00:00
Hey everyone, it's Mikki here, you're listening to Mikkipedia, and this week on the podcast, I speak to Dr Anna Lembke.

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So Dr Anna and I talk all about dopamine and addiction. We discuss what people get wrong about addiction, if it's black and white or is it a spectrum. Are all addictions bad? For example, exercise, the potential for food to be addictive and why this is a contentious issue, and even the potential for anything to be addictive. We do a deep dive into this whole topic. We also discuss who's most at risk of

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Becoming Addicted, The Impact of the Pandemic, Both the Good and the Bad, and any other insights that Anna has that weren't explored in her book, Dopamine Nation, that was published back in 2021. And as the name suggests, dopamine is the predominant neurotransmitter that is responsible for a lot of our motivation drive and the potential.

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to be addicted. But of course, it's such a complex issue. So it's not just dopamine, but we of course talk a lot about the role of the brain and dopamine in this discussion. Dr. Anna Lemke received her undergraduate degree in humanities from Yale University and her medical degree from Stanford University. She is currently professor and medical director of addiction medicine in Stanford University School of Medicine.

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She's also program director of the Stanford Addiction Medicine Fellowship, chief of the Stanford Addiction Medicine Dual Diagnosis Clinic, and a diplomat of the American Board of Psychiatry and Neurology and the American Board of Addiction Medicine. In 2016, Anna published drug dealer MD, How Doctors Were Duped, Patients Got Hooked, and Why It's So Hard to Stop.

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that was highlighted in the New York Times as one of the top five books to read to understand the opioid epidemic. And she also appeared in the Netflix documentary The Social Dilemma. If you haven't seen it, really good documentary, I'd highly recommend it, which is an unvarnished look at the impact of social media on our lives. Her latest book, which is the one that Anna and I focus on in today's interview, is Dopamine Nation, Finding Balance in the Age of Indulgence. And it

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Times bestseller and has been translated into 30 languages. It combines the neuroscience of addiction with the wisdom of recovery to explore the problem of compulsive overconsumption in a dopamine overloaded world. Anna and I have such a good conversation and I really think you're going to love our discussion. Just before we crack into it though, I'd like to remind you that the best way to support this podcast is to hit the subscribe button on your favourite podcast listening platform.

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that increases the visibility of the podcast and amongst literally thousands of other podcasts that people could listen to. So more people get the opportunity to hear conversations that I have with guests like Anna, who are just experts in their field, because it is so helpful. And if you feel like leaving me a five star review, it'll just prove how awesome you are too. I will put links in the show notes to both Dopamine Nation and of course to Anna's bio, but for now,

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Enjoy this conversation with Dr Anne Lembke.

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Anna, thank you so much for taking time with me this morning to chat about addiction, concepts in your book, which would just sort of, to my mind, and for the people around me, it seemed to explode the conversation around dopamine and addiction, but not addiction from the sort of, I suppose, the, if I say conventional way that we might describe something, but just.

03:56
almost at a lower level. So I suppose my, well, one of my first questions is, is it black or white that some people will have an addiction and others just won't? Or is there a spectrum on that? Yeah. So we codified addiction as a spectrum disorder with the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. So I think intuitively we can all sense.

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that it is a spectrum, that there are some people who are severely addicted who lose everything, who end up homeless and jail, et cetera, people with terminal addiction who die of their disease. And then there's sort of everything in between, including a sort of pre-addicted state where people are engaging in risky behavior, but maybe haven't quite crossed the threshold into what we would consider to be a pathological mental health disorder that we designate as addiction.

04:54
Let me say that it can be a difficult judgment call at that end of the spectrum. You know, some people's addiction is another person's passion. So it's not that it's an easy call to make when it's on the more mild forms, but it's definitely, there's no doubt it's a spectrum. I can imagine with some people it would be, you know, if I observe a person's behavior, and I'm like, you're clearly addicted, and I wonder to what extent, I mean, obviously it must be important for the...

05:22
person who I'm referring to either recognizes that that's the case or actually just views it differently like you've said. Like I can imagine that would be a difficult sort of situational conversation. That is the scenario that we encounter more often than not, which is to say people who clearly manifest the signs and symptoms of addiction but who don't themselves recognize having a problem. And let me just say that you could almost say that in the early stages in particular that that's universal.

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And it's a very funny trick of the brain that we're all vulnerable to, where we are not good observers of our own consumptive behaviors when we're chasing dopamine. You know, one of the examples in my book that I talk about is my own sort of mild addiction to romance novels. I'm an addiction psychiatrist, and I really didn't see it happening until I was quite far along, and until I actually articulated or described my behavior to another human.

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which is one of the therapeutic roles that we can play is to just listen attentively as someone describes their behaviors. Because it becomes real to them, they see it, they literally see it for the first time only when they're describing it. In the field of addiction, we often refer to this as denial. One of my patients like to say that denial is actually an acronym for don't even know I am lying.

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which I just think is, which is great, right? Because it really is like that. It's like we see the behavior, but then we sort of block it out and don't see it. Is everyone vulnerable to becoming addicted to something? Does that term get sort of bandied about? From the way you're describing it, it almost seems like it might not be, but what is your perspective on our vulnerability to addiction? Yes and yes. So I think especially in this day and age, we're all vulnerable.

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to addiction or certainly much more vulnerable than we were in prior generations because of the world that we live in now with almost infinite access to highly reinforcing substances and behaviors. And yes, the term gets bandied about, gets trivialized. Some people argue that you can't be addicted to behaviors like reading romance novels or playing video games or pornography.

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I make the opposite argument that really, you can get addicted to almost anything now. But at the same time, I do appreciate that we don't wanna trivialize the term and that when I'm using the term addiction, I'm talking about an unhealthy, maladaptive pathological pattern of consumption. And that's something different from a habit or a passion or something like that.

08:07
Yeah, yeah. And I imagine obviously, with your background, you'll be thinking about it in terms of the DSCM-5 classification for addiction. Whereas when I'm talking about it, I may know some of the elements that might sort of categorize someone, but I'm certainly, I'm not well versed in that because it's just not my field. You know, yeah, you know, I think I don't think you really, I mean, yes, I vaguely reference the DSM. I've been doing this so long that I

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very seldom actually sit down and like go through the actual checklist, you know? It's really just pattern recognition. And the definition of addiction that I like, broadly speaking, is the continued compulsive use of a substance or behavior despite harm to self and or others. Sometimes that's harm that the individual themselves recognize. And oftentimes, as we discussed, it's harm that the individual doesn't recognize because it's hard to see that until it becomes very extreme.

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So, again, if it walks like a duck and it talks like a duck, it's a duck. I bet you in your field with your knowledge of human behavior and food consumption issues that you actually probably could pretty well diagnose it yourself, which is also an important point to emphasize that we don't have brain scans or blood tests to diagnose addiction. It is based on pattern recognition. Yeah. A couple of things sort of spring to mind. And if I'll start at one end of the spectrum.

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is exercise. You know, I'm a runner and I feel my absolute best when I'm able to get out in the morning and run. And it really sets me up for the day. And when I am unable to do it, my mood is lower. And it's not endorphins. People talk about endorphins. It's like, no, it's not that, something else. And then of course, I think I mentioned to you in an email, Rich Roll, who I believe I know you've done a podcast with. He's great. He talks about

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how he sort of transferred his addiction to from sort of alcohol and drugs and junk food to exercise but the outcome is different for him because he's not numbing the way he feels but he's really leaning into how he feels and it's really raw and real. Do you have any comments on any of that Anna?

10:21
Yeah, so we often see that people who overcome severe addictions to things like drugs and alcohol and other obvious intoxicants, gambling, sex, pornography, shopping, gaming, will often transfer that intensity to a behavior like exercise. So first of all, that's a common thing. And depending upon what they transfer that energy to, it can be good or bad, right? If they go from...

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you know, smoking cigarettes to smoking cannabis, that's not something that we consider to be a move in the right direction. But if they go from, you know, smoking cigarettes, drinking alcohol, whatever it is, to some kind of exercise regimen, especially if it's salutary, if there's real obvious mental and physical health benefits, we consider that to be a good investment of that kind of passion and energy.

11:15
However, it is also true that people can get addicted to things like exercise, especially in a day and age when even exercise has become drugified with the advent of all of these machines, the way that we count ourselves, the leaderboards, the way we have ranks. Now we're comparing ourselves to people all over the world, my time, your time. And although still those are harder addictions because they require this sort of upfront investment of painful effort.

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You know, people can get addicted and will experience physiologic withdrawal when they stop. So it's important to keep that in mind and we do occasionally treat people with exercise addiction. What does that look like? That looks often like they're continuing to exercise despite bodily harm or they're exercising to such an extreme that there are significant opportunity costs, time not spent with people they love, time not engaging in work that they care about.

12:13
Et cetera, et cetera. Yeah. Oh, that just sounds like someone training for an Iron Man, doesn't it? No. Not really. Yeah. I mean, it's a good point because it does highlight the intersection between how we define addiction and what are cultural norms, right? It's the same thing. Our heroes today are workaholics, right? Or they're professional athletes. So these are people who are doing hard things

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to quite an extreme and we celebrate them. Are they experiencing significant personal costs because of that? Probably, but there's also significant personal gain, fame, fortune, you name it. So there is this very interesting way in which culture and society interplay with how we define this thing.

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On the other hand, again, that's why it's so instructive to look at the most extreme versions because those extreme versions, I think we can see a reflection of our own behavior and sort of go, oh, now that wouldn't be good, right? Something short of that is what I'm going for. Yeah. My brother was highly addicted. I say highly, and he would probably look back and think he was addicted and see it as well to gaming. Right.

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seemed to be. And then something switched in him and maybe he started playing golf on the video games. And then suddenly he developed this absolute passion for golf. And now instead of gaming, I mean, certainly he doesn't do it. He was almost able to flick the switch on his behavior there to enjoy it a few hours a week. And now he spends hours on the golf course, which I think is, that's the interesting thing I think with

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this idea of addiction and of course I picked this up in your book as well, even though there was a protocol you used, which we will talk about soon, the dopamine fast. But whereas it seemed sort of addicting to him at a time, for a time, and then he was able to switch it to something else. And if I just add to that, but I see the same thing with, for example, alcohol behavior as well, like super heavy drinking and then that's not working for me, switching to absolutely not drinking.

14:37
Again, my brother, and this is okay for me to talk about because he talks about it publicly. All of those things, are they in the realm of what we're talking about? Yeah. So I really appreciate that story about your brother. I think it might be worth highlighting for a moment why spending hours playing actual golf is better than spending hours on video games.

15:03
And the key difference there is that he is engaging in an embodied activity, right? He is moving his body, he's connecting mind and body, plus he's outside, you know, and so he's getting vitamin D, he's getting fresh air, but I think that's a key distinction. You know, anything in too much excess is probably not good, but even if we're gonna talk about many hours spent doing something, better that that be some embodied activity.

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moving our body, especially in the sedentary world that we live in now. Then your other point or question, I'm sorry, I forgot what it was. Yes. No, it was almost like the drinking behavior. Oh, yeah. I got it. Yes. Then there's this whole notion of what we call natural recovery.

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psychiatric criteria for an addiction, who at some point without any treatment or any really intervention from some kind of external, we mediated other person or what have you, just realize that this is not good and manage to change their behaviors. Now interestingly, you know, the sort of mothership of

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many of these concepts as alcoholics anonymous, right? Starts in the 1930s by two alcoholics who got together, helped each other and found that was more effective than going to see any kind of doctor. And what alcoholics anonymous would say or has said for a long time is that natural recovery doesn't exist. And then if you have somebody, and it's sort of a tautology, they would say, well, if you have somebody who was able to just naturally,

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you know, change that behavior, then they were never an alcoholic in the first place, right? Or they were never addicted to X in the first place. But I don't think that's true. I think we can very clearly see in the clinical setting, but also there's a small literature to support this, that there are people out there who meet criteria for, specifically the literature is around alcohol use disorder. So alcohol addiction, who get into natural recovery on their own. Maybe they mature, they sometimes talk about maturing out of it.

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maybe their life circumstance changes, but for one reason or another, they kind of figure it out and then typically they're not drinking anymore and they're not having that problem. Even more interesting, some of them are going back to using alcohol in moderation and able to do that without returning to that kind of maladaptive pattern.

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In my clinical experience, that is a very small sliver of people who can actually go back to drinking. But natural recovery exists and drinking in moderation after having been drinking in an alcoholic way, although rare, also exists. Yeah. Super interesting. And, Anna, obviously your book, Dopamine Nation, was geared towards dopamine. But neurotransmitters, our hormones, the way our body responds isn't always just in isolation.

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What other enzymes or neurotransmitters are at play when it comes to this whole concept of addiction and how we respond in certain situations? Is it just dopamine? Oh, not at all. So I use a very simplified metaphor of the pleasure pain balance, and I focus on dopamine really as just a way to help people understand homeostasis, which is one of the major pivotal concepts.

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that we need to understand to know what happens in the brain when we become addicted. But it's by no means as simple as that. There are many, many neurotransmitters, chemicals, cells involved. It's a very complex pathophysiology that we're only just now beginning to understand. Other feel-good neurotransmitters like the monoamines, serotonin, norepinephrine are key, dinorphin.

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which is one of the chemicals that is released when we're experiencing painful experiences binding to the kappa receptor. So it's not at all just sort of about dopamine. However, dopamine has become a kind of common currency for neuroscientists to measure pleasure, reward, and motivation because all reinforcing substances and behaviors, no matter their chemical cascade, at the end of the day, ultimately,

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release dopamine in the brain's reward pathway, the more dopamine released and the faster that it's released, the more reinforcing or potentially addictive that substance or behavior. Okay, and you mentioned that the body sort of wants homeostasis, and you've talked about an evolutionary basis for that balance between pleasure and pain. And the more pleasure that we are aiming to derive,

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from whatever it is that we're doing, the more the body or our brain tries to tip us into that pain cycle. Can you describe that evolutionary basis? Yeah, I mean, if, you know, I think what's really important to remember is that for most of human existence, we have lived on a planet of scarcity and ever present danger. And in that kind of environment, we had to work very hard.

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to get even the merest rewards to keep us alive, food, clothing, shelter, finding a mate. Our entire days, our entire lives, we're dedicated to just surviving, right? And as such, our brains evolved this mechanism that made us the ultimate seekers, never satisfied with what we have, always looking for more. And the pleasure pain balance is a kind of metaphor for that mechanism.

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which talks about how if we find something that's pleasurable, reinforcing, and usually those are related to the natural rewards of food, clothing, shelter, finding a mate, then we experience dopamine release in the reward pathway that feels good, and then we want to repeat that behavior, and we invest more time and energy. But no sooner is that dopamine release than above baseline levels, because we're always releasing dopamine at a kind of tonic baseline.

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then our brain down regulates dopamine transmission, not just to baseline, but below baseline. That's the experience of craving. And that craving is what motivates us to continue to do more work to get more reward. And again, that's key. That's what has kept us alive, through the many millions of years of evolution. The problem is that we are living in an unprecedented time in human history when we have changed the planet. We've changed our environment.

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We've made these, you know, basic survival for most people alive today is not the issue that it was. And beyond that, we have drugified almost every human behavior and substance we ingest. We've made it more reinforcing, it releases more dopamine. We've made it more accessible, more available, more novel. We've made more of it so we don't run out. We have more leisure time. We have more disposable income than ever before, even among the poorest of the poor.

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especially in rich nations. And the result is that we're now fighting against our own biology. Yeah. And I imagine in the example of like, you know, the poorest of the poor or, or the lower socioeconomic, if you like, like people who have to work hard jobs, two jobs, try and support a family that the, if I say cheap pleasure, that's not what I mean, but there are so many things

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have some level of enjoyment of life that probably fall into a lot of the things that we're talking about, like gaming and fast food and all the rest of it. Right, I mean, many of these jobs today in the lower socioeconomic strata are very stressful jobs and jobs in which the meaning of the work is divorced from the actual work itself. So people work on an assembly line who have to do a repetitive behavior over and over again, who don't actually get to see the product and how it's used and experienced.

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the joy of that. And then at the end of the day like that, people are stressed out and they're looking to sort of feel better and with access to many cheap, quick sources of dopamine, those individuals are vulnerable to want to engage in those activities, consume those substances as a way to restore homeostasis and get back to their baseline. And then that drives this kind of work hard, play hard where we're constantly

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going from one extreme to the other, pleasure pain, pleasure pain, which is also not good for our reward pathway. Anna, with children, I read an article a few years ago that talked about the impact of gaming for children on their brains and that they were more vulnerable because of the developing brain to get sort of sucked into the addictive nature of things like gaming to the point where they would become completely different children.

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when you sort of tore it away from them because you were tearing away this really exciting world and now they had to exist in this super boring, engaging with family, you know, doing the dishes, that kind of thing. And I've seen it firsthand and friends talk about it firsthand as well. Is it because of their developing brains that they may be more vulnerable to some of these effects or is it, but what does that come down to?

24:45
Well, in terms of sort of, you know, the manifestation of withdrawal when the games are taken away, I mean, that's real physiologic withdrawal, right? Games, moving images, videos, these are highly potent stimuli. They go right to our visual cortex. They stimulate our reward circuitry. They release dopamine. But again, with repetitive behavior, they ultimately drive dopamine levels down to this chronic dopamine deficit state. Now we have to stay engaged with the games.

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just to kind of bring our dopamine levels back up to baseline. And then when we stop or when it's taken away, we crash hard. So we see a lot of kids become acutely dysregulated and they're literally in withdrawal and the universal symptoms of withdrawal from any addictive substance or behavior are anxiety, irritability, insomnia, dysphoria and craving. So kids will definitely manifest physiologic withdrawal.

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And then more broadly, the notion of the hijacked brain is this idea that the reward pathways get taken over by this highly reinforcing substance or behavior such that other things lose their salience, right? Other things like talking with family, reading a book, going outside are no longer rewarding. And I guess I just wanna emphasize that because I think that phenomenon is the same.

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across the spectrum, right? That the changes in dopamine, that hijacking of the reward pathway, the resetting our hedonic or joy set point in that chronic dopamine deficit state. Now what's different about kids is that kids at age five have more neuronal synapses and neurons than at any point in adult life because they're primed for learning, right? They're like these totipotent cells.

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But from about age five to about age 25, the brain slowly cuts back on the neurons that we're not using and myelinates or makes more efficient the neurons that we use most often, such that by about age 25, we created the neurological scaffolding that we will use for our entire adult lives. That means that age five, 25, and it's probably frankly birth to age 25, that's a window of opportunity.

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and it's also a window of vulnerability. Because if you have a kid who's given an iPad at age five or whatever the age is, and does almost nothing but play on that iPad through adolescence, that means they're gonna have a very elaborate neurological scaffolding for iPads and the things that you get on iPads, but they're gonna have very limited neurological scaffolding for things like frustration tolerance, right? Learning to sit with uncomfortable emotions.

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without changing the field. They're gonna have very limited attention span, very limited ability to wait for an answer or go searching for an answer. And, and I'm not really sure how this mechanism works, but it's, we see it clinically and I've heard it from many different parents. There's a kind of a sociopathy that we see with kids who play a lot of video games, a loss of empathy, unable.

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to really put themselves into somebody else's shoes and imagine their experience, express empathy, help others. And they really start to look totally sociopathic, perfectly normal kids, right? Who then, you're screaming at their parents, won't help out with family chores, are unkind to siblings. And then you take away the games and you leave enough time.

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for their brain to reset. And that's really important because in those first 10 to 14 days, they're gonna be in withdrawal and look kind of crazy. But if you can get them to about week three or week four, what we see is parents saying, I got my kid back again. Oh, this is the child that I knew and recognized. And I think this is really profound because as a clinician who teaches this, I get to see this a lot. And what I'm talking about is how incredibly personality disordered people look when they are in their addiction.

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narcissistic, borderline, sociopathic, antisocial. And when they get into recovery, in the majority of instances, all of that disappears. All of it. They don't look personality disordered. They are not personality disordered. They're, in many instances, wonderful people. So I just think, you know, it's really profound, the extent to which this chasing dopamine can make us a kind of shadow version of ourselves.

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Yeah. And obviously you just mentioned it there, the sort of taking away the sort of, on this instance, you know, the gaming, the device. And of course, in your book, you talk about dopamine fasts. So is that essential? That's the same thing, essentially. It's just the removal of the thing that's causing the problem and waiting it out. Like is that...

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what a dopamine fast is. Yeah, so the idea is that by constantly pinging our reward pathway with this fire hose of dopamine, our brain has been forced to accommodate that by down-regulating our own dopamine production and transmission. Again, this is an oversimplification, not just to baseline, but below baseline into this dopamine deficit state, which is experienced as depression, anxiety, irritability, insomnia, craving, and manifests as this kind of personality disorder and sociopathic state in many instances.

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by taking away the drug of choice for long enough, we allow the brain to register, oh, I'm no longer getting this external source of dopamine. It's now time for me to upregulate my own dopamine production and with enough abstinence from that drug of choice. And on average, in our clinical experience, it takes about 30 days for people to begin to reset reward pathways and regenerate healthy sources of dopamine.

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basically people get back to that baseline homeostasis and feel so much better. Not just better than they did in those first two weeks, but in many instances better than they have in a long time, less depressed, less anxious, more present, all of those things. This is not to say that people are cured at a month, but it's to say that they can begin to see a light at the end of the tunnel of how they might live in the world and feel better.

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without that behavior, without that drug, which is really important because when people come with this pathological consumptive behavior, they can only imagine one of two realities. I either continue to use my drug and be miserable, or I stop using my drug and be miserable. And what we're saying is if you stop using your drug, you will be more miserable for about 10 to 14 days, but then you will actually get to a place where you will feel better.

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And the longer you can go without using the more that those gains accrue. I should emphasize this is not an intervention that we would do with somebody who's at risk of life-threatening withdrawal from alcohol or benzos or opioids. They need a medically managed detox to get off. That is often a slow taper or other medicines to help them get off. And it's not something we would do in the outpatient setting with someone who'd repeatedly tried to stop on their own and wasn't able to. We would refer that person to some kind of inpatient setting.

32:15
where the same thing is happening, right? I mean, that's what rehab is for. It's to put people in a contained environment where they don't have access to their drugs, so they can stop for long enough, 30 days typically, to kind of reset reward pathways, get back control of their prefrontal cortex, and go out into the world with half a chance of maintaining their recovery. Yeah, and then what is the next steps, I guess, there? Because is it just that, you know, that's it for them, and it's now up to them to...

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not go back and sort of use the device or whatever it is that they've been addicted to? Or are there other adjacent treatments? Obviously, you mentioned the in-person and the sort of the therapy that someone can get. But what else can someone do to sort of ensure that they don't fall back or slide back? Is it therapy, actually? Yeah, I mean, so many things, so many things. So addiction is a biopsychosocial disease, which means that it has biological origins, psychological contributors,

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social phenomenon, very much so like a virus. So the interventions are also biopsychosocial. There are medicines that we have to help people maintain a pedative control. Individual and group psychotherapy has been shown to be helpful. Engagement in mutual help groups like Alcoholics Anonymous, Narcotics Anonymous, Scamblers Anonymous, Sexaholics Anonymous, you name it, it's out there, can be extremely helpful and may even be more helpful than individual.

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or group psychotherapy, especially when you track those people beyond a year. And, you know, spiritual practices, physical practices, all kinds of things that people can do. And I guess for parents who have kids and they're sort of recognizing some of the behaviors that we're talking about, would it be sort of trying to engage them?

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beyond that sort of month or 14 days into something else that hopefully the kid's gonna spark an interest in and is that kind of like a good course of action? Yeah, that can be very helpful. There's literature showing, for example, that kids who engage in some types of sports are at decreased risk for addiction than kids who don't. We know that in general, kids who spend more time online consuming digital media are at risk for all kinds of outcomes.

34:37
But also in particular, the family unit can make some serious changes together that will really help. Limiting the amount, especially if it's a digital, if it's a digital media problem, limiting the amount of access to digital media in the home, either by having a time of day when the device devices get powered down, parents included, right? Or just shutting off Wi-Fi to the house at a certain time of day or actually.

35:05
permanently taking the device away from the child, especially a younger child, but, you know, and have, and then implementing group activities that they do together as a family that are specifically not device related. Board games, being in nature, you know, family meetings where you talk about things that are affecting the family, all kinds of things that people used to do in plenty and now struggle to think of, you know, cooking, gardening, there's so many things.

35:32
But, you know, I mean, if I had one piece of advice for parents, very simple was try not to be on your device when you're with your child. Yeah. Super hard, but, you know, really powerful. And then have as, you know, your default in general, especially the smartphone, have it powered off. You know, have it powered off and only turn it on when you need to use it as a tool, not as a drug. Yeah, yeah, no, that's really nice. Anna, obviously we've gone through sort of unprecedented times.

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of late over the last few years with the pandemic. And I wonder whether you observed what was occurring with regards to people's behaviors because we were either locked into our homes, we were unable to see people. And just any of your sort of thoughts around that, like, did you, yeah, did you sort of, I don't know, feel a bit of despair at what was occurring?

36:26
Do we know, do we understand anything more in this area because of what occurred? Yeah, so it was a very interesting time. And what I saw was, what I sometimes refer to as a sort of musical chairs phenomenon, that people were rotating around a limited number of chairs. And when the music stopped, i.e. sheltering in place began, there were some folks who got chairs and then other people who really didn't.

36:53
The people who didn't get chairs, as I would liken to people who were living alone, were very isolated, began consuming more alcohol, more drugs. Drug overdoses in this country had started to go down in 2018, 2019, and then during the pandemic shot up again. So we lost more people to drug overdoses during that time. People drank more alcohol. They smoked more pot.

37:18
You know, we had people coming in who had never before struggled with addiction, who had new onset addictive disorders because of the pandemic related to drugs, alcohol, digital media. You know, kids losing valuable learning and socialization during that time period. However, I will also say that there was also the opposite. We had, for example, many patients who came to our clinic

37:47
who had been struggling with addiction for years. And the pandemic was the first time that they actually could take a pause, really reflect on that behavior and take the time to get help. And not only was it a time to get help, but it was easier for them to remain abstinent because they weren't constantly being triggered by our very triggering environment. They weren't going to the grocery store and going down the booze aisle. They weren't constantly being invited to parties where pills and pot were passed around.

38:17
you know, people who were living together with other people, you know, and experiencing positive relationships had a real flight into wellness, less depression, less anxiety. So I really saw kind of these two extremes where some people got much sicker and other people got much healthier, kind of depending on where they were in that musical chairs. Yeah, and then now in terms of your clinic and your practice, is it sort of,

38:47
Has that changing and people gotten better and people got worse? Is it just sort of offset and the numbers are sort of the same or is it? Well, I mean, drug overdoses sadly have continued to rise. That's largely due to increasing access to highly potent and lethal fentanyl and opioids. It's just killing people all over the United States, which was a trend that was already happening but is continuing to happen, which is really sad and just devastating.

39:17
And then there were people who were able to get into and maintain recovery during the pandemic who have now relapsed again for the, you know, right? So now we're back into the world. People are, we have these chaotic, stressful, you know, hyper-connected lives and those people are finding that that's really hard for them and they kind of look back sort of nostalgically at sheltering in place. And then likewise, we have other people who did not thrive during that time and are happy that it's over and are doing much better.

39:45
connecting better socially and such. Yeah. Do you see, Anna, a shift anytime in the next like two or three decades about how we live our lives? And like, I can't, you know, I think about this from a food perspective, like fast food doesn't go anywhere, cheap food isn't, people aren't sort of downscaling the options available for people that can sort of help drive some of these behaviors which are unhelpful. Like in your field, do you sort of think, well,

40:13
and now it's all about, it'll always be about management because things aren't gonna change at that sort of large scale that might be required to actually sort of, I don't know, make a dent. Well, I'm ultimately optimistic that we'll figure it out because humans do that, but I think it will take centuries. I think in the immediate future, we are going to be dealing with a scourge of addictive behavior of all kinds, you know, to food.

40:41
to digital media, to drugs, to alcohol. As we work to try to limit access, which is important to do, to these unhealthy substances and behaviors, there will be new ones that crop up. As we think about digital media and the kind of guardrails that the government and schools and corporations could and should impose, that will help to some extent, but people who are really motivated will find a workaround. So I think it's gonna be an iterative

41:11
process of figuring this out. And it's gonna have to come, not just through technological solutions, but also frankly through changing societal norms, around what people really consider to be healthy normative behavior, and what is considered to be sort of outrageous. Smoking is a good example, right? In the 1940s and 50s.

41:38
We had doctors as part of smoking, you know, cigarette camp, to sell cigarettes, right? Smoking, you know, yeah, it'll, you know, pep you up, keep you going, what have you. And we look back at them and it's like, how could they not have realized? And I really do think the way that we give, you know, iPads to small children and the way that we bring our smartphones everywhere. And I think we'll look back. Maybe it will take, you know.

42:04
50 or 100 years, but we'll look back and be like, I can't believe we did that. Like that was so insane that we had that kind of unfettered access to the internet for small children in particular. Yeah, yeah, I hope so. It's not a tangent, but related more to the medication side of things. Obviously in nutrition and in a lot of areas, and it's actually a type two diabetes drug, but there's been this increase

42:34
in availability of those GLP-1 inhibitors, which, and I'm not an expert in it at all, but what I know is that they're increasingly available for people who don't even have sort of a life-threatening obesity problem, but they're taking them to lose five or 10 pounds or whatever. And as I understand, these could theoretically influence the dopamine pathway,

43:04
And obviously that will relate to sort of food intake and the reward they get from food and maybe even mood regulation. And do you know anything about that space and sort of what's happening there and any thoughts or insights? Yeah, I mean, to me, it's a sort of meta commentary on the addictive nature of our food supply and the ubiquity of foods that are so tasty and so reinforcing.

43:34
that once we begin eating them, it is very difficult to stop. And that would be generally true for all of us. We were not evolved for the food that we now eat. And I see, you know, whether it's bypass surgeries, you know, sleeves, you know, operations to make intestinal tract smaller, or, you know, these kinds of modulators of the insulin glucagon system as

44:03
desperate attempts to try to adapt to our current highly addictive food supply. So I get it. I am dismayed by people who are not struggling with severe obesity. Using these agents, it seems like they should be reserved for people who really need them.

44:28
And also, it's early days, right? Like there might be some very serious adverse side effects. We're already seeing that. There's a black box warning about intestinal blockage. I wouldn't be surprised if there's ultimately some kind of black box warning about mood effects as we've had with appetite modulators in the past. So I think...

44:56
we really should proceed with caution. Now, having said that, it's very clear that they can be extremely helpful, these medications for a pedative control of anything involving carbohydrates or sugars. And alcohol is a carbohydrate. So we are also in some cases of treatment refractory alcohol addiction using these for our patients. And with some patients, they're finding that their cravings just disappear. And these are people who've been struggling for years.

45:26
to manage this problem. So, on the one hand, I'm quite grateful that we have new agents and that we're exploring them, especially for the people who really, really need them. But on the other hand, again, I think we need to be very cautious because every drug has its downsides. And I think we haven't yet fully seen what these drugs will do, good and bad. Yeah, no, that makes perfect sense.

45:52
And with regards to addiction, are there any genetic tests actually that people can do to understand better their potential risk to become addicted to anything? You know, they've got a lot of these DNA, like sort of at home DNA tests that you can run and then get analyzed. Is there anything that you've seen clinically meaningful? The short answer is no. It's going to be a complex polygenic phenomenon.

46:22
as I alluded to before, a biopsychosocial disease. So it's really a disease about the interaction between our brains and the environment that we live in. I always like to say that people with severe addiction, millions of years ago, would have been the most valuable members of a tribe because they were willing to work harder, walk further, sweat more to get those rare rewards that were so key for everybody's survival. Today, that kind of tenacity is a real potential liability.

46:52
And yet people in recovery are, as I mentioned, modern day profits, because if they can figure out how to live in this drugified world, then they have a lot of wisdom for all of us. Yeah, so that's what I would say to that. Yeah, thank you, Anna. And finally,

47:13
I mean, your book was amazing and I listened to it and you did such a great job at reading it. I listened to it on an audible and I just loved it. It was great. So I highly recommend it even if people have, because I've got both copies. I just, you know, I don't know, I just really enjoyed it. Is there anything in your book that you sort of reflect on and might change if there's a second edition or any new sites?

47:41
insights into the research? Yeah. I mean, it's so funny. Writing a book is such an organic experience. It's kind of like giving birth to a child. You sort of don't know really what is going to come out at the end. Then ultimately, you only see it one way and then the world perceives it in their own way. You're lucky if you get readers. I've been very lucky to have that. I'm very grateful for that.

48:09
So I can't really say I would change one thing or another. It sort of is what it is and it has a life of its own. And I just, you know, sort of borrowed from God, that kind of idea. We are coming out with a dopamine, an interactive dopamine nation workbook this year, slated for publication in October, but it might be earlier. And this is just an opportunity for people who want to actively engage in the dopamine fast. The chapters align with the dopamine acronym.

48:38
and who wanna go through that exercise and maybe don't wanna see a professional or maybe wanna use the workbook with a professional, but also they could do it on their own. I had a lot of teachers and parents reach out to me and say, is there a version of this without the masturbation machine, which as you know is how. And so the workbook is a version of that that I hope will be interactive and also useful for parents and children and teachers of young kids. Yeah.

49:06
That is awesome, Anna. Thank you so much. And thank you so much for your time this morning. Yeah, my pleasure. Great questions. Yeah, thank you. And amazing book. Where can people find more about you and your research? And of course, your book and the the soon to be released workbook. Yeah, so the book and the workbook will be available wherever books are sold. And that's

49:36
figure out what I'm thinking about. Yeah, yeah. You're not on X much, I don't think, I haven't seen much. No, you know, I'm not on- Or threads or whatever it is. No, I've never gotten on any social media. I wouldn't be able to handle it. I would immediately, you know, it would take over my life. I know that about myself, so I don't even go there. Yeah, that's smart. Know yourself, that is very smart. Yeah. Yeah, thank you so much, Anna. You're welcome.

50:10
Alrighty, hopefully you enjoyed that as much as I enjoyed chatting to Anna. As I said, I've got links to the book in the show notes and I listened to it and it was such a fabulous listen. Anna narrates it herself and it is, yeah, it is a phenomenal listen. So I highly recommend it. Of course, reading is good too. Next week on the podcast, I have the pleasure of chatting to Lara Brydon and Nikki Kaye.

50:37
who are both experts in the field of women's health and hormones. So we have a great conversation around hormones, hormone replacement therapy, and a whole host of other things. So that is next week. Until then though, you can catch me over on threads, Instagram and Twitter @mikkiwilliden, Facebook @mikkiwillidennutrition or head to my website mikkiwilliden.com, and you can book a one-on-one call with me. All right team, have the best week. See you later.