Giải Mã Hoóc-Môn Dopamine PDF EPUB

" Giải Mã Hoóc-Môn Dopamine PDF EPUB 🔙 Quay lại trang tải sách pdf ebook Giải Mã Hoóc-Môn Dopamine PDF EPUB Ebooks Nhóm Zalo An imprint of Penguin Random House LLC penguinrandomhouse.com Copyright © 2021 by Anna Lembke Penguin supports copyright. Copyright fuels creativity, encourages diverse voices, promotes free speech, and creates a vibrant culture. Thank you for buying an authorized edition of this book and for complying with copyright laws by not reproducing, scanning, or distributing any part of it in any form without permission. You are supporting writers and allowing Penguin to continue to publish books for every reader. DUTTON and the D colophon are registered trademarks of Penguin Random House LLC. library of congress cataloging-in-publication data Names: Lembke, Anna, 1967- author. Title: Dopamine nation : finding balance in the age of indulgence / Anna Lembke, M.D. Description: New York : Dutton, [2021] | Includes bibliographical references and index. Identifiers: LCCN 2020041077 (print) | LCCN 2020041078 (ebook) | ISBN 9781524746728 (hardcover) | ISBN 9781524746735 (ebook) Subjects: LCSH: Pleasure. | Pain. | Compulsive behavior. | Internet—Social aspects. | Substance abuse. Classification: LCC BF515 .L46 2020 (print) | LCC BF515 (ebook) | DDC 152.4/2—dc23 LC record available at https://lccn.loc.gov/2020041077 LC ebook record available at https://lccn.loc.gov/2020041078 book design by lorie pagnozzi, adapted for ebook by estelle malmed While the author has made every effort to provide accurate telephone numbers, internet addresses, and other contact information at the time of publication, neither the publisher nor the author assumes any responsibility for errors or for changes that occur after publication. Further, the publisher does not have any control over and does not assume any responsibility for author or third-party websites or their content. Neither the publisher nor the author is engaged in rendering professional advice or services to the individual reader. The ideas, procedures, and suggestions contained in this book are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision. Neither the author nor the publisher shall be liable or responsible for any loss or damage allegedly arising from any information or suggestion in this book. pid_prh_5.7.1_c0_r0 For Mary, James, Elizabeth, Peter, and little Lucas CONTENTS Introduction The Problem PART I The Pursuit of Pleasure chapter one: Our Masturbation Machines chapter two: Running from Pain chapter three: The Pleasure-Pain Balance PART II Self-Binding chapter four: Dopamine Fasting chapter five: Space, Time, and Meaning chapter six: A Broken Balance? PART III The Pursuit of Pain chapter seven: Pressing on the Pain Side chapter eight: Radical Honesty chapter nine: Prosocial Shame Conclusion Lessons of the Balance Author’s Note Notes Bibliography Acknowledgments Index INTRODUCTION The Problem Feelin’ good, feelin’ good, all the money in the world spent on feelin’ good. —LEVON HELM T his book is about pleasure. It’s also about pain. Most important, it’s about the relationship between pleasure and pain, and how understanding that relationship has become essential for a life well lived. Why? Because we’ve transformed the world from a place of scarcity to a place of overwhelming abundance: Drugs, food, news, gambling, shopping, gaming, texting, sexting, Facebooking, Instagramming, YouTubing, tweeting . . . the increased numbers, variety, and potency of highly rewarding stimuli today is staggering. The smartphone is the modern-day hypodermic needle, delivering digital dopamine 24/7 for a wired generation. If you haven’t met your drug of choice yet, it’s coming soon to a website near you. Scientists rely on dopamine as a kind of universal currency for measuring the addictive potential of any experience. The more dopamine in the brain’s reward pathway, the more addictive the experience. In addition to the discovery of dopamine, one of the most remarkable neuroscientific findings in the past century is that the brain processes pleasure and pain in the same place. Further, pleasure and pain work like opposite sides of a balance. We’ve all experienced that moment of craving a second piece of chocolate, or wanting a good book, movie, or video game to last forever. That moment of wanting is the brain’s pleasure balance tipped to the side of pain. This book aims to unpack the neuroscience of reward and, in so doing, enable us to find a better, healthier balance between pleasure and pain. But neuroscience is not enough. We also need the lived experience of human beings. Who better to teach us how to overcome compulsive overconsumption than those most vulnerable to it: people with addiction. This book is based on true stories of my patients falling prey to addiction and finding their way out again. They’ve given me permission to tell their stories so that you might benefit from their wisdom, as I have. You may find some of these stories shocking, but to me they are just extreme versions of what we are all capable of. As philosopher and theologian Kent Dunnington wrote, “Persons with severe addictions are among those contemporary prophets that we ignore to our own demise, for they show us who we truly are.” Whether it’s sugar or shopping, voyeuring or vaping, social media posts or The Washington Post, we all engage in behaviors we wish we didn’t, or to an extent we regret. This book offers practical solutions for how to manage compulsive overconsumption in a world where consumption has become the all-encompassing motive of our lives. In essence, the secret to finding balance is combining the science of desire with the wisdom of recovery. PART I The Pursuit of Pleasure CHAPTER 1 Our Masturbation Machines I went to greet Jacob in the waiting room. First impression? Kind. He was in his early sixties, middleweight, face soft but handsome . . . aging well enough. He wore the standard-issue Silicon Valley uniform: khakis and a casual button-down shirt. He looked unremarkable. Not like someone with secrets. As Jacob followed me through the short maze of hallways, I could feel his anxiety like waves rolling off my back. I remembered when I used to get anxious walking patients back to my office. Am I walking too fast? Am I swinging my hips? Does my ass look funny? It seems so long ago now. I admit I’m a battle-hardened version of my former self, more stoic, possibly more indifferent. Was I a better doctor then, when I knew less and felt more? We arrived at my office and I shut the door behind him. Gently, I offered him one of two identical, equal-in-height, two-feet-apart, green-cushioned, therapy-sanctioned chairs. He sat. So did I. His eyes took in the room. My office is ten by fourteen feet, with two windows, a desk with a computer, a sideboard covered with books, and a low table between the chairs. The desk, the sideboard, and the low table are all made of matching reddish-brown wood. The desk is a hand-me-down from my former department chair. It’s cracked down the middle on the inside, where no one else can see it, an apt metaphor for the work I do. On top of the desk are ten separate piles of paper, perfectly aligned, like an accordion. I am told this gives the appearance of organized efficiency. The wall décor is a hodgepodge. The requisite diplomas, mostly unframed. Too lazy. A drawing of a cat I found in my neighbor’s garbage, which I took for the frame but kept for the cat. A multicolored tapestry of children playing in and around pagodas, a relic from my time teaching English in China in my twenties. The tapestry has a coffee stain, but it’s only visible if you know what you’re looking for, like a Rorschach. On display is an assortment of knickknacks, mostly gifts from patients and students. There are books, poems, essays, artwork, postcards, holiday cards, letters, cartoons. One patient, a gifted artist and musician, gave me a photograph he had taken of the Golden Gate Bridge overlaid with his hand drawn musical notes. He was no longer suicidal when he made it, yet it’s a mournful image, all grays and blacks. Another patient, a beautiful young woman embarrassed by wrinkles that only she saw and no amount of Botox could erase, gave me a clay water pitcher big enough to serve ten. To the left of my computer, I keep a small print of Albrecht Dürer’s Melencolia 1. In the drawing, Melancholia personified as a woman sits stooped on a bench surrounded by the neglected tools of industry and time: a caliper, a scale, an hourglass, a hammer. Her starving dog, ribs protruding from his sunken frame, waits patiently and in vain for her to rouse herself. To the right of my computer, a five-inch clay angel with wings wrought from wire stretches her arms skyward. The word courage is engraved at her feet. She’s a gift from a colleague who was cleaning out her office. A leftover angel. I’ll take it. I’m grateful for this room of my own. Here, I am suspended out of time, existing in a world of secrets and dreams. But the space is also tinged with sadness and longing. When my patients leave my care, professional boundaries forbid that I contact them. As real as our relationships are inside my office, they cannot exist outside this space. If I see my patients at the grocery store, I’m hesitant even to say hello lest I declare myself a human being with needs of my own. What, me eat? Years ago, when I was in my psychiatry residency training, I saw my psychotherapy supervisor outside his office for the first time. He emerged from a shop wearing a trench coat and an Indiana Jones– style fedora. He looked like he’d just stepped off the cover of a J. Peterman catalogue. The experience was jarring. I’d shared many intimate details of my life with him, and he had counseled me as he would a patient. I had not thought of him as a hat person. To me, it suggested a preoccupation with personal appearance that was at odds with the idealized version I had of him. But most of all, it made me aware of how disconcerting it might be for my own patients to see me outside my office. I turned to Jacob and began. “What can I help you with?” Other beginnings I’ve evolved over time include: “Tell me why you’re here,” “What brings you in today?” and even “Start at the beginning, wherever that is for you.” Jacob looked me over. “I am hoping,” he said in a thick Eastern European accent, “you would be a man.” I knew then we would be talking about sex. “Why?” I asked, feigning ignorance. “Because it might be hard for you, a woman, to hear about my problems.” “I can assure you I’ve heard almost everything there is to hear.” “You see,” he stumbled, looking shyly at me, “I have the sex addiction.” I nodded and settled into my chair. “Go on . . .” Every patient is an unopened package, an unread novel, an unexplored land. A patient once described to me how rock climbing feels: When he’s on the wall, nothing exists but infinite rock face juxtaposed against the finite decision of where next to put each finger and toe. Practicing psychotherapy is not unlike rock climbing. I immerse myself in story, the telling and retelling, and the rest falls away. I’ve heard many variations on the tales of human suffering, but Jacob’s story shocked me. What disturbed me most was what it implied about the world we live in now, the world we’re leaving to our children. Jacob started right in with a childhood memory. No preamble. Freud would have been proud. “I masturbated first time when I was two or three years old,” he said. The memory was vivid for him. I could see it on his face. “I am on the moon,” he continued, “but it is not really the moon. There is a person there like a god . . . and I have sexual experience which I don’t recognize . . .” I took moon to mean something like the abyss, nowhere and everywhere simultaneously. But what of God? Aren’t we all yearning for something beyond ourselves? As a young schoolboy, Jacob was a dreamer: buttons out of order, chalk on his hands and sleeves, the first to look out the window during lessons, and the last to leave the classroom for the day. He masturbated regularly by the time he was eight years old. Sometimes alone, sometimes with his best friend. They had not yet learned to be ashamed. But after his First Communion, he was awakened to the idea of masturbation as a “mortal sin.” From then on, he only masturbated alone, and he visited the Catholic priest of his family’s local church every Friday to confess. “I masturbate,” he whispered through the latticed opening of the confessional. “How many times?” asked the priest. “Every day.” Pause. “Don’t do it again.” Jacob stopped talking and looked at me. We shared a small smile of understanding. If such straightforward admonitions solved the problem, I would be out of a job. Jacob the boy was determined to obey, to be “good,” and so he clenched his fists and didn’t touch himself there. But his resolve only ever lasted two or three days. “That,” he said, “was the beginning of my double life.” The term double life is as familiar to me as ST segment elevation is to the cardiologist, stage IV is to the oncologist, and hemoglobin A1C is to the endocrinologist. It refers to the addicted person’s secret engagement with drugs, alcohol, or other compulsive behaviors, hidden from view, even in some cases from their own. Throughout his teens, Jacob returned from school, went to the attic, and masturbated to a drawing of the Greek goddess Aphrodite he had copied from a textbook and hidden between the wooden floorboards. He would later look on this period of his life as a time of innocence. At eighteen he moved to live with his older sister in the city to study physics and engineering at the university there. His sister was gone much of the day working, and for the first time in his life, he was alone for long stretches. He was lonely. “So I decided to make a machine . . .” “A machine?” I asked, sitting up a little straighter. “A masturbation machine.” I hesitated. “I see. How did it work?” “I connect a metal rod to a record player. The other end I connect to an open metal coil, which I wrap with a soft cloth.” He drew a picture to show me. “I put the cloth and the coil around my penis,” he said, pronouncing penis as if it were two words: pen like the writing instrument, and ness like the Loch Ness Monster. I had an urge to laugh but, after a moment’s reflection, realized the urge was a cover for something else: I was afraid. Afraid that after inviting him to reveal himself to me, I wouldn’t be able to help him. “As the record player move round and round,” he said, “the coil go up and down. I adjust the speed of the coil by adjusting the speed of the record player. I have three different speeds. In this way, I bring myself to the edge . . . many times, without going over. I also learn that smoking a cigarette at the same time brings me back from the edge, so I use this trick.” Through this method of microadjustments, Jacob was able to maintain a preorgasm state for hours. “This,” he said, nodding, “very addictive.” Jacob masturbated for several hours a day using his machine. The pleasure for him was unrivaled. He swore he would stop. He hid the machine high up in a closet or dismantled it completely and threw away the parts. But a day or two later, he was pulling the parts down from the closet or out of the trash can, only to reassemble them and start again. — Perhaps you are repulsed by Jacob’s masturbation machine, as I was when I first heard about it. Perhaps you regard it as a kind of extreme perversion that is beyond everyday experience, with little or no relevance to you and your life. But if we do that, you and I, we miss an opportunity to appreciate something crucial about the way we live now: We are all, of a sort, engaged with our own masturbation machines. Circa age forty, I developed an unhealthy attachment to romance novels. Twilight, a paranormal romance about teenage vampires, was my gateway drug. I was embarrassed enough to be reading it, much less admitting I was enthralled by it. Twilight hit that sweet spot between love story, thriller, and fantasy, the perfect escape as I rounded the corner of my midlife bend. I was not alone. Millions of women my age were reading and fanning Twilight. There was nothing unusual per se about my getting caught up in a book. I’ve been a reader all my life. What was different was what happened next. Something I couldn’t account for based on past proclivities or life circumstance. When I finished Twilight, I ripped through every vampire romance I could get my hands on, and then moved on to werewolves, fairies, witches, necromancers, time travelers, soothsayers, mind readers, fire wielders, fortune-tellers, gem workers . . . you get the idea. At some point, tame love stories no longer satisfied, so I searched out increasingly graphic and erotic renditions of the classic boy-meets girl fantasy. I remember being shocked at how easy it was to find graphic sex scenes right there on the general fiction shelves at my neighborhood library. I worried that my kids had access to these books. The raciest thing at my local library growing up in the Midwest was Are You There, God? It’s Me, Margaret. Things escalated when, at the urging of my tech-savvier friend, I got a Kindle. No more waiting for books to be delivered from another library branch or hiding steamy book jackets behind medical journals, especially when my husband and kids were around. Now, with two swipes and a click, I had any book I wanted instantly, anywhere, anytime: on the train, on a plane, waiting to get my hair cut. I could just as easily pass off Darkfever, by Karen Marie Moning, as Crime and Punishment by Dostoyevsky. In short, I became a chain reader of formulaic erotic genre novels. As soon as I finished one e-book, I moved on to the next: reading instead of socializing, reading instead of cooking, reading instead of sleeping, reading instead of paying attention to my husband and my kids. Once, I’m ashamed to admit, I brought my Kindle to work and read between patients. I looked for ever-cheaper options all the way down to free. Amazon, like any good drug dealer, knows the value of a free sample. Once in a while I found a book of real quality that happened to be cheap; but most of the time, they were truly terrible, relying on worn-out plot devices and lifeless characters, chock-full of typos and grammatical errors. But I read them anyway because I was increasingly looking for a very specific type of experience. How I got there mattered less and less. I wanted to indulge in that moment of mounting sexual tension that finally gets resolved when the hero and heroine hook up. I no longer cared about syntax, style, scene, or character. I just wanted my fix, and these books, written according to a formula, were designed to hook me. Every chapter ended on a note of suspense, and the chapters themselves built toward the climax. I started rushing through the first part of the book until I got to the climax and didn’t bother to read the rest after it was done. I am now sadly in possession of the knowledge that if you open any romance novel to approximately three-quarters of the way through, you can get right to the point. About a year into my new obsession with romance, I found myself up at 2:00 a.m. on a weeknight reading Fifty Shades of Grey. I rationalized it was a modern-day telling of Pride and Prejudice—right up until I got to the page on “butt plugs” and had a flash of insight that reading about sadomasochistic sex toys in the wee hours of the morning was not how I wanted to be spending my time. 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. What happened to me is trivial compared to the lives of those with overpowering addiction, but it speaks to the growing problem of compulsive overconsumption that we all face today, even when our lives are good. I have a kind and loving husband, great kids, meaningful work, freedom, autonomy, and relative wealth—no trauma, social dislocation, poverty, unemployment, or other risk factors for addiction. Yet I was compulsively retreating further and further into a fantasy world. The Dark Side of Capitalism At age twenty-three, Jacob met and married his wife. They moved together into the three-room apartment she shared with her parents, and he left his machine behind—forever, he hoped. He and his wife registered to get an apartment of their own but were told the wait would be twenty-five years. This was typical in the 1980s in the Eastern European country where they lived. Instead of consigning themselves to decades of living with her parents, they decided to earn extra money on the side to buy their own place sooner. They started a computer business importing machines from Taiwan, joining the growing underground economy. Their business prospered, and they soon became rich by local standards. They acquired a house and plot of land. They had two children, a son and a daughter. Their upward trajectory seemed assured when Jacob was offered a job working as a scientist in Germany. They jumped at the chance to move west, further his career, and provide their children with all the opportunities that Western Europe could offer. The move offered opportunities all right, not all of them good. “Once we move to Germany, I discover pornography, porn-kinos, live shows. This town I live in is known for this, and I cannot resist. But I manage. I manage for ten years. I am working as a scientist, working hard, but in 1995, everything change.” “What changed?” I asked, already guessing the answer. “The Internet. I am forty-two years old, and doing okay, but with the Internet, my life start to fall apart. Once in 1999, I am in same hotel room I stay in maybe fifty times before. I have big conference, big talk the next day. But I stay up all night watching porn instead of preparing my talk. I show up at the conference with no sleep and no talk. I give a speech, very bad. I almost lose my job.” He looked down and shook his head, remembering. “After that I start a new ritual,” he said. “Every time I go into hotel room, I place sticky notes all around—on the bathroom mirror, the TV, the remote control—saying, ‘Don’t do it.’ I don’t even last one day.” I was struck by how much hotel rooms are like latter-day Skinner boxes: a bed, a TV, and a minibar. Nothing to do but press the lever for drug. He looked down again and the silence stretched. I gave him time. “That was when I first think about ending my life. I think the world will not miss me, and maybe better without me. I walk to the balcony and look down. Four stories . . . that would be enough.” — 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’re more likely to try it. In trying it, we’re more likely to get addicted to it. The current US opioid epidemic is a tragic and compelling example of this fact. The quadrupling of opioid prescribing (OxyContin, Vicodin, Duragesic fentanyl) in the United States between 1999 and 2012, combined with widespread distribution of those opioids to every corner of America, led to rising rates of opioid addiction and related deaths. A task force appointed by the Association of Schools and Programs of Public Health (ASPPH) issued a report on November 1, 2019, concluding, “The tremendous expansion of the supply of powerful (high-potency as well as long-acting) prescription opioids led to scaled increases in prescription opioid dependence, and the transition of many to illicit opioids, including fentanyl and its analogs, which have subsequently driven exponential increases in overdose.” The report also stated that opioid use disorder “is caused by repeated exposure to opioids.” Likewise, decreasing the supply of addictive substances decreases exposure and risk of addiction and related harms. A natural experiment in the last century to test and prove this hypothesis was Prohibition, a nationwide constitutional ban on the production, importation, transportation, and sale of alcoholic beverages in the United States from 1920 to 1933. Prohibition led to a sharp decrease in the number of Americans consuming and becoming addicted to alcohol. Rates of public drunkenness and alcohol-related liver disease decreased by half during this period in the absence of new remedies to treat addiction. There were unintended consequences, of course, such as the creation of a large black market run by criminal gangs. But the positive impact of Prohibition on alcohol consumption and related morbidity is widely underrecognized. The reduced drinking effects of Prohibition persisted through the 1950s. Over the subsequent thirty years, as alcohol became more available again, consumption steadily increased. In the 1990s, the percentage of Americans who drank alcohol increased by almost 50 percent, while high-risk drinking increased by 15 percent. Between 2002 and 2013, diagnosable alcohol addiction rose by 50 percent in older adults (over age sixty-five) and 84 percent in women, two demographic groups who had previously been relatively immune to this problem. To be sure, increased access is not the only risk for addiction. The risk increases if we have a biological parent or grandparent with addiction, even when we’re raised outside the addicted home. Mental illness is a risk factor, although the relationship between the two is unclear: Does the mental illness lead to drug use, does drug use cause or unmask mental illness, or is it somewhere in between? Trauma, social upheaval, and poverty contribute to addiction risk, as drugs become a means of coping and lead to epigenetic changes —heritable changes to the strands of DNA outside of inherited base pairs—affecting gene expression in both an individual and their offspring. These risk factors notwithstanding, increased access to addictive substances may be the most important risk factor facing modern people. Supply has created demand as we all fall prey to the vortex of compulsive overuse. 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. The cigarette-rolling machine invented in 1880, for example, made it possible to go from four cigarettes rolled per minute to a staggering 20,000. Today, 6.5 trillion cigarettes are sold annually around the world, translating to roughly 18 billion cigarettes consumed per day, responsible for an estimated 6 million deaths worldwide. In 1805, the German Friedrich Sertürner, while working as a pharmacist’s apprentice, discovered the painkiller morphine—an opioid alkaloid ten times more potent than its precursor opium. In 1853, the Scottish physician Alexander Wood invented the hypodermic syringe. Both of these inventions contributed to hundreds of reports in late-nineteenth-century medical journals of iatrogenic (physician-initiated) cases of morphine addiction. In an attempt to find a less addictive opioid painkiller to replace morphine, chemists came up with a brand-new compound, which they named “heroin” for heroisch, the German word for “courageous.” Heroin turned out to be two to five times more potent than morphine and gave way to the narcomania of the early 1900s. Today, potent pharmaceutical-grade opioids such as oxycodone, hydrocodone, and hydromorphone are available in every imaginable form: pills, injection, patch, nasal spray. In 2014, a middle-aged patient walked into my office sucking on a bright red fentanyl lollipop. Fentanyl, a synthetic opioid, is fifty to one hundred times more potent than morphine. Beyond opioids, many other drugs are also more potent today than in yesteryear. Electronic cigarettes—chic, discreet, odorless, rechargeable nicotine delivery systems—lead to higher levels of blood nicotine over shorter periods of consumption than traditional cigarettes. They also come in a multitude of flavors designed to appeal to teenagers. Today’s cannabis is five to ten times more potent than the cannabis of the 1960s and is available in cookies, cakes, brownies, gummy bears, blueberries, “pot tarts,” lozenges, oils, aromatics, tinctures, teas . . . the list is endless. Food is manipulated by technicians around the world. Following World War I, the automation of chip and fry production lines led to the creation of the bagged potato chip. In 2014, Americans consumed 112.1 pounds of potatoes per person, of which 33.5 pounds were fresh potatoes and the remaining 78.5 pounds were processed. Copious amounts of sugar, salt, and fat are added to much of the food we eat, as well as thousands of artificial flavors to satisfy our modern appetite for things like French toast ice cream and Thai tomato coconut bisque. With increasing access and potency, polypharmacy—that is, using multiple drugs simultaneously or in close proximity—has become the norm. My patient Max found it easier to draw out a timeline of his drug use than to explain it to me. As you can see in his illustration, he started at age seventeen with alcohol, cigarettes, and cannabis (“Mary Jane”). By age eighteen, he was snorting cocaine. At age nineteen, he switched to OxyContin and Xanax. Through his twenties, he used Percocet, fentanyl, ketamine, LSD, PCP, DXM, and MXE, eventually landing on Opana, a pharmaceutical-grade opioid that led him to heroin, where he stayed until he came to see me at age thirty. In total, he went through fourteen different drugs in a little over a decade. 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. DRUG USE TIMELINE Furthermore, the technology itself is addictive, with its flashing lights, musical fanfare, bottomless bowls, and the promise, with ongoing engagement, of ever-greater rewards. My own progression from a relatively tame vampire romance novel to what amounts to socially sanctioned pornography for women can be traced to the advent of the electronic reader. The act of consumption itself has become a drug. My patient Chi, a Vietnamese immigrant, got hooked on the cycle of searching for and buying products online. The high for him began with deciding what to buy, continued through anticipating delivery, and culminated in the moment he opened the package. Unfortunately, the high didn’t last much beyond the time it took him to rip off the Amazon tape and see what was inside. He had rooms full of cheap consumer goods and was tens of thousands of dollars in debt. Even then, he couldn’t stop. To keep the cycle going, he resorted to ordering ever-cheaper goods—key chains, mugs, plastic sunglasses—and returning them immediately upon arrival. The Internet and Social Contagion Jacob decided not to end his life that day in the hotel. The very next week, his wife was diagnosed with brain cancer. They returned to their home country and he spent the next three years taking care of her until she died. In 2001, at age forty-nine, he reconnected with and married his high school sweetheart. “I tell her before we marry about my problem. But maybe I minimize when I tell her.” Jacob and his new wife bought a home together in Seattle. Jacob commuted to a job as a scientist in Silicon Valley. The more time he spent in Silicon Valley and away from his wife, the more he returned to old patterns of pornography and compulsive masturbation. “I never do pornography when we are together. But when I am here in Silicon Valley or traveling, and she is not with me, then I do.” Jacob paused. What came next was clearly difficult for him to talk about. “Sometimes when I play with electricity, in my job, I can feel something in my hands. I am curious. I begin to wonder what it would feel like to touch my penis with a current. So I start to research online, and I discover a whole community of people using electrical stimulation. “I attach electrodes and wires to my stereo system. I try an alternating current using the voltage from the stereo system. Then instead of simple wire, I attach electrodes made of cotton in salty water. The higher the volume on the stereo, the higher the current. At low volume, I feel nothing. At higher volume, it is painful. In between, I can orgasm from the sensation.” My eyes got wide. I couldn’t help it. “But this very dangerous,” he continued. “I realize if a power outage, this could lead to power surge, and then I could get hurt. People have died doing this. Online I learn I can buy a medical kit, like a . . . what do you call them, those machines to treat pain . . .” “A TENS unit?” “Yes, a TENS unit, for six hundred dollars, or I can make my own for twenty dollars. I decide to make my own. I buy the material. I make the machine. It works. It works well.” He paused. “But then the real discovery. I can program it. I can create custom routines and synchronize the music with the feeling.” “What kinds of routines?” “Hand job, blow job. You name it. And then I discover not just my routines. I go online and download other people’s routines, and share mine. Some people write programs to sync up with porn videos, so you feel what you’re watching . . . just like virtual reality. The pleasure, it comes from the sensation of course, but also from building the machine, and anticipating what it will do, and experimenting with ways to improve it, and sharing with others.” He smiled, remembering, just before his face fell, anticipating what came next. Scrutinizing me, I could tell he was gauging whether I could take it. I braced myself and nodded for him to go on. “It gets worse. There are chat rooms where you can watch people pleasure themselves, live. It’s free to watch, but option to buy tokens. I give tokens for good performance. I film myself and put online. Just my private parts. No other part of me. It is exhilarating at first, having strangers watch me. But I feel guilty too, that watching would give others the idea, and they might get addicted.” — In 2018, I served as a medical expert witness in the case of a man who plowed his truck into two teenagers, killing both. He was driving under the influence of drugs. As part of that litigation, I spent time talking to Detective Vince Dutto, a lead crime investigator in Placer County, California, where the trial took place. Curious about his work, I asked him about any changes in patterns he’d seen over the last twenty years. He told me about the tragic case of a six-year-old boy who sodomized his younger, four-year-old brother. “Normally, when we get these calls,” he said, “it’s because some adult the child has contact with is sexually abusing him, and then the kid reenacts it on another kid, like his little brother. But we did a thorough investigation and there was no evidence the older brother was being abused. His parents were divorced and worked a lot, so the kids were kind of raising themselves, but there was no active sexual abuse going on. “What eventually came out in this case was the older brother had been watching cartoons on the Internet and stumbled across some Japanese anime cartoon showing all kinds of sex acts. The kid had his own iPad, and no one was policing what he was doing, and after watching a bunch of these cartoons, he decided to try it out on his little brother. Now, that kind of thing, in more than twenty years of police work, I’ve never seen before.” The Internet promotes compulsive overconsumption not merely by providing increased access to drugs old and new, but also by suggesting behaviors that otherwise may never have occurred to us. Videos don’t just “go viral.” They’re literally contagious, hence the advent of the meme. Human beings are social animals. When we see others behaving in a certain way online, those behaviors seem “normal” because other people are doing them. “Twitter” is an apt name for the social media messaging platform favored by pundits and presidents alike. We are like flocks of birds. No sooner has one of us raised a wing in flight than the entire flock of us is rising into the air. — Jacob looked down at his hands. He couldn’t meet my eyes. “Then I meet a lady in this chat room. She like to dominate men. I introduce her into the electrical stuff, and then I give her the ability to control the electricity remotely: frequency, volume, structure of the pulses. She likes to bring me to the edge, and then let me not go over. She does this ten times, and other people watch, and make comments. We develop the friendship, this lady and I. She never wants to show her face. But I saw her once, by accident, when her camera fell for a moment.” “How old was she?” I asked. “In her forties, I guess . . .” I wanted to ask what she looked like but sensed my own prurient curiosity at play here, rather than his therapeutic needs, so I refrained. Jacob said, “My wife discover all this, and she say she will leave me. I promise to stop. I tell my lady friend online I am quitting. My lady friend very angry. My wife very angry. I hate myself then. I stop for a while. Maybe a month. But then I start up again. Just me and my machine, not the chat rooms. I lie to my wife, but eventually she discover. Her therapist tell her to leave me. So my wife, she leave me. She move to our house in Seattle, and now I am alone.” Shaking his head, he said, “It never as good as I imagine. The reality always less. I tell myself never again, and I destroy the machine and throw it away. But at four a.m. the next morning, I am getting it from the trash and building it again.” Jacob looked at me with pleading eyes. “I want to stop. I want to. I don’t want to die an addict.” I’m not sure what to say. I imagine him attached by his genitals through the Internet to a room full of strangers. I feel horror, compassion, and a vague and disquieting sense that it could have been me. — Not unlike Jacob, we are all at risk of titillating ourselves to death. Seventy percent of world global deaths are attributable to modifiable behavioral risk factors like smoking, physical inactivity, and diet. The leading global risks for mortality are high blood pressure (13 percent), tobacco use (9 percent), high blood sugar (6 percent), physical inactivity (6 percent), and obesity (5 percent). In 2013, an estimated 2.1 billion adults were overweight, compared with 857 million in 1980. There are now more people worldwide, except in parts of sub-Saharan Africa and Asia, who are obese than who are underweight. Rates of addiction are rising the world over. The disease burden attributed to alcohol and illicit drug addiction is 1.5 percent globally, and more than 5 percent in the United States. These data exclude tobacco consumption. Drug of choice varies by country. The US is dominated by illicit drugs, Russia and Eastern Europe by alcohol addiction. 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 fifty years of age. The poor and undereducated, especially those living in rich nations, are most susceptible to the problem of compulsive overconsumption. They have easy access to high-reward, high potency, high-novelty drugs at the same time that they lack access to meaningful work, safe housing, quality education, affordable health care, and race and class equality before the law. This creates a dangerous nexus of addiction risk. Princeton economists Anne Case and Angus Deaton have shown that middle-aged white Americans without a college degree are dying younger than their parents, grandparents, and great grandparents. The top three leading causes of death in this group are drug overdoses, alcohol-related liver disease, and suicides. Case and Deaton have aptly called this phenomenon “deaths of despair.” Our compulsive overconsumption risks not just our demise but also that of our planet. The world’s natural resources are rapidly diminishing. Economists estimate that in 2040 the world’s natural capital (land, forests, fisheries, fuels) will be 21 percent less in high income countries and 17 percent less in poorer countries than today. Meanwhile, carbon emissions will grow by 7 percent in high-income countries and 44 percent in the rest of the world. We are devouring ourselves. CHAPTER 2 Running from Pain I met David in 2018. He was physically unremarkable: white, medium build, brown hair. He had an uncertainty about him that made him seem younger than the thirty-five years documented in the medical record. I found myself thinking, He won’t last. He’ll come back to clinic once or twice and I’ll never see him again. But I’ve learned my powers of prognostication are unreliable. I’ve had patients I was convinced I could help who proved to be intractable, and others I deemed hopeless who were surprisingly resilient. Hence, when seeing new patients now, I try to quiet that doubting voice and remember that everyone’s got a shot at recovery. “Tell me what brings you in,” I said. David’s problems began in college, but more precisely the day he walked into student mental health services. He was a twenty-year old sophomore undergraduate in upstate New York looking for help with anxiety and poor school performance. His anxiety was triggered by interacting with strangers, or anyone he didn’t know well. His face would flush, his chest and back would get damp, and his thoughts would get jumbled. He avoided classes where he had to speak in front of others. He dropped out of a required speech and communications seminar twice, eventually fulfilling the requirement by taking an equivalent class at community college. “What were you afraid of?” I asked. “I was afraid to fail. I was afraid to be exposed as not knowing. I was afraid to ask for help.” After a forty-five-minute appointment and a pencil-and-paper test that took less than five minutes to complete, he was diagnosed with attention deficit disorder (ADD) and generalized anxiety disorder (GAD). The psychologist who administered the test recommended he follow up with a psychiatrist to prescribe an antianxiety medication and, David said, a “stimulant for my ADD.” He was not offered psychotherapy or other nonmedication behavioral modification. David went to see a psychiatrist, who prescribed Paxil, a selective serotonin reuptake inhibitor to treat depression and anxiety, and Adderall, a stimulant to treat ADD. “So how did it go for you—the meds, I mean?” “The Paxil helped with the anxiety a little at first. It dampened down some of the worst sweating, but it wasn’t a cure. I ended up changing my major from computer engineering to computer science, thinking that would help. It required less interaction. “But because I wasn’t able to speak up and say I didn’t know, I failed an exam. Then I failed the next one. Then I dropped out for a semester not to take a hit on my grade point average. Eventually, I switched out of the school of engineering altogether, which was really sad because it was what I loved and really wanted to do. I became a history major: The classes were smaller, only twenty people, and I could get away with being less interactive. I could take the blue book home and work by myself.” “What about the Adderall?” I asked. “I’d take ten milligrams first thing every morning before class. It helped me get that deep focus. But looking back, I think I just had bad study habits. Adderall helped me make up for that, but it also helped me procrastinate. If there was a test and I hadn’t studied, I’d take Adderall around the clock, all through the day and night, to cram for the exam. Then it got to where I couldn’t study without it. Then I started needing more.” I wondered how hard it had been for him to acquire additional pills. “Was it hard to get more?” “Not really,” he said. “I always knew when a refill was due. I’d call the psychiatrist a few days before. Not a lot of days before, just one or two, so they wouldn’t get suspicious. Actually, I’d run out like . . . ten days before, but if I called a few days before, they’d refill it right then. I also learned it was better to talk to the P.A., the physician’s assistant. They’d be more likely to refill without asking too many questions. Sometimes I’d make up excuses, like say there was a problem with the mail-order pharmacy. But most of the time I didn’t have to.” “It sounds like the pills weren’t really helping.” David paused. “In the end, it came down to comfort. It was easier to take a pill than feel the pain.” — In 2016, I gave a presentation on drug and alcohol problems to faculty and staff at the Stanford student mental health clinic. It had been some months since I’d been to that part of campus. I arrived early and, while I waited in the front lobby to meet my contact, my attention was drawn to a wall of brochures for the taking. There were four brochures in all, each with some variation of the word happiness in the title: The Habit of Happiness, Sleep Your Way to Happiness, Happiness Within Reach, and 7 Days to a Happier You. Inside each brochure were prescriptions for achieving happiness: “List 50 things that make you happy,” “Look at yourself in the mirror [and] list things you love about yourself in your journal,” and “Produce a stream of positive emotions.” Perhaps most telling of all: “Optimize timing and variety of happiness strategies. Be intentional about when and how often. For acts of kindness: Self-experiment to determine whether performing many good deeds in one day or one act each day is most effective for you.” These brochures illustrate how the pursuit of personal happiness has become a modern maxim, crowding out other definitions of the “good life.” Even acts of kindness toward others are framed as a strategy for personal happiness. Altruism, no longer merely a good in itself, has become a vehicle for our own “well-being.” Philip Rieff, a mid-twentieth-century psychologist and philosopher, foresaw this trend in The Triumph of the Therapeutic: Uses of Faith After Freud: “Religious man was born to be saved; psychological man is born to be pleased.” Messages exhorting us to pursue happiness are not limited to the realm of psychology. Modern religion too promotes a theology of self-awareness, self-expression, and self-realization as the highest good. In his book Bad Religion, writer and religious scholar Ross Douthat describes our New Age “God Within” theology as “a faith that’s at once cosmopolitan and comforting, promising all the pleasures of exoticism . . . without any of the pain . . . a mystical pantheism, in which God is an experience rather than a person. . . . It’s startling how little moral exhortation there is in the pages of the God Within literature. There are frequent calls to ‘compassion’ and ‘kindness,’ but little guidance for people facing actual dilemmas. And what guidance there is often amounts to ‘if it feels good, do it.’ ” My patient Kevin, nineteen years old, was brought to see me by his parents in 2018. Their concerns were the following: He wouldn’t go to school, couldn’t keep a job, and wouldn’t follow any of the household rules. His parents were as imperfect as the rest of us, but they were trying hard to help him. There was no evidence of abuse or neglect. The problem was they seemed unable to put any constraints on him. They worried that by making demands, they would “stress him out” or “traumatize him.” Perceiving children as psychologically fragile is a quintessentially modern concept. In ancient times, children were considered miniature adults, fully formed from birth. For most of Western civilization, children were regarded as innately evil. The job of parents and caregivers was to enforce extreme discipline in order to socialize them to live in the world. It was entirely acceptable to use corporal punishment and fear tactics to get a child to behave. No longer. Today, many parents I see are terrified of doing or saying something that will leave their child with an emotional scar, thereby setting them up, so the thinking goes, for emotional suffering and even mental illness in later life. This notion can be traced to Freud, whose groundbreaking psychoanalytic contribution was that early childhood experiences, even those long forgotten or outside of conscious awareness, can cause lasting psychological damage. Unfortunately, Freud’s insight that early childhood trauma can influence adult psychopathology has morphed into the conviction that any and every challenging experience primes us for the psychotherapy couch. Our efforts to insulate our children from adverse psychological experiences play out not just in the home but also in school. At the primary school level, every child receives some equivalent of the “Star of the Week” award—not for any particular accomplishment but in alphabetical order. Every child is taught to be on the lookout for bullies lest they become bystanders instead of upstanders. At the university level, faculty and students talk about triggers and safe spaces. That parenting and education are informed by developmental psychology and empathy is a positive evolution. We should acknowledge every person’s worth independent of achievement, stop physical and emotional brutality on the schoolyard and everywhere else, and create safe spaces to think, learn, and discuss. But I worry that we have both oversanitized and overpathologized childhood, raising our children in the equivalent of a padded cell, with no way to injure themselves but also no means to ready themselves for the world. By protecting our children from adversity, have we made them deathly afraid of it? By bolstering their self-esteem with false praise and a lack of real-world consequences, have we made them less tolerant, more entitled, and ignorant of their own character defects? By giving in to their every desire, have we encouraged a new age of hedonism? Kevin shared his life philosophy with me in one of our sessions. I must admit I was horrified. “I do whatever I want, whenever I want. If I want to stay in my bed, I stay in my bed. If I want to play video games, I play video games. If I want to snort a line of coke, I text my dealer, he drops it off, and I snort a line of coke. If I want to have sex, I go online and find someone and meet them and have sex.” “How’s that working out for you, Kevin?” I asked. “Not very well.” For a single instant he looked ashamed. Over the past three decades, I have seen growing numbers of patients like David and Kevin who appear to have every advantage in life—supportive families, quality education, financial stability, good health—yet develop debilitating anxiety, depression, and physical pain. Not only are they not functioning to their potential; they’re barely able to get out of bed in the morning. — The practice of medicine has likewise been transformed by our striving for a pain-free world. Prior to the 1900s, doctors believed some degree of pain was healthy. Leading surgeons of the 1800s were reluctant to adopt general anesthesia during surgery because they believed that pain boosted the immune and cardiovascular response and expedited healing. Although there’s no evidence I know of showing that pain in fact speeds up tissue repair, there is emerging evidence that taking opioids during surgery slows it down. The famous seventeenth-century physician Thomas Sydenham said this about pain: “I look upon every . . . effort calculated totally to subdue that pain and inflammation dangerous in the extreme. . . . For certainty a moderate degree of pain and inflammation in the extremities are the instruments which nature makes use of for the wisest purposes.” By contrast, doctors today are expected to eliminate all pain lest they fail in their role as compassionate healers. Pain in any form is considered dangerous, not just because it hurts but also because it’s thought to kindle the brain for future pain by leaving a neurological wound that never heals. The paradigm shift around pain has translated into massive prescribing of feel-good pills. Today, more than one in four American adults—and more than one in twenty American children—takes a psychiatric drug on a daily basis. The use of antidepressants like Paxil, Prozac, and Celexa is rising in countries all over the world, with the United States topping the list. Greater than one in ten Americans (110 people per 1,000) takes an antidepressant, followed by Iceland (106/1,000), Australia (89/1,000), Canada (86/1,000), Denmark (85/1,000), Sweden (79/1,000), and Portugal (78/1,000). Among twenty-five countries, Korea was last (13/1,000). Antidepressant use rose 46 percent in Germany in just four years, and 20 percent in Spain and Portugal during the same period. Although data for other Asian countries, including China, are not available, we can infer growing use of antidepressants by looking at sales trends. In China, sales of antidepressants reached $2.61 billion in 2011, up 19.5 percent from the previous year. Prescriptions of stimulants (Adderall, Ritalin) in the United States doubled between 2006 and 2016, including in children younger than five years old. In 2011, two-thirds of American children diagnosed with ADD were prescribed a stimulant. Prescriptions for sedative medications like benzodiazepines (Xanax, Klonopin, Valium), also addictive, are on the rise, perhaps to compensate for all those stimulants we’re taking. Between 1996 and 2013 in the United States, the number of adults who filled a benzodiazepine prescription increased by 67 percent, from 8.1 million to 13.5 million people. In 2012, enough opioids were prescribed for every American to have a bottle of pills, and opioid overdoses killed more Americans than guns or car accidents. Is it any wonder, then, that David assumed he should numb himself with pills? — Beyond extreme examples of running from pain, we’ve lost the ability to tolerate even minor forms of discomfort. We’re constantly seeking to distract ourselves from the present moment, to be entertained. As Aldous Huxley said in Brave New World Revisited, “the development of a vast mass communications industry, concerned in the main neither with the true nor the false, but with the unreal, the more or less totally irrelevant . . . failed to take into account man’s almost infinite appetite for distractions.” Along similar lines, Neil Postman, the author of the 1980s classic Amusing Ourselves to Death, wrote, “Americans no longer talk to each other, they entertain each other. They do not exchange ideas, they exchange images. They do not argue with propositions; they argue with good looks, celebrities, and commercials.” My patient Sophie, a Stanford undergraduate from South Korea, came in seeking help for depression and anxiety. Among the many things we talked about, she told me she spends most of her waking hours plugged into some kind of device: Instagramming, YouTubing, listening to podcasts and playlists. In session with her I suggested she try walking to class without listening to anything and just letting her own thoughts bubble to the surface. She looked at me both incredulous and afraid. “Why would I do that?” she asked, openmouthed. “Well,” I ventured, “it’s a way of becoming familiar with yourself. Of letting your experience unfold without trying to control it or run away from it. All that distracting yourself with devices may be contributing to your depression and anxiety. It’s pretty exhausting avoiding yourself all the time. I wonder if experiencing yourself in a different way might give you access to new thoughts and feelings, and help you feel more connected to yourself, to others, and to the world.” She thought about that for a moment. “But it’s so boring,” she said. “Yes, that’s true,” I said. “Boredom is not just boring. It can also be terrifying. It forces us to come face-to-face with bigger questions of meaning and purpose. But boredom is also an opportunity for discovery and invention. It creates the space necessary for a new thought to form, without which we’re endlessly reacting to stimuli around us, rather than allowing ourselves to be within our lived experience.” The next week, Sophie experimented with walking to class without being plugged in. “It was hard at first,” she said. “But then I got used to it and even kind of liked it. I started noticing the trees.” Lack of Self-Care or Mental Illness? Back to David, who was, in his own words, taking “Adderall around the clock.” After he graduated from college in 2005, he moved back in with his parents. He thought about going to law school, took the LSATs, and even did okay, but when it came down to applying, he didn’t feel like it. “I mostly sat on the couch and built up a lot of anger and resentment: at myself, at the world.” “What were you angry about?” “I felt like I’d wasted my undergraduate education. I hadn’t studied what I really wanted to study. My girlfriend was still back at school . . . doing great, getting a master’s. I was wallowing at home doing nothing.” After David’s girlfriend graduated, she landed a job in Palo Alto. He followed her there, and in 2008 they were married. David got a job at a technology start-up, where he interacted with young, smart engineers who were generous with their time. He got back into coding and learned all the stuff he had meant to study in college but was too afraid to pursue in a room full of students. He got promoted to software developer, was working fifteen-hour days, and ran thirty miles a week in his spare time. “But to make all that happen,” he said, “I was taking more Adderall, not just in the morning, but all through the day. I’d wake up in the morning, take Adderall. Get home, eat dinner, take more Adderall. Pills became my new normal. I was also drinking huge amounts of caffeine. Then I’d hit the end of the night, and I needed to go to sleep, and I’m like, Okay, what do I do now? So I went back to the psychiatrist and talked her into giving me Ambien. I pretended like I didn’t know what Ambien was, but my mom had taken Ambien for a long time, and a couple uncles too. I also talked her into a limited prescription of Ativan for anxiety before presentations. From 2008 to 2018, I was taking up to thirty milligrams of Adderall a day, fifty milligrams of Ambien a day, and three to six milligrams of Ativan a day. I thought, I have anxiety and ADHD and I need this to function.” David attributed fatigue and inattentiveness to a mental illness rather than to sleep deprivation and overstimulation, a logic he used to justify continued use of pills. I’ve seen a similar paradox in many of my patients over the years: They use drugs, prescribed or otherwise, to compensate for a basic lack of self-care, then attribute the costs to a mental illness, thus necessitating the need for more drugs. Hence poisons become vitamins. “You were getting your A vitamins: Adderall, Ambien, and Ativan,” I joked. He smiled. “I guess you could say that.” “Did your wife or anybody else know what was going on with you?” “No. Nobody did. My wife had no idea. Sometimes I would drink alcohol when I ran out of Ambien, or get angry and yell at her when I took too much Adderall. But other than that, I hid it pretty well.” “So then what happened?” “I got tired of it. Tired of taking uppers and downers day and night. I started thinking about ending my life. I thought I’d be better off, and other people would be better off. But my wife was pregnant, so I knew I needed to make a change. I told her I needed help. I asked her to take me to the hospital.” “How did she react?” “She took me to the emergency room, and when it all came out, she was shocked.” “What shocked her?” “The pills. All the pills I was taking. My huge stash. And how much I had been hiding.” David was admitted to the inpatient psychiatric ward and diagnosed with stimulant and sedative addiction. He stayed in the hospital until he finished withdrawing from Adderall, Ambien, and Ativan, and until he was no longer suicidal. It took two weeks. He was discharged home to his pregnant wife. — We’re all running from pain. Some of us take pills. Some of us couch surf while binge-watching Netflix. Some of us read romance novels. We’ll do almost anything to distract ourselves from ourselves. Yet all this trying to insulate ourselves from pain seems only to have made our pain worse. According to the World Happiness Report, which ranks 156 countries by how happy their citizens perceive themselves to be, people living in the United States reported being less happy in 2018 than they were in 2008. Other countries with similar measures of wealth, social support, and life expectancy saw similar decreases in self-reported happiness scores, including Belgium, Canada, Denmark, France, Japan, New Zealand, and Italy. Researchers interviewed nearly 150,000 people in twenty-six countries to determine the prevalence of generalized anxiety disorder, defined as excessive and uncontrollable worry that adversely affected their life. They found that richer countries had higher rates of anxiety than poor ones. The authors wrote, “The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.” 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 sociodemographic index (income), especially North America. Physical pain too is increasing. Over the course of my career, I have seen more patients, including otherwise healthy young people, presenting with full body pain despite the absence of any identifiable disease or tissue injury. The numbers and types of unexplained physical pain syndromes have grown: complex regional pain syndrome, fibromyalgia, interstitial cystitis, myofascial pain syndrome, pelvic pain syndrome, and so on. When researchers asked the following question to people in thirty countries around the world—“During the past four weeks, how often have you had bodily aches or pains? Never; seldom; sometimes; often; or very often?”—they found that Americans reported more pain than any other country. Thirty-four percent of Americans said they felt pain “often” or “very often,” compared to 19 percent of people living in China, 18 percent of people living in Japan, 13 percent of people living in Switzerland, and 11 percent of people living in South Africa. The question is: Why, in a time of unprecedented wealth, freedom, technological progress, and medical advancement, do we appear to be unhappier and in more pain than ever? The reason we’re all so miserable may be because we’re working so hard to avoid being miserable. CHAPTER 3 The Pleasure-Pain Balance N euroscientific advances in the last fifty to one hundred years, including advances in biochemistry, new imaging techniques, and the emergence of computational biology, shed light on fundamental reward processes. By better understanding the mechanisms that govern pain and pleasure, we can gain new insight into why and how too much pleasure leads to pain. Dopamine The main functional cells of the brain are called neurons. They communicate with each other at synapses via electrical signals and neurotransmitters. Neurotransmitters are like baseballs. The pitcher is the presynaptic neuron. The catcher is the postsynaptic neuron. The space between pitcher and catcher is the synaptic cleft. Just as the ball is thrown between pitcher and catcher, neurotransmitters bridge the distance between neurons: chemical messengers regulating electrical signals in the brain. There are many important neurotransmitters, but let’s focus on dopamine. NEUROTRANSMITTER Dopamine was first identified as a neurotransmitter in the human brain in 1957 by two scientists working independently: Arvid Carlsson and his team in Lund, Sweden, and Kathleen Montagu, based outside of London. Carlsson went on to win the Nobel Prize in Physiology or Medicine. Dopamine is not the only neurotransmitter involved in reward processing, but most neuroscientists agree it is among the most important. Dopamine may play a bigger role in the motivation to get a reward than the pleasure of the reward itself. Wanting more than liking. Genetically engineered mice unable to make dopamine will not seek out food, and will starve to death even when food is placed just inches from their mouth. Yet if food is put directly into their mouth, they will chew and eat the food, and seem to enjoy it. Debates about differences between motivation and pleasure notwithstanding, dopamine is used to measure the addictive potential of any behavior or drug. The more dopamine a drug releases in the brain’s reward pathway (a brain circuit that links the ventral tegmental area, the nucleus accumbens, and the prefrontal cortex), and the faster it releases dopamine, the more addictive the drug. DOPAMINE REWARD PATHWAYS IN THE BRAIN This is not to say that high-dopamine substances literally contain dopamine. Rather, they trigger the release of dopamine in our brain’s reward pathway. For a rat in a box, chocolate increases the basal output of dopamine in the brain by 55 percent, sex by 100 percent, nicotine by 150 percent, and cocaine by 225 percent. Amphetamine, the active ingredient in the street drugs “speed,” “ice,” and “shabu” as well as in medications like Adderall that are used to treat attention deficit disorder, increases the release of dopamine by 1,000 percent. By this accounting, one hit off a meth pipe is equal to ten orgasms. REWARDS AND DOPAMINE RELEASE Pleasure and Pain Are Co-Located In addition to the discovery of dopamine, neuroscientists have determined that 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. Imagine our brains contain a balance—a scale with a fulcrum in the center. When nothing is on the balance, it’s level with the ground. When we experience pleasure, dopamine is released in our reward pathway and the balance tips to the side of pleasure. The more our balance tips, and the faster it tips, the more pleasure we feel. But here’s the important thing about the balance: It wants to remain level, that is, in equilibrium. It does not want to be tipped for very long to one side or another. Hence, every time the balance tips toward pleasure, powerful self-regulating mechanisms kick into action to bring it level again. These self-regulating mechanisms do not require conscious thought or an act of will. They just happen, like a reflex. I tend to imagine this self-regulating system as little gremlins hopping on the pain side of the balance to counteract the weight on the pleasure side. The gremlins represent the work of homeostasis: the tendency of any living system to maintain physiologic equilibrium. Once the balance is level, it keeps going, tipping an equal and opposite amount to the side of pain. 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. As it turns out, many physiologic processes in the body are governed by similar self-regulating systems. For example, Johann Wolfgang von Goethe, Ewald Hering, and others have demonstrated how color perception is governed by an opponent-process system. Looking closely at one color for a sustained period spontaneously produces an image of its “opposing” color in the viewer’s eye. Stare at a green image against a white background for a period of time, and then look away at a blank white page, and you will see how your brain creates a red afterimage. The perception of green gives way in succession to the perception of red. When green is turned on, red can’t be, and vice versa. Tolerance (Neuroadaptation) We’ve all experienced craving in the aftermath of pleasure. Whether it’s reaching for a second potato chip or clicking the link for another round of video games, it’s natural to want to re-create those good feelings or try not to let them fade away. The simple solution is to keep eating, or playing, or watching, or reading. But there’s a problem with that. With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer, a process scientists call neuroadaptation. That is, with repetition, our gremlins get bigger, faster, and more numerous, and we need more of our drug of choice to get the same effect. Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose, is called tolerance. Tolerance is an important factor in the development of addiction. For me, reading the Twilight saga for a second time was pleasurable but not as pleasurable as the first time. By the fourth time I read it (yes, I read the entire saga four times), my pleasure was significantly diminished. The rereading never quite measured up to that first go-round. Furthermore, each time I read it, I was left with a deeper sense of dissatisfaction in its aftermath and a stronger desire to regain the feeling I had while reading it the first time. As I became “tolerant” to Twilight, I was forced to seek out newer, more potent forms of the same drug to try to recapture that earlier feeling. With prolonged, heavy drug use, the pleasure-pain balance eventually gets weighted to the side of pain. Our hedonic (pleasure) set point changes as our capacity to experience pleasure goes down and our vulnerability to pain goes up. You might think of this as the gremlins camped out on the pain side of the balance, inflatable mattresses and portable barbecues in tow. I became acutely aware of this effect of high-dopamine addictive substances on the brain’s reward pathway in the early 2000s, when I started seeing more patients coming in to clinic on high-dose, long term opioid therapy (think OxyContin, Vicodin, morphine, fentanyl) for chronic pain. Despite prolonged and high-dose opioid medications, their pain had only gotten worse over time. Why? Because exposure to opioids had caused their brain to reset its pleasure-pain balance to the side of pain. Now their original pain was worse, and they had new pain in parts of their body that used to be pain free. This phenomenon, widely observed and verified by animal studies, has come to be called opioid-induced hyperalgesia. Algesia, from the Greek word algesis, means sensitivity to pain. What’s more, when these patients tapered off opioids, many of them experienced improvements in pain. Neuroscientist Nora Volkow and colleagues have shown that heavy, prolonged consumption of high-dopamine substances eventually leads to a dopamine deficit state. Volkow examined dopamine transmission in the brains of healthy controls compared to people addicted to a variety of drugs two weeks after they stopped using. The brain images are striking. In the brain pictures of healthy controls, a kidney-bean-shaped area of the brain associated with reward and motivation lights up bright red, indicating high levels of dopamine neurotransmitter activity. In the pictures of people with addiction who stopped using two weeks prior, the same kidney-bean-shaped region of the brain contains little or no red, indicating little or no dopamine transmission. As Dr. Volkow and her colleagues wrote, “The decreases in DA D2 receptors in the drug abusers, coupled to the decreases in DA release, would result in a decreased sensitivity of reward circuits to stimulation by natural rewards.” Once this happens, nothing feels good anymore. To put it another way, the players on Team Dopamine take their balls and their mitts and go home. EFFECTS OF ADDICTION ON DOPAMINE RECEPTORS In the approximately two years in which I compulsively consumed romance novels, I eventually reached a place where I could not find a book I enjoyed. It was as if I had burned out my novel-reading pleasure center, and no book could revive it. The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind. Reading had always been my primary source of pleasure and escape, so it was a shock and a grief when it stopped working. Even then it was hard to abandon. My patients with addiction describe how they get to a point where their drug stops working for them. They get no high at all anymore. Yet if they don’t take their drug, they feel miserable. The universal symptoms of withdrawal from any addictive substance are anxiety, irritability, insomnia, and dysphoria. A pleasure-pain balance tilted to the side of pain is what drives people to relapse even after sustained periods of abstinence. When our balance is tilted to the pain side, we crave our drug just to feel normal (a level balance). 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 physical and psychological suffering of protracted withdrawal. Here’s the good news. If we wait long enough, our brains (usually) readapt to the absence of the drug and we reestablish our baseline homeostasis: a level balance. 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. People, Places, and Things The pleasure-pain balance is triggered not only by reexposure to the drug itself but also by exposure to cues associated with drug use. In Alcoholics Anonymous, the catchphrase to describe this phenomenon is people, places, and things. In the world of neuroscience, this is called cue-dependent learning, also known as classical (Pavlovian) conditioning. Ivan Pavlov, who won the Nobel Prize in Physiology or Medicine in 1904, demonstrated that dogs reflexively salivate when presented with a slab of meat. When the presentation of meat is consistently paired with the sound of a buzzer, the dogs salivate when they hear the buzzer, even if no meat is immediately forthcoming. The interpretation is that the dogs have learned to associate the slab of meat, a natural reward, with the buzzer, a conditioned cue. What’s happening in the brain? By inserting a detection probe into a rat’s brain, neuroscientists can demonstrate that dopamine is released in the brain in response to the conditioned cue (e.g., a buzzer, metronome, light) well before the reward itself is ingested (e.g., cocaine injection). The pre-reward dopamine spike in response to the conditioned cue explains the anticipatory pleasure we experience when we know good things are coming. DOPAMINE LEVELS: ANTICIPATION AND CRAVING Right after the conditioned cue, brain dopamine firing decreases not just to baseline levels (the brain has a tonic level of dopamine firing even in the absence of rewards), but below baseline levels. This transient dopamine mini-deficit state is what motivates us to seek out our reward. Dopamine levels below baseline drive craving. Craving translates into purposeful activity to obtain the drug. My colleague Rob Malenka, an esteemed neuroscientist, once said to me that “the measure of how addicted a laboratory animal is comes down to how hard that animal is willing to work to obtain its drug—by pressing a lever, navigating a maze, climbing up a chute.” I’ve found the same to be true for humans. Not to mention that the entire cycle of anticipation and craving can occur outside the threshold of conscious awareness. Once we get the anticipated reward, brain dopamine firing increases well above tonic baseline. But if the reward we anticipated doesn’t materialize, dopamine levels fall well below baseline. Which is to say, if we get the expected reward, we get an even bigger spike. If we don’t get the expected reward, we experience an even bigger plunge. DOPAMINE LEVELS: ANTICIPATION AND CRAVING We’ve all experienced the letdown of unmet expectations. An expected reward that fails to materialize is worse than a reward that was never anticipated in the first place. How does cue-induced craving translate to our pleasure-pain balance? The balance tips to the side of pleasure (a dopamine mini spike) in anticipation of future reward, immediately followed by a tip to the side of pain (a dopamine mini deficit) in the aftermath of the cue. The dopamine deficit is craving and drives drug-seeking behavior. Over the past decade, significant advances have been made in understanding the biological cause of pathological gambling, leading to the reclassification of gambling disorders in the Diagnostic and Statistical Manual of Mental Disorders (5th edition) as addictive disorders. Studies indicate that dopamine release as a result of gambling links to the unpredictability of the reward delivery, as much as to the final (often monetary) reward itself. The motivation to gamble is based largely on the inability to predict the reward occurrence, rather than on financial gain. In a 2010 study, Jakob Linnet and his colleagues measured the dopamine release in people addicted to gambling and in healthy controls while winning and losing money. There were no distinct differences between the two groups when they won money; however, when compared to the control group, the pathological gamblers showed a marked increase in dopamine levels when they lost money. The amount of dopamine released in the reward pathway was at its highest when the probability of losing and winning was nearly identical (50 percent)—representing maximum uncertainty. Gambling disorder highlights the subtle distinction between reward anticipation (dopamine release prior to reward) and reward response (dopamine release after or during reward). My patients with gambling addiction have told me that while playing, a part of them wants to lose. The more they lose, the stronger the urge to continue gambling, and the stronger the rush when they win—a phenomenon described as “loss chasing.” I suspect something similar is going on with social media apps, where the response of others is so capricious and unpredictable that the uncertainty of getting a “like” or some equivalent is as reinforcing as the “like” itself. — The brain encodes long-term memories of reward and their associated cues by changing the shape and size of dopamine producing neurons. For example, the dendrites, the branches off the neuron, become longer and more numerous in response to high dopamine rewards. This process is called experience-dependent plasticity. These brain changes can last a lifetime and persist long after the drug is no longer available. Researchers explored the effects of cocaine exposure on rats by injecting them with the same amount of cocaine on successive days for a week and measuring how much they ran in response to each injection. A rat injected with cocaine will run across the cage instead of keeping to the periphery like normal rats do. The amount of running can be measured by using beams of light that project across the cage. The more times the rat breaks the beams of light, the more it’s running. The scientists found that with each successive day of cocaine exposure, the rats progressed from a lively jog on the first day, to an outright running frenzy on the last, showing a cumulative sensitization to the effects of cocaine. Once the researchers stopped administering cocaine, the rats stopped running. One year later—a veritable lifetime for a rat—the scientists reinjected the rats with cocaine one time, and the rats were immediately running as they had on the final day of the original experiment. When the scientists examined the rats’ brains, they saw cocaine induced changes in the rats’ reward pathways consistent with persistent cocaine sensitization. These findings show that a drug like cocaine can alter the brain forever. Similar findings have been shown with other addictive substances, from alcohol to opioids to cannabis. In my clinical work I see people who struggle with severe addiction slipping right back into compulsive use with a single exposure, even after years of abstinence. This may occur because of persistent sensitization to the drug of choice, the distant echoes of earlier drug use. — Learning also increases dopamine firing in the brain. Female rats housed for three months in a diverse, novel, and stimulating environment show a proliferation of dopamine-rich synapses in the brain’s reward pathway compared to rats housed in standard laboratory cages. The brain changes that occur in response to a stimulating and novel environment are similar to those seen with high-dopamine (addictive) drugs. But if the same rats are pretreated with a stimulant such as methamphetamine, a highly addictive drug, before entering the enriched environment, they fail to show the synaptic changes seen previously with exposure to the enriched environment. These findings suggest that methamphetamine limits a rat’s ability to learn. Here’s some good news. My colleague Edie Sullivan, a world expert on alcohol’s effects on the brain, has studied the process of recovery from addiction and discovered that although some brain changes due to addiction are irreversible, it is possible to detour around these damaged areas by creating new neural networks. This means that although the brain changes are permanent, we can find new synaptic pathways to create healthy behaviors. Meanwhile, the future holds tantalizing possibilities for ways to reverse the scars of addiction. Vincent Pascoli and his colleagues injected rats with cocaine, which demonstrated the expected behavioral changes (frenzied running), then used optogenetics—a biological technique that involves the use of light to control neurons —to reverse the synaptic brain changes caused by cocaine. Maybe someday optogenetics will be possible on human brains. The Balance Is Only a Metaphor In real life, pleasure and pain are more complex than the workings of a balance. What’s pleasurable for one person may not be for another. Each person has their “drug of choice.” Pleasure and pain can occur simultaneously. For example, we can experience both pleasure and pain when eating spicy food. Not everyone starts out with a level balance: Those with depression, anxiety, and chronic pain start with a balance tipped to the side of pain, which may explain why people with psychiatric disorders are more vulnerable to addiction. Our sensory perception of pain (and pleasure) is heavily influenced by the meaning we ascribe to it. Henry Knowles Beecher (1904–1976) served as a military doctor during World War II in North Africa, Italy, and France. He observed and reported on 225 soldiers with severe war-theater wounds. Beecher was strict with his study inclusion criteria, surveying only those men who “had one of five kinds of severe wounds chosen as representative; extensive peripheral soft-tissue injury, compound fracture of a long bone, a penetrated head, a penetrated chest, or a penetrated abdomen . . . were clear mentally, and . . . were not in shock at the time of questioning.” Beecher made a remarkable discovery. Three-quarters of these badly injured soldiers reported little or no pain in the immediate aftermath of their wounds, despite life-threatening injuries. He concluded that their physical pain was tempered by the emotional relief of escaping “from an exceedingly dangerous environment, one filled with fatigue, discomfort, anxiety, fear and real danger of death.” Their pain, such as it was, gave them “a ticket to the safety of the hospital.” By contrast, a case report from the British Medical Journal published in 1995 details the case of a twenty-nine-year-old construction worker who walked into the emergency room after landing footfirst on a fifteen-centimeter nail, which was sticking up out of the top of his construction boot, having penetrated through leather, flesh, and bones. “The smallest movement of the nail was painful [and] he was sedated with fentanyl and midazolam,” powerful opioids and sedatives. But when the nail was pulled out from below and the boot removed, it became apparent that “the nail had penetrated between the toes: the foot was entirely uninjured.” — Science teaches us that every pleasure exacts a price, and the pain that follows is longer lasting and more intense than the pleasure that gave rise to it. With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases. By imprinting instant and permanent memory, we are unable to forget the lessons of pleasure and pain even when we want to: hippocampal tattoos to last a lifetime. The phylogenetically uber-ancient neurological machinery for processing pleasure and pain has remained largely intact throughout evolution and across species. It is perfectly adapted for a world of scarcity. Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death. By raising our neural set point with repeated pleasures, we become endless strivers, never satisfied with what we have, always looking for more. But herein lies the problem. Human beings, the ultimate seekers, have responded too well to the challenge of pursuing pleasure and avoiding pain. As a result, we’ve transformed the world from a place of scarcity to a place of overwhelming abundance. Our brains are not evolved for this world of plenty. As Dr. Tom Finucane, who studies diabetes in the setting of chronic sedentary feeding, said, “We are cacti in the rain forest.” And like cacti adapted to an arid climate, we are drowning in dopamine. The net effect is that we now need more reward to feel pleasure, and less injury to feel pain. This recalibration is occurring not just at the level of the individual but also at the level of nations. Which invites the question: How do we survive and thrive in this new ecosystem? How do we raise our children? What new ways of thinking and acting will be required of us as denizens of the twenty first century? Who better to teach us how to avoid compulsive overconsumption than those most vulnerable to it: those struggling with addiction. Shunned for millennia across cultures as reprobates, parasites, pariahs, and purveyors of moral turpitude, people with addiction have evolved a wisdom perfectly suited to the age we live in now. What follows are lessons of recovery for a reward-weary world. PART II Self-Binding I’ CHAPTER 4 Dopamine Fasting m here because my parents made me come,” Delilah said in that sullen voice that is the hallmark of the American teenager. “Okay,” I said. “Why do your parents want you to see me?” “They think I’m smoking too much pot, but my problem is anxiety. I smoke because I’m anxious, and if you could do something about that, then I wouldn’t need the weed.” I was gripped by a moment of overwhelming sadness. Not because I didn’t know what to recommend, but because I was afraid she wouldn’t take my advice. “Okay, then let’s start there,” I said. “Tell me about your anxiety.” Long-limbed and graceful, she folded her legs underneath her. “It started in junior high,” she said, “and it’s just gotten worse over the years. Anxiety is like the first thing I feel when I wake up in the morning. Hitting my wax pen is the only thing that gets me out of bed.” “Your wax pen?” “Yeah, I vape now. I used to do blunts and bongs, Sativa in the daytime and Indica before bed. But now I’m into concentrates . . . wax, oil, budder, shatter, scissor, dust, QWISO. I mostly use a vape pen, but sometimes a Volcano. . . . I don’t love edibles, but I’ll use them in between or in an emergency when I can’t smoke.” D Stands for Data By prompting her to say more about her “wax pen,” I was inviting Delilah to delve into the nitty-gritty details of her everyday use. My conversation with her was guided by a framework I’ve developed over the years for talking with patients about the problem of compulsive overconsumption. This framework is easily remembered by the acronym DOPAMINE, which applies not just to conventional drugs like alcohol and nicotine but also to any high-dopamine substance or behavior we ingest too much of for too long, or simply wish we had a slightly less tortured relationship with. Although originally developed for my professional practice, I’ve also applied it to myself and my own maladaptive habits of consumption. — The d in DOPAMINE stands for data. I begin by gathering the simple facts of consumption. In Delilah’s case, I explored what she was using, how much, and how often. When it comes to cannabis, the dizzying list of products and delivery mechanisms that Delilah described is standard fare for my patients nowadays. Many of them have the equivalent of a PhD in Pot by the time they come to see me. In contrast to the 1960s, when recreational weekends-only use was normative, my patients start smoking the moment they wake up in the morning and keep going all day long until they go to bed again. This is concerning on many levels, not the least of which is that daily use has been linked to addiction. For myself, I began to suspect I was teetering into the danger zone when reading romance novels started to take up hours a day and days at a time. O Stands for Objectives “What does smoking do for you?” I asked Delilah. “How does it help?” “It’s the only thing that works for my anxiety,” she said. “Without it I’d be nonfunctional . . . I mean even more nonfunctional than I am now.” — In asking Delilah to tell me how cannabis helped her, I was validating that it was doing something positive or she wouldn’t be using it. The o in DOPAMINE stands for objectives for using. Even seemingly irrational behavior is rooted in some personal logic. People use high-dopamine substances and behaviors for all kinds of reasons: to have fun, to fit in, to relieve boredom, to manage fear, anger, anxiety, insomnia, depression, inattention, pain, social phobia . . . the list goes on. I used romance to escape what for me was a painful transition away from parenting young children to parenting teenagers, a job at which I felt much less skilled. I was also assuaging my grief at never having another baby, something I wanted and my husband did not, creating a tension in our marriage and in our sex life that hadn’t existed before. P Stands for Problems “Any downsides from smoking? Unintended consequences?” I asked. “The only bad thing about smoking,” Delilah said, “is that my parents are always on my back. If they would just leave me alone, there wouldn’t be any downsides.” I paused to notice the sun glinting on her hair. She was the picture of health despite the fact that she was ingesting more than a gram of cannabis a day. Youth, I thought, compensates for so much. — The p in DOPAMINE stands for problems related to use. High-dopamine drugs always lead to problems. Health problems. Relationship problems. Moral problems. If not right away, then eventually. That Delilah could not see downsides—except the mounting conflict between her and her parents—is typical for teenagers . . . and not just teenagers. This disconnect occurs for a number of reasons. First, most of us are unable to see the full extent of the consequences of our drug use while we’re still using. High-dopamine substances and behaviors cloud our ability to accurately assess cause and effect. As the neuroscientist Daniel Friedman, who studies the foraging practices of red harvester ants, once remarked to me, “The world is sensory rich and causal poor.” That is to say, we know the doughnut tastes good in the moment, but we are less aware that eating a doughnut every day for a month adds five pounds to our waistline. Second, young people, even heavy users, are more immune to the negative consequences of use. As one high school teacher remarked to me, “Some of my best students smoke pot every day.” As we age, however, the unintended consequences of chronic use multiply. Most of my patients who come in voluntarily for treatment are middle-aged. They seek me out because they’ve reached a tipping point where the downsides of their use outweigh the upsides. As they say in AA, “I’m sick and tired of being sick and tired.” My teenage patients, by contrast, are neither sick nor tired. Even so, getting teenagers to see some negative consequences of their use while they’re still using, even if it’s only that other people don’t like it, can be a point of leverage for getting them to stop. And stopping, even just for a period of time, is essential for getting them to see true cause and effect. A Stands for Abstinence “I do have an idea about what might help you,” I said to Delilah, “but it will require you to do something really hard.” “What’s that?” “I’d like you to try an experiment.” “An experiment?” She tilted her head to the side. “I’d like you to stop using cannabis for a month.” Her face was impassive. “Let me explain. First, treatments for anxiety are unlikely to work while you’re smoking that much cannabis. Second, and more importantly, there’s a distinct possibility that if you stop smoking for a whole month, your anxiety will get better all on its own. Of course, at first you’ll feel worse due to withdrawal. But if you can get through the first two weeks, there’s a good chance that in the second two weeks you’ll start to feel better.” She remained quiet, so I continued. I explained to her that any drug that stimulates our reward pathway the way cannabis does has the potential to change our brain’s baseline anxiety. What feels like cannabis treating anxiety may in fact be cannabis relieving withdrawal from our last dose. Cannabis becomes the cause of our anxiety rather than the cure. The only way to know for sure is to lay off for a month. “Can I stop for a week?” she asked. “I’ve done that before.” “A week would be good, but in my experience, a month is usually the minimum amount of time it takes to reset the brain’s reward pathway. If you don’t feel better after four weeks of abstaining, that’s also useful data. That means the cannabis isn’t driving this, and we need to think about what else is. So what do you think? Do you think you would be able and willing to stop cannabis for a month?” “Hmmm. . . . I don’t think I’m ready to try quitting now, but maybe later. For sure I’m not going to be smoking like this forever.” “Do you still want to be using cannabis like this ten years from now?” “No. No way. Definitely not.” She shook her head vigorously. “How about five years from now?” “No, not in five years either.” “How about a year from now?” Pause. Chuckle. “I guess you got me there, Doc. If I don’t want to be using like this in a year, I might as well try to stop now.” She looked at me and smiled. “Okay, let’s do this.” In asking Delilah to consider her current behavior in light of her future self, I hoped that quitting smoking would take on new urgency. It seemed to have worked. — The a in DOPAMINE stands for abstinence. 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’re feeling. To put it in terms of the pleasure-pain balance, fasting from dopamine allows sufficient time for the gremlins to hop off the balance and for the balance to go back to the level position. The question is: How long do people need to abstain in order to experience the brain benefits of stopping? Think back to the imaging study by neuroscientist Nora Volkow, showing that dopamine transmission is still below normal two weeks after quitting drugs. Her study is consistent with my clinical experience that two weeks of abstinence is not enough. At two weeks, patients are usually still experiencing withdrawal. They are still in a dopamine deficit state. On the other hand, four weeks is often sufficient. Marc Schuckit and his colleagues studied a group of men who were drinking alcohol daily in large quantities and also met criteria for clinical depression, or what is called major depressive disorder. Schuckit, a professor of experimental psychology at San Diego State University, is best known for demonstrating that biological sons of “alcoholics” have an increased genetic risk of developing an alcohol use disorder, compared to those without this genetic load. I had the pleasure of learning from Marc, a gifted teacher, at a series of conferences on addiction in the early 2000s. The depressed men in Schuckit’s study went into the hospital for four weeks, during which time they received no treatment for depression, other than stopping alcohol. After one month of not drinking, 80 percent no longer met criteria for clinical depression. This finding implies that for the majority, clinical depression was the result of heavy drinking and not a co-occurring depressive disorder. Of course there are other explanations for these results: the therapeutic milieu of the hospital environment, spontaneous remission, the episodic nature of depression, which can come and go independent of external factors. But the robust findings are remarkable given that standard treatments for depression, whether medications or psychotherapy, have a 50 percent response rate. Naturally I’ve seen patients who need less than four weeks to reset their reward pathway, and others who need far longer. Those who have been using more potent drugs in larger quantities for longer duration will typically need more time. Younger people recalibrate faster than older people, their brains being more plastic. Furthermore, physical withdrawal varies drug to drug. It can be minor for some drugs like video games but potentially life threatening for others, like alcohol and benzodiazepines. Which brings us to an important caveat: I never suggest a dopamine fast to individuals who might be at risk to suffer life threatening withdrawal if they were to quit all of a sudden, as in cases of severe alcohol, benzodiazepine (Xanax, Valium, or Klonopin), or opioid dependence and withdrawal. For those patients, medically monitored tapering is necessary. Sometimes, patients ask if they can swap one drug for another: cannabis for nicotine, video games for pornography. This is seldom an effective long-term strategy. Any reward that is potent enough to overcome the gremlins and tip the balance toward pleasure can itself be addictive, thereby resulting in trading one addiction for another (cross addiction). Any reward that is not potent enough won’t feel like a reward, which is why when we’re consuming high-dopamine rewards, we lose the ability to take joy in ordinary pleasures. A minority of patients (about 20 percent) don’t feel better after the dopamine fast. That’s important data too, because it tells me that the drug wasn’t the main driver of the psychiatric symptom and that the patient likely has a co-occurring psychiatric disorder that will require its own treatment. Even when the dopamine fast is beneficial, a co-occurring psychiatric disorder should be treated concurrently. Managing addiction without also addressing other psychiatric disorders typically leads to bad outcomes for both. Nonetheless, to appreciate the relationship between the substance use and the psychiatric symptoms, I need to observe the patient for a sufficient period of time off high-dopamine rewards. M Stands for Mindfulness “I want you to be prepared,” I said to Delilah, “for feeling worse before you feel better. By this I mean, when you first stop cannabis, your anxiety will get worse. But remember, this is not the anxiety you’ll have to live with off cannabis. This is withdrawal-mediated anxiety. The longer you can go without using, the faster you’ll get to that place where you’re feeling better. Usually patients report a turning point at around two weeks.” “Okay. What am I supposed to do in the meantime? Do you have any pills you can give me?” “There’s nothing I can give you to take the pain away that’s not also addictive. Since we don’t want to trade one addiction for another, what I’m asking you to do is tolerate the pain.” Gulp. “Yeah, I know. Hard. But it’s also an opportunity. A chance for you to observe yourself as separate from your thoughts, emotions, and sensations, including pain. This practice is sometimes called mindfulness.” — The m of DOPAMINE stands for mindfulness. Mindfulness is a term that is tossed around so often now, it has lost some of its meaning. Evolved from the Buddhist spiritual tradition of meditation, it has been adopted and adapted by the West as a wellness practice across many different disciplines. It has so fully penetrated Western consciousness that it’s now routinely taught in American elementary schools. But what actually is mindfulness? Mindfulness is simply the ability to observe what our brain is doing while it’s doing it, without judgment. This is trickier than it sounds. The organ we use to observe the brain is the brain itself. Weird, right? When I look at the Milky Way galaxy in the night sky, I’m always struck by how mysterious it is that we can be a part of something that looks so far away and separate. Practicing mindfulness is something like observing the Milky Way: It demands that we see our thoughts and emotions as separate from us and yet, simultaneously, a part of us. Also, the brain can do some pretty weird things, some of which are embarrassing, hence the need for being without judgment. Reserving judgment is important to the practice of mindfulness because as soon as we start condemning what our brain is doing— Ewww! Why would I be thinking about that? I’m a loser. I’m a freak —we stop being able to observe. Staying in the observer position is essential to getting to know our brains and ourselves in a new way. I remember standing in the kitchen in 2001 holding my newborn baby in my arms and experiencing an intrusive image of smashing her head against the refrigerator or the kitchen counter and watching it implode like a soft melon. The image was fleeting but vivid, and had I not been a regular practitioner of mindfulness, I would have done my best to ignore it. Initially, I was horrified. As a psychiatrist I had treated mothers who, as a result of their mental illness, thought they had to kill their children to save the world. One of them actually did, an outcome I recall with sadness and regret to this day. So when I experienced an image of hurting my own child, I wondered if I was joining their ranks. But remembering to observe without judgment, I followed the image and the feeling where they led and discovered that I didn’t want to smash my baby’s head; rather I had a great fear of doing so. The fear had manifested as the image. Instead of condemning myself, I was able to have compassion for myself. I was grappling with the enormity of my responsibilities as a new mother, and what it meant to care for such a helpless creature, wholly dependent on me to protect her. Mindfulness practices are especially important in the early days of abstinence. Many of us use high-dopamine substances and behaviors to distract ourselves from our own thoughts. When we first stop using dopamine to escape, those painful thoughts, emotions, and sensations come crashing down on us. The trick is to stop running away from painful emotions, and instead allow ourselves to tolerate them. When we’re able to do this, our experience takes on a new and unexpectedly rich texture. The pain is still there, but somehow transformed, seeming to encompass a vast landscape of communal suffering, rather than being wholly our own. When I gave up my reading habit, I was gripped in the first several weeks by an existential terror. I lay on the couch in the evening, a time when I would normally reach for a book or some other method of distraction, with my hands folded over my stomach, trying to relax but instead feeling full of dread. I was astounded that such a seemingly small change in my daily routine could fill me with so much anxiety. Then as the days passed and I continued the practice, I experienced a gradual relaxing of my mental boundaries and an opening up of my awareness. I began to see that I didn’t need to continually distract myself from the present moment. That I could live in it and tolerate it, and maybe even something more. I Stands for Insight Delilah agreed to a month of abstinence. When she returned, her skin was glowing, the hunched shoulders were gone, and her sullen demeanor was replaced with a radiant smile. She strode into my office and took a chair. “Well, I did it! And you’re not going to believe this, Doc, but my anxiety is gone. Gone!” “Tell me what happened.” “The first few days were bad. I felt blah. I threw up on the second day. Insane! I never throw up. I had this really sick feeling. That’s when I realized I was withdrawing, and that motivated me to keep going with abstinence.” “Why would that motivate you?” “Because it was the first piece of evidence I had that I was really addicted.” “So how did it go after that? How do you feel now?” “Dude. So much better. Wow. Less anxiety. Definitely. That word anxiety doesn’t even come into my head. It used to rule my day. Clear-headed. I don’t have to worry about my parents smelling it and getting mad. I’m not anxious at school anymore. The paranoia and suspiciousness . . . that’s gone. I put so much time and mental effort into organizing my next high, rushing off to do it. It’s such a relief not to have to do that anymore. I’m saving money. I’ve discovered events I enjoy more sober . . . like family events. “Doctor, I’m telling you the truth, I did not see weed as a problem. I really didn’t see it. But now that I’ve stopped smoking, I realize how much smoking was causing anxiety instead of curing it. I’d been smoking for five years without a break, and I didn’t see what it was doing to me. I’m honestly kind of shocked.” — The i of DOPAMINE stands for insight. I have seen again and again in clinical care, and in my own life, how the simple exercise of abstaining from our drug of choice for at least four weeks gives clarifying insight into our behaviors. Insight that simply is not possible while we continue to use. N Stands for Next Steps As my visit with Delilah came to an end, I asked her about goals for the next month. “So what do you think?” I said. “Do you want to continue to abstain for the next month, or do you want to return to using?” “Being sober,” said Delilah, “I’m the best version of me.” I savored the moment. “But,” she said, “I still really like weed, and I miss the creative feeling it gives me, and the escape. I don’t want to stop using. I’d like to go back to using, but not the way I was using before.” — The n of DOPAMINE stands for next steps. This is where I ask my patients what they want to do after their month of abstinence. The vast majority of my patients who are able to abstain for a month and experience the benefits of abstinence nonetheless want to go back to using their drug. But they want to use differently than they were using before. The overarching theme is that they want to use less. An ongoing controversy in the field of addiction medicine is whether people who have been using drugs in an addictive way can return to moderate, nonrisky use. For decades the wisdom of Alcoholics Anonymous dictated that abstinence is the only option for people with addiction. But emerging evidence suggests that some people who have met criteria for addiction in the past, especially those with less severe forms of addiction, can return to using their drug of choice in a controlled way. In my clinical experience, this has been true. E Stands for Experiment The e and final letter of DOPAMINE stands for experiment. This is where patients go back out into the world armed with a new dopamine set point (a level pleasure-pain balance) and a plan for how to maintain it. Whether the goal is continued abstinence or moderation, like Delilah’s, we strategize together for how to achieve it. Through a gradual process of trial and error, we figure out what works and what doesn’t. I would be remiss if I didn’t point out that the goal of moderation, especially for people with severe addiction, can backfire, contributing to a precipitous escalation in use after a period of abstinence, sometimes referred to as the abstinence violation effect. Rats who show a genetic propensity to become addicted will, after a two-to-four-week period of abstaining from alcohol, binge on alcohol as soon as they have access to it again, and continue to use heavily thereafter as if they had never abstained. A similar phenomenon has been observed in rats exposed to and hooked on high-calorie foods. The effect is attenuated in rats and mice less genetically predisposed to compulsive consumption. What’s not clear in animal studies is whether this binge-after abstinence phenomenon is unique to drugs that are caloric, like food and alcohol, and not seen with noncaloric drugs like cocaine; or whether the real driver is the genetic predisposition of the rats themselves. Even when moderation is achievable, many of my patients report it’s too exhausting to continue, and they ultimately opt for abstinence for the long haul. But how about patients addicted to food? Or smartphones? Drugs that can’t be stopped altogether? The question of how to moderate is becoming an increasingly important one in modern-day life, because of the sheer ubiquity of high-dopamine goods, making us all more vulnerable to compulsive overconsumption, even when not meeting clinical criteria for addiction. Further, as digital drugs like smartphones have become embedded into so many aspects of our lives, figuring out how to moderate their consumption, for ourselves and our children, has become a matter of urgency. To that end, I now introduce a taxonomy of self-binding strategies. But before we talk about self-binding, let’s review the steps of the dopamine fast, the ultimate goal of which is to restore a level balance (homeostasis) and renew our capacity to experience pleasure in many different forms. CHAPTER 5 Space, Time, and Meaning I n the fall of 2017, after a year of abstaining from compulsive sexual behaviors, Jacob relapsed. He was sixty-five years old. The trigger was a trip to Eastern Europe to see his family, complicated by his current wife and his children from his first marriage not getting along—the problem of money and who gets what, an old refrain. Two weeks into his three-week trip, his children were angry because he had not given them the money they’d asked for. His wife was angry because he was even considering giving them money. He was afraid to disappoint anyone and hence threatened to disappoint them all. He e-mailed me from overseas to let me know he was struggling. He hadn’t relapsed yet but was close. I did some phone coaching and told him to come see me as soon as he got home. He came into the office a week after he returned, but by then it was too late. “It is the TV in the hotel room that get me started craving again,” he said to me. “I want to watch the US Open. I lie there flipping through the channels, feeling depressed, thinking about my family, and my wife, and how everyone is angry at me. I see a naked woman on TV. Until I watch TV, I am pretty good. I am not getting urges. The biggest mistake is when I switch on the TV, I start thinking about returning to my old habits, and I can’t stop the thoughts.” “Then what happened?” “On Tuesday, I go home. I don’t go to work. I stay home watching YouTube. I see body painting . . . people painting each other’s naked bodies. A kind of art, I guess. On Wednesday, I cannot resist any longer. I go out and buy the parts to make my machine again.” “Your electrical stimulation machine?” “Yes,” he said sadly, only barely meeting my eyes. “The problem is when you start, you can be in ecstasy for a very long time. It’s like being in a trance. And it’s such a relief. I don’t think about anything else. I go twenty hours without stopping. I go all day Wednesday and through the night. On Thursday morning, I throw the machine parts away in my garbage and go back to work. On Friday morning, I take them out of the garbage again and repair them and use all day. On Friday night, I call my sponsor, and go to a Sexaholics Anonymous meeting on Saturday. On Sunday, I take the parts out of the garbage and use again. And on Monday again. I want to stop but I can’t. What should I do?” “Pack up the machine and any spare parts,” I told him, “and put it all in the garbage. Then take the garbage to the dump or somewhere else where it is impossible for you to retrieve it.” He nodded understanding. “Then anytime you get the idea or urge or craving to use, drop to your knees and pray. Just pray. Ask God to help you, but do it from your knees. That’s important.” I converged the mundane and the metaphysical. Nothing was too low or too high for my consideration. Telling him to pray was breaking unwritten rules, of course. Doctors don’t talk about God. But I believe in believing, and my instincts told me this would resonate for Jacob, raised Roman Catholic. Telling him to drop to his knees was also a way to insert some physicality into it, anything to break the mental compulsion that was compelling him to use. Or maybe I recognized some deeper need he had to act out his submission. “After you’ve prayed,” I said, “then get up and call your sponsor.” He nodded again. “Oh, and forgive yourself, Jacob. You’re not a bad man. You’ve got problems, just like the rest of us.” — Self-binding is the term to describe Jacob’s act of throwing out his machine. It is the way we intentionally and willingly create barriers between ourselves and our drug of choice in order to mitigate compulsive overconsumption. Self-binding is not primarily a matter of will, although personal agency plays some part. Rather, self binding openly recognizes the limitations of will. The key to creating effective self-binding is first to acknowledge the loss of voluntariness we experience when under the spell of a powerful compulsion, and to bind ourselves while we still possess the capacity for voluntary choice. If we wait until we feel the compulsion to use, the reflexive pull of seeking pleasure and/or avoiding pain is nearly impossible to resist. In the throes of desire, there’s no deciding. But by creating tangible barriers between ourselves and our drug of choice, we press the pause button between desire and action. Further, self-binding has become a modern necessity. External rules and sanctions like taxes on cigarettes, age restrictions on alcohol, and laws prohibiting cocaine possession, although necessary, will never be sufficient in a world where access to an ever-growing variety of high-dopamine goods is practically infinite. My patients have been telling me about their self-binding strategies for years. At some point I started writing them down. I repurpose strategies I learn from patients to advise other patients, as I did with Jacob when I told him to dispose of his machine in a remote dumpster that wouldn’t allow him to retrieve it later. I ask my patients, “What kinds of barriers can you put into place to make it harder for you to get easy access to your drug of choice?” I have even used self-binding in my own life to manage problems of compulsive overconsumption. Self-binding can be organized into three broad categories: physical strategies (space), chronological strategies (time), and categorical strategies (meaning). As you will see in what follows, self-binding is not fail-safe, particularly for those with severe addictions. It too can fall prey to self-deception, bad faith, and faulty science. But it is a good and necessary place to start. Physical Self-Binding Of the many dangers that awaited Homer’s Odysseus on his journey home from the Trojan War, the first was the Sirens, those half woman, half-bird creatures whose enchanted song lured sailors to their death on the rocky cliffs of nearby islands. The only way for a sailor to pass the Sirens unharmed was by not hearing them sing. Odysseus ordered his crew to put beeswax in their ears and tie him to the mast of the sailing ship, binding him even tighter if he begged to be unfastened or tried to break loose. As this famous Greek myth illustrates, one form of self-binding is to create literal physical barriers and/or geographical distance between ourselves and our drug of choice. Here are some examples my patients have told me about: “I unplugged my TV and put it in my closet.” “I banished my game console to the garage.” “I don’t use credit cards. Only cash.” “I call hotels beforehand to ask them to remove the minibar.” “I call hotels beforehand to ask them to remove the minibar and the television.” “I put my iPad in a safety deposit box at Bank of America.” My patient Oscar, a rotund man in his late seventies with a scholarly mind, a booming voice, and a penchant for talking in soliloquies, so much so that he made a muddle of group therapy and had to drop out, had a habit of drinking to excess while working in his study, tinkering in his garage, and puttering in his garden. By trial and error he learned that to prevent this behavior, he had to remove all alcohol from his home. Any alcohol brought into the house needed to be locked up in a file cabinet for which only his wife had the key. Using this method, Oscar was able to successfully abstain from alcohol for years. But I warned you that self-binding is no guarantee. Sometimes the barrier itself becomes an invitation to a challenge. Solving the puzzle of how to get our drug of choice becomes part of its appeal. One day, Oscar’s wife, on her way out of town, locked an expensive bottle of wine in a file cabinet and took the keys with her. The first evening she was away, Oscar got to thinking about the bottle of wine he knew was there. The thought intruded on his consciousness like a physical presence. It wasn’t painful, just annoying. If I just go take a peek and make sure it’s all locked away, I’ll stop thinking about it, he told himself. He walked to his wife’s study and pulled on the drawer. To his surprise, the drawer opened half an inch, and he could see the bottle standing upright between the files. Not enough to get it out, but enough to see the cork, tantalizingly out of reach. He stood staring into the darkened drawer for a full minute, contemplating the bottle. A part of him wanted to shut the drawer. Another part of him couldn’t stop staring at it. Then something in his brain clicked and he decided—or maybe he stopped trying not to decide. He moved into action. He hurried to the garage for his toolbox. Settling down to work, he used a wide range of tools to try to dismantle the lock and open the drawer. He worked with laser focus and determination. But he couldn’t open the drawer. Every tool he tried failed to penetrate the lock. Then the answer dawned on him like a knot suddenly coming loose under his fingers. Of course. Why didn’t I think of it before? It’s so obvious. He sat up. No need to hurry now. His goal was in reach. He quietly packed up his tools save one, his long-stem pliers. He uncorked the bottle with the long-stem pliers, laid the cork and pliers gently on the table, and went to the kitchen to get the only remaining tool he would need: a long plastic straw. Where Oscar’s file cabinet failed, new devices like the kSafe kitchen safe might have done the trick. About the size of a bread box and made of impenetrable clear plastic, the kSafe holds everything from cookies to iPhones to opioid medication. A spin of the dial locks the safe on a timer. Once the timer has been set, there’s no getting past the lock or penetrating the clear plastic material until the time is up. — Physical self-binding is now available from your local apothecary. Instead of locking our drugs away in a file cabinet, we have the option of imposing locks at the cellular level. The medication naltrexone is used to treat alcohol and opioid addiction, and is being used for a variety of other addictions as well, from gambling to overeating to shopping. Naltrexone blocks the opioid receptor, which in turn diminishes the reinforcing effects of different types of rewarding behavior. I’ve had patients report a near or complete cessation of alcohol craving with naltrexone. For patients who have struggled for decades with this problem, the ability to not drink at all, or to drink in moderation like “normal people,” comes as a revelation. Because naltrexone blocks our endogenous opioid system, people have reasonably wondered if it might induce depression. There’s no reliable evidence of that, but I do occasionally see patients who report a flatlining of pleasure with naltrexone. One patient said to me, “Naltrexone helps me not drink alcohol, but I don’t enjoy bacon as much as I used to, or hot showers, and I can’t get a runner’s high.” We worked around this by having him take naltrexone half an hour before entering a risky drinking situation, such as a happy hour. This naltrexone-as-needed approach allowed him to drink in moderation and also enjoy bacon again. In the summer of 2014, one of my students and I traveled to China to interview people seeking treatment for heroin addiction at New Hospital, a voluntary, non-government-sponsored addiction treatment hospital in Beijing. We talked to a thirty-eight-year-old man who described how prior to coming to New Hospital for treatment, he had received the “addiction surgery.” The addiction surgery involved insertion of a long-acting naltrexone implant to block the effects of heroin. “In 2007,” he said, “I went to Wuhan province for the surgery. My parents made me go, and they paid for it. I don’t know for sure what the surgeons did, but I can tell you it didn’t work. After the surgery, I kept shooting up heroin. I couldn’t get the feeling anymore, but I did it anyway because shooting up was my habit. For the next six months I shot up every day with no feeling. I did not think about stopping because I still had money to buy it. After six months, the feeling came back. So I’m here now, hoping they’ll have something new and better for me.” This anecdote illustrates that pharmacotherapy alone, without insight, understanding, and the will to change behavior, is unlikely to be successful. Another medication that is used to treat alcohol addiction is disulfiram. Disulfiram interrupts alcohol metabolism, leading to the accumulation of acetaldehyde, which in turn causes a severe flushing reaction, nausea, vomiting, elevated blood pressure, and an overall feeling of malaise. Taking disulfiram daily is an effective deterrent for those who are trying to abstain from alcohol, especially for people who wake up in the morning determined not to drink but by the evening have lost their resolve. It turns out that willpower is not an infinite human resource. It’s more like exercising a muscle, and it can get tired the more we use it. As one patient put it, “With disulfiram, I only need to decide once a day not to drink. I don’t have to keep deciding all day long.” Some people, most commonly East Asians, have a genetic mutation that causes them to have a disulfiram-like reaction to alcohol without the drug. These individuals have historically had lower rates of alcohol addiction. Of note, in recent decades, increased alcohol consumption in East Asian countries has led to higher rates of alcohol addiction even among this previously protected group. Scientists are now discovering that those with the mutation who drink anyway are at higher risk for alcohol-related cancers. As with all forms of self-binding, disulfiram is fallible. My patient Arnold had been drinking heavily for decades, a problem that only got worse after he suffered a serious stroke and lost some of his frontal lobe function. His cardiologist told him he had to stop drinking or he would die. The stakes were high. I prescribed disulfiram, and told Arnold the drug would make him sick if he drank while on it. In order to ensure Arnold took it, his wife administered it to him every morning and checked his mouth afterward to make sure he’d swallowed it. One day while his wife was out, Arnold made his way over to the liquor store, got a fifth of whiskey, and drank it. When his wife came home and found him drunk, what puzzled her most was why the disulfiram hadn’t made him sick. Arnold was intoxicated, but he wasn’t ill. A day later he confessed. For the preceding three days, he hadn’t swallowed the pill. Instead, he’d wedged it in the gap left by a missing tooth. — Other modern forms of physical self-binding involve anatomical changes to our bodies; for example, weight-loss surgeries such as gastric banding, sleeve gastrectomy, and gastric bypass. These surgeries effectively create a smaller stomach and/or bypass the part of the gut that absorbs calories. The gastric band puts a physical ring around the stomach, making it smaller without removing any part of the stomach or small intestine. The sleeve gastrectomy surgically removes part of the stomach to make it smaller. Gastric bypass surgery reroutes the small intestine around the stomach and duodenum, where nutrients are absorbed. My patient Emily received gastric bypass surgery in 2014 and was thereby able to go from 250 pounds to 115 in the course of a year. No other interventions—and she had tried them all—had enabled her to lose weight. Emily is not alone. Weight-loss surgeries are a proven effective intervention for obesity, especially when other remedies have failed. But they’re not without unintended consequences. One in four gastric bypass surgery recipients develops a new problem with alcohol addiction. In the wake of her surgery, Emily too became addicted to alcohol. The reasons are many. Most people who are obese have an underlying food addiction, which is not adequately addressed with surgery alone. Few people who undergo these surgeries get the behavioral and psychological interventions they need to help them change their eating habits. Hence many of them resume eating in unhealthy ways, expand their now smaller stomachs, and end up with medical complications and the need for repeat surgeries. When food is no longer an option, many switch from food to another drug, like alcohol. Further, the surgery alters how alcohol is metabolized, increasing the rate of absorption. The absence of a normal-size stomach means alcohol is absorbed into the bloodstream almost instantaneously and avoids the first-pass metabolism that usually occurs in the stomach. As a result, patients get intoxicated faster and stay intoxicated longer on less alcohol, akin to getting an alcohol IV. We can and should celebrate a medical intervention that can improve the health of so many people. But the fact that we must resort to removing and reshaping internal organs to accommodate our food supply marks a turning point in the history of human consumption. — From lockboxes that limit our access, to medications that block our opioid receptors, to surgeries that shrink our stomachs, physical self binding is everywhere in modern life, illustrating our growing need to put the brakes on dopamine. As for me, when books were just one click away, I was prone to linger in fantasy longer than I wanted to, or than was good for me. I got rid of my Kindle and its easy access to a steady stream of downloadable erotica. As a result, I was better able to moderate my tendency to indulge in candy fiction. The simple act of having to go to the library or a bookstore created a useful barrier between me and my drug of choice. Chronological Self-Binding Another form of self-binding is the use of time limits and finish lines. By restricting consumption to certain times of the day, week, month, or year, we narrow our window of consumption and thereby limit our use. For example, we can tell ourselves we’ll consume only on holidays, only on weekends, never before Thursday, never before 5:00 p.m., and so on. """