so our compulsive overconsumption is not just destroying our own bodies and our own mental health, it's also destroying our planet. But just taking ourselves as the first place to begin here. If you look at the world’s death… causes of death, 70% of global deaths are due to diseases caused by modifiable risk factors and the top three are smoking, poor diet, and inactivity. So we have really literally reached a tipping point where we are titillating ourselves to death. We are also consuming our planet. And so, you know, this compulsive overconsumption, again, not just hurting ourselves, but hurting this beautiful planet that we occupy. For the first time in human history. There are more people on planet earth who are obese than who are underweight. And I think the most vulnerable people in the world today are actually poor people living in rich nations, because poor people living in rich nations have access to many of these hits of dopamine with more disposable income and access to leisure goods than ever before in human history. While not having the same kind of access to healthy dopamine, like the opportunity to be in nature. The opportunity to have positive learning experiences are positive social connections,

Sana Qadar: So, a dire situation but there are ways to enact change.

Anna Lembke: Yes, and I guess I would just add that I've talked a lot today and I talk a lot in my book about what we as individuals can do. But this is obviously a collective problem not just left to the individual. Our schools, our governments, the corporations that make in profit from these digital drugs, must also come to the table and work together to help solve this problem. It's not something that a single family with parents swimming upstream are going to be able to solve. 

Sana Qadar: Absolutely. All right, I want to thank you Dr. Anna Lembke for your time tonight. Your book is called, Dopamine Nation: Finding Balance in an Age of Indulgence. This event is presented by the UNSW Centre for Ideas and UNSW Medicine and Health, as part of National Science Week and the Sydney Science Festival. To hear about upcoming events and podcasts, please subscribe to the UNSW centre for ideas newsletter, or visit centreforideas.com. I'm Sana Qadar, I host All in the Mind on ABC RN. Thank you and good night.

Ann Mossop: Thanks for listening. For more information visit centreforideas.com and don't forget to subscribe wherever you get your podcasts.