60 Quotes on addiction and reclaiming the balance between pleasure and pain (by Anna Lembke)

1. The more dopamine in the brain's reward pathway, the more addictive the experience. (p. 2)
2. Addiction broadly defined is the continued and compulsive consumption of a substance or behavior (gambling, gaming, sex) despite its harm to self and/or others. (p. 16)
3. One of the biggest risk factors for getting addicted to any drug is easy access to that drug. When it's easier to get a drug, we are more likely to try it. In trying it, we are more likely to get addicted to it. (p. 18)
4. Our dopamine economy, or what historian David Courtwright has called “limbic capitalism,” is driving this change, aided by transformational technology that has increased not just access, but also drug numbers, variety, and potency. (p. 20)
5. The world now offers a full complement of digital drugs that didn't exist before, or if they did exist, they now exist on digital platforms that have exponentially increased their potency and availability. These include online pornography, gambling, and video games, to name a few. (p. 23)
6. The relentless pursuit of pleasure (and avoidance of pain) leads to pain. (p. 234)
7. We've lost the ability to tolerate even minor forms of discomfort. We are constantly seeking to distract ourselves from the present moment, to be entertained. (p. 40)
8. Prior to 1900, doctors believed some degree of pain was healthy. “Moderate degrees of pain and inflammation in the extremities are the instruments which nature makes use of for the wisest purpose,” writes the famous seventeenth-century physician Thomas Sydenham about pain. (p. 38)
9. Perceiving children as psychologically fragile is a quintessentially modern concept. In ancient times, children were considered miniature adults, fully formed from birth. (p. 35)
10. Over the course of my career, I've seen more patients, including otherwise healthy young people, presenting with full-body pain despite the absence of any identifiable disease or tissue injury. (p. 45)
11. The reason we are all so miserable may be because we are working so hard to avoid being miserable. (p. 46)
12. Dopamine may play a bigger role in the motivation to get a reward than the pleasure of the reward itself: wanting more than liking. (p. 48)
13. Dopamine is used to measure the addictive potential of any behavior or drug. The more dopamine the drug releases in the brain's reward pathway (...), and the faster it releases dopamine, the more addictive the drug. (p. 49)
14. Pleasure and pain are processed in overlapping brain regions and work via an opponent-process mechanism. Another way to say this is that pleasure and pain work like a balance. (p. 50)
15. In the 1970s, social scientists Richard Solomon and John Corbit called this reciprocal relationship between pleasure and pain the opponent-process theory: “Any prolonged or repeated departures from hedonic or affective neutrality ... have a cost.” That cost is an “after-reaction” that is opposite in value to the stimulus. Or, as the old saying goes, What goes up must come down. (p. 52)
16. The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind. (p. 57)
17. My patients with addiction describe how they get to a point where the drug stops working for them. They get no high at all anymore. Yet, if they don't take their drug, they feel miserable. (p. 57)
18. Recovery begins with abstinence. (p. 234)
19. The neuroscientist George Koob calls this phenomenon “dysphoria driven relapse,” wherein a return to using is driven not by the search for pleasure, but by the desire to alleviate the physical and psychological suffering of protracted withdrawal. (p. 57)
20. Here's the good news. That if we wait long enough, our brains usually readapt to the absence of the drug, and we reestablish our baseline homeostasis: a level balance. (p. 57)
21. Abstinence resets the brain's reward pathway and with it our capacity to take joy in simpler pleasures. (p. 234)
22. Once our balance is level, we are again able to take pleasure in everyday, simple rewards. Going for a walk. Watching the sun rise. Enjoying a meal with friends. (p. 58)
23. Abstinence is necessary to restore homeostasis, and with it, our ability to get pleasure from less potent rewards, as well as see the true cause and effect between our substance use and the way we are feeling. (p. 77)
24. When we are consuming high-dopamine rewards, we lose the ability to take joy in ordinary pleasures. (p. 80)
25. Mindfulness practices (or the ability to observe what our brain is doing while it's doing it without judgment), are especially important in the early days of abstinence. (p. 83)
26. Pharmacotherapy alone, without insight, understanding, and the will to change behavior, is unlikely to be successful. (p. 97)
27. From lockboxes that limit our access, to medications that block our opioid receptors, to surgeries that shrink our stomach, physical self-binding is everywhere in modern life, illustrating our growing need to put the brakes on dopamine. (p. 100)
28. Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine-overloaded world. (p. 234)
29. These medications can be lifesaving tools, and I am grateful to have them in clinical practice. But there is a cost to medicating away every type of human suffering, and as we shall see, there is an alternative path that might work better: embracing pain. (p. 135)
30. Unlike pressing on the pleasure side, the dopamine that comes from pain is indirect and potentially more enduring. (p. 144)
31. With intermittent exposure to pain, our natural hedonic set point gets weighted to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time. (p. 145)
32. Socrates mused on the relationship between pain and pleasure more than two thousand years ago: “The two will never be found together in a man, and yet, if you seek the one and obtain it, you are almost bound always to get the other as well, just as though they were both attached to one and the same head.” (p. 147)

    

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33. Just as pain is the price we pay for pleasure, so too is pleasure our reward for pain. (p. 148)
34. Pressing on the pain side resets our balance to the side of pleasure. (p. 234)
35. Hormesis is a branch of science that studies the beneficial effects of administering small to moderate doses of noxious and/or painful stimuli, such as cold, heat, gravitational changes, radiation, food restriction, and exercise. Hormesis comes from the ancient Greek hormáein: to set in motion, impel, urge on. (p. 148)
36. A key to well-being is for us to get off the couch and move our real bodies, not our virtual ones (...) Exercise has a more profound and sustained positive effect on mood, anxiety, cognition, energy, and sleep than any pill I can prescribe. (p. 152)
37. But pursuing pain instead of pleasure is also countercultural, going against all the feel-good messages that pervade so many aspects of modern life. (p. 152)
38. The intentional application of pain to treat pain has been around since at least Hippocrates (...). The popularity of heroic therapies began to decline in the twentieth century as the medical profession discovered drug therapy. (p. 153)
39. The kind of single-minded focus typical of the workaholic, also heavily rewarded in modern rich nations, can be a trap when it keeps us from intimate connections with friends and family and the rest of our lives. (p. 169)
40. Telling the truth draws people in, especially when we are willing to expose our own vulnerabilities. This is counterintuitive because we assume that unmasking the less desirable aspects of ourselves will drive people away (...) In fact, the opposite happens. People come closer. (p. 182)
41. Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset.
42. First, radical honesty promotes awareness of our actions. Second, it fosters intimate human connections. Third, it leads to a truthful autobiography, which holds us accountable not just to our present but also to our future selves. Further, telling the truth is contagious and might even prevent the development of future addiction. (p. 175)
43. Lying in a world of plenty risks isolation, craving, and pathological overconsumption. (p. 172)
44. Radical honesty is essential not just to recovery from addiction, but for all of us trying to live a more balanced life in our reward-saturated ecosystem. (p. 175)
45. Consistent with the lived experience of people in recovery, truth-telling may change the brain, allowing us to be more aware of our pleasure-pain balance and the mental processes driving compulsive overconsumption, and thereby change our behavior. (p. 179)
46. Consuming leads to isolation and indifference, as the drug comes to replace the reward obtained from being in relationship with others. (p. 184)
47. When my patients start telling stories that accurately portray their responsibility, I know they are getting better (...) If the narrative never moves beyond victimhood, it is difficult for healing to occur. (p. 187)
48. The victim narrative reflects a wider societal trend in which we are all prone to see ourselves as the victims of circumstance and deserving of compensation or reward for our suffering. (p. 187)
49. As Aeschylus said, “We must suffer, suffer into truth.” (p. 189)
50. Winnicott postulated that the creation of the false self can lead to feelings of profound emptiness (...) Social media has contributed to the problem of false self by making it far easier for us, and even encouraging us, to curate narratives of our lives that are far from reality. (p. 191)
51. Truth-telling engenders a plenty mindset. Lying engenders a scarcity mindset. When the people around us are reliable and tell the truth, including keeping promises they have made to us, we feel more confident about the world and our own future in it. We feel we can rely not just on them, but also on the world to be an orderly, predictable, safe kind of a place. (p. 195)
52. One of my psychiatric colleagues once said to me, “If we don't like our patients, we can't help them.” (p. 208)
53. The patient's story recaptures not just the patient's humanity, but also our own. (p. 210)
54. Prosocial shame affirms that we belong to the human tribe. (p. 234)
55. Without shame, society would descend into chaos. Feeling shame for transgressive behaviors is appropriate and good. Prosocial shame is further predicated on the idea that we are all flawed, capable of making mistakes, and in need of forgiveness. (p. 216)
56. Overconsumption leads to shame, which demands radical honesty and leads not to shunning, as we saw with destructive shame, but to acceptance and empathy, coupled with a set of required actions to make amends. The result is increased belonging and decreased consumption. (p. 217)
57. We've established radical honesty as a core family value. If we are open and honest with our children about our struggles, we create a space for them to be open and honest about their own. (p. 224)
58. This type of radical honesty without shaming is also important to teach children their strengths and weaknesses. (p. 224)
59. Together we reaffirmed as a family that ours is one in which people will make mistakes but will not be permanently condemned or cast out. We are learning and growing together. (p. 226)
60. This radical honesty also sent the message that we can't be good at everything. (p. 227)
61. Instead of running away from the world, we can find escape by immersing ourselves in it. (p. 234)
62. I urge you to find a way to immerse yourself fully in the life that you've been given. To stop running from whatever you are trying to escape, and instead to stop, and turn, and face whatever it is. Then I invite you to work toward it. (p. 253)
63. Kent Dunnington: “Persons with severe addictions are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are”. (p. 2)

Some data from the book

• Global deaths from addiction have risen in all age groups between 1990 and 2017, with more than half the deaths occurring in people younger than 50 years of age. (p. 29)
• Greater than one in ten Americans (110 people per 1,000) takes an antidepressant, followed by Iceland, Australia, Canada, Denmark, Sweden, and Portugal (78/1,000). (p. 39)
• The number of new cases of depression worldwide increased 50 percent between 1990 and 2017. The highest increases in new cases were seen in regions with the highest socio-demographic index (income), especially North America. (p. 45)

Anna Lembke

Dopamine Nation

Headline Press

London 2021

274 pp.