321 – Dopamine and addiction: navigating pleasure, pain, and the path to recovery

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Anna Lembke is the Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic and author of Dopamine Nation: Finding Balance in the Age of Indulgence. In this episode, Anna dives deep into the biochemistry and neurobiology of addiction, exploring the critical role of dopamine and the prefrontal cortex. She shares her framework for diagnosing and treating addiction, providing real-world examples involving alcohol, gambling, cannabis, social media, and more. Anna outlines the risk factors for addiction, including inherited and nurture-based risks, explores the rise of addictions in younger generations, and discusses effective ways to address these issues with children. Additionally, she touches on healthy coping strategies, the evolution of the “marshmallow experiment,” and provides insights into GLP-1 agonists as a possible tool for addiction treatment. Finally, she reflects on the value of 12-step programs and how she navigates the emotional challenges of her work.

We discuss:

0:00:00 - Intro
0:01:11 - The role of dopamine and the prefrontal cortex in addiction
0:12:18 - The clinical definition of addiction and the behavioral criteria for diagnosing it
0:16:44 - Assessing alcohol use: patterns, risks, and addiction diagnosis
0:21:38 - Applying the addiction diagnosis framework using gambling as an example
0:25:48 - Exploring addiction variability: how nature, nurture, and access shape individual vulnerability and drug of choice
0:43:33 - How abstinence from addictive behaviors can help reset the brain’s reward system and improve mental health
0:54:29 - Safely abstaining from addiction substances, drugs needing medical supervision, and other key considerations
1:02:40 - Transitioning from abstinence to long-term recovery: tools and considerations
1:13:18 - Exploring behavioral addictions like sex addiction, and the gender differences in addiction patterns
1:19:13 - Factors contributing to the increasing levels of addiction across the world
1:30:21 - How online pornography can affect young boys' developing brains and lead to addictive behaviors, and strategies for parents to address this issue
1:43:05 - The link between social media use and declines in mental health, potential solutions, and protective measures
1:53:32 - How exercise affects brain chemistry, the role of dopamine and endorphins, and how exercise can become addictive
1:57:04 - Cold-water immersion for mood regulation, and other healthy coping strategies
2:04:47 - The “marshmallow experiment”: how broken promises affect behavior and trustworthy environments help children develop self-control
2:09:30 - Can GLP-1 agonists be useful in treating addiction?
2:17:57 - The benefits of 12-step programs
2:24:14 - Why understanding a patient’s story is essential for meaningful psychiatric care
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The Peter Attia Drive is a deep-dive podcast focusing on maximizing longevity, and all that goes into that from physical to cognitive to emotional health. With over 90 million episodes downloaded, it features topics including exercise, nutritional biochemistry, cardiovascular disease, Alzheimer’s disease, cancer, mental health, and much more.

Peter Attia is the founder of Early Medical, a medical practice that applies the principles of Medicine 3.0 to patients with the goal of lengthening their lifespan and simultaneously improving their healthspan.

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