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+ This 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, texting, texting, texting, texting, texting, texting, texting, texting, texting, texting, texting, sexting,, Facebook, Facebook, and Instagram, and YouTubeing, and tweeting, and tweeting, tweeting, tweeting, tweeting, 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 slash 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. 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 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, and 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. 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 Denington wrote, persons with severe addictions are among those contemporary profits that we ignore profits 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 over-consumption in a world where consumption has become the all-encompassing motive of our lives. of our lives. In essence, the secret to finding balance is combining the science of desire with the wisdom of recovery. Part 1. The Pursuit of Pleasure. Chapter 1. Our Masterbation Machines. I went to greet Jacob in the waiting room. First Impression? He was in his early 60s, middle-weight, 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-hearted 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. 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 10 by 14 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, the sideboard and the low table are all made of matching British brown wood. The desk is a hand-me-down for my former department chair. It's cracked down the middle on the inside where no one else can see it an app metaphor for the work I do. On top of the desk are 10 separate piles of paper perfectly aligned like an accordion. I am told this gives the appearance of organized efficiency. The wall DCOR 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 20s. The tapestry has a coffee stain but it's only visible if you know what you're looking for, like a roar shock. On display is an assortment of nignex, from patients and students 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 10. To the left of my computer, I keep a small print of Albrick D. Rhears Melancholia 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. 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. 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. years ago when I was a 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 just stepped off the cover of A.J. Peterman catalog. The experience was jarring.

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+ 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-wheeleders, fortune-tellers, gem workers. You get the idea! At some point, tame love stories no longer satisfied, so I searched out increasingly graphic and erratic 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 in 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-savrier 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 dark fever by Karen Marie Monning 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 between patience. 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. 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 built toward the climax. I started a minute the climax. I started a minute- 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 2.0am on a weeknight reading 50 Shades of Gray. I rationalized it was a modern day telling of pride and prejudice right up until I got to the page on But Plugs and had a flash of insight that reading about sadomasochistic sex toys in the we 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 slash 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. 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 23 Jacob met and married his wife. They moved together into the three-room apartment she shared with her parents and 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 weight would be 25 years. This was typical in the 1,980S 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 site to buy their own place sooner. They started a computer business importing importing machines from Taiwan 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 provided their children with all the opportunities that Western Europe could offer. All right, not all of them good. Once we move to Germany, I discover pornography, porn kinos, life shows. This town I live in is known for this, and I cannot resist. But I manage. I manage for 10 years. I am working as a scientist, working hard, but in 1995, everything changed. What changed? I asked, already guessing the answer. The Internet. I am 42 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 50 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... and shook his head remembering. After that I start a new ritual, he said. Every time I go into hotel room, I play 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 mini bar. Nothing to do but press the lever for drug. He looked down again and the silence stretched. 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 walked to the balcony and looked 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. and trying to get addicted to it. U.S. opioid epidemic is a tragic and compelling example of this fact. The quadrupling of opioid prescribing, OxyContin, Vicodin, Duregisic fentanyl in the United States between 1,999 and 2012, combined with widespread distribution of those opioids to every corner of America, led to rising rates of opioid addiction

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+ and related deaths. A task force appointed by the Association of Schools and Programs of Public Health, ASP pH, 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 analogues, which have subsequently driven 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 the United States from the United States from the United States 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 under recognized. The reduced drinking effects of prohibition persisted through the 1,950S. Over the subsequent 30 years, as alcohol became more available again, consumption steadily increased. In the 1,990S, the percentage of Americans who drank alcohol increased by almost 50% while high drinking increased by 15%. while high-risk drinking increased by 15%. Between 2002 and 2013, diagnosable alcohol addiction rose by 50% and older adults over age 65 and 84% 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- of inherited-a-a-a-aherited-a-gen-genes, affecting gene- gene expression- gene expression, gene expression, gene expression, gene expression, gene expression, and both an 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 Cordwright has called limbic capitalism, is driving this aided by transformational technology that has increased not with the other. 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. million deaths worldwide. In 185, the German Friedrich Sirriner, while working as a pharmacist's apprentice, discovered the painkiller morphine and opioid alkaloid 10 times more potent than its precursor opium. In 1853, the Scottish physician Alexander would invented the hypodermic syringe. Both of these inventions contributed to hundreds of reports in late 19th century medical journals ofiatrogenic, 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 heroish, the German word for courageous. Heroin turned out to be two to five times more potent than morphine and gave way to the narco-maniate of the early 1900 S. Today, potent pharmaceutical grade opioids such as Oxycodone, Hydrocodone, and hydromorphone are available in every imaginable form. 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 50 to 100 times more potent than morphine. Beyond opioids, many other drugs are also more potent today than in yesterday year. Electronic cigarettes chic, discrete odorless, rechargeable nicotine delivery systems lead to higher levels of blood nicotine over shorter 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 1,960S and is available in cookies, cakes, brownies, gummy bears, blueberries, pot tarts, lozenges, oils, aromatics, aromatics, tinctics, tinctures, tinctures, 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. 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, poly pharmacy 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 used than to explain it to me. it to me. As you can see in his illustration he started at age 17 with alcohol, cigarettes, and cannabis, Mary Jane by age 18, he was snorting cocaine. At age 19 he switched to OxyContin and and Xanax. Through his 20s he used Percocet, fentanyl, ketamine, LSD, PCP, DXM, and MXE, eventually landing on opanna, a pharmaceutical grade opioid that led him to heroin, where he stayed until he came to see me at age 30. In total, he went through 14 different drugs and 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.

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+ 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, a Vietnamese immigrant, got 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 didn'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 Contagent. 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, he returned to their home country, and he spent the next three years taking care of her. 49, 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 and salty water. The higher the volume on the stereo, the higher the current. at low volume, I feel nothing. 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 $600 or I can make my own for $20. 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. He smiled, remembering, just before his face fell, anticipating what came next. Scrudinizing 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 Duto Duto, 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 20 years. He told me about the tragic case of a six-year-old boy who sodomized his younger for a year old brother.. Normally, when we get these calls, he said, it's because some adult the child has contact with his sexually abusing him, and then the kid reenaxed on another kid like his little brother. He 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 these cartoons. he decided to try it out on his little brother. Now, that kind of thing, in more than 20 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 app named 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 liked to dominate men. I introduced 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...

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+ go over. She does this ten times and other people watch and make comments. We developed 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 40s, I guess. I wanted to ask what she looked like, but since my own purrian curiosity at play here rather than his therapeutic needs, so I had a therapeutic needs. So I had a refrained. Jacob said, my wife discover all this and she says 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 stopped for a while. Maybe a month. But then I start up again. Just me and my machine, not the chat rooms. I lied to my wife, but eventually she will. But eventually she will. discover. Her therapist tell her to leave me. So my wife, she leave me. She moved 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 4 a.m. the next morning I am getting it from the trash and building it again. Jacob looked at me with pleading 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. of titillating ourselves to death. 70% 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% tobacco use, 9% high blood sugar, 6% physical inactivity, 6% and obesity 5%. 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% globally and more than 5% 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 1,900 and 2017 with more than half the deaths occurring in people younger than 50 years of age. The poor and under educated, especially those living in rich nations, are most susceptible to the problem of compulsive overconsumption. consumption. 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 and 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, fisheries, fuels will be 21 percent less than. less in high-income countries and 17% less in poorer countries than today. Meanwhile carbon emissions will grow by 7% in high-income countries and 44% 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-billed, brown hair. He had an uncertainty about him that made him brown hair. He had an uncertainty about him that made him seen younger than the 35 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 prove to be intractable and others I deemed hopeless who were surprisingly resilient 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 20-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 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 communication 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. 45 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, G.A.D. The psychologist who administered the test recommended he follow up with a psychiatrist to prescribe an anti-anxiety medication, and David said, a stimulant for my ADD. He was not offered psychotherapy or other non-medication behavioral modification. behavioral modification. David went to see a psychiatrist who prescribed Paxil, a selective serotonin re-uptake inhibitor, to treat depression and anxiety, and adder-all, a stimulant to treat ADDie. 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 have a psychiatrist. 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.

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+ 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 20 people, and I could get away with being less interactive. I could take the blue book home and work by myself. What about the adder-all? I asked. I'd take 10 milligrams first thing every morning before class. It helped me get that deep focus. But looking back, I think I just had bad steady 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. 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 seven 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 and produce a stream of positive emotions. Perhaps most telling of all, optimizes timing and variety of happiness strategies. Be intentional about when and how often. For acts of kindness, self-expariment 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. Altoism, no longer merely a good in itself, has become a vehicle for our own well-being. Philip Rife, a mid-20th 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 Exorting us to pursue happiness are not limited to the realm of psychology. Modern religion too promotes the theology of self-awareness, self-expression, and self-realization as the highest good. In his book Bad Religion, writer and religious scholar Ross Dauphin 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 dilemmis. And what guidance there is often amounts to if it feels good, do it. My patient Kevin, 19 years old, was brought to see me by his parents in 2018. 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, as psychologically 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 and later life. This notion can be traced to Freud, whose groundbreaking psycho-analytic contribution was that early childhood experiences, even those long forgotten or outside of conscious awareness, can cause lasting psychological psychological damage. Fortunately, 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 particular accomplishment, but in alphabetical order. 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 over-sanitized and over-pathologized 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 of their own character, and ignorant of their own character, own character, character, or own character, or own character, or own character, 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.

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+ 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 six, 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 pain-free world. 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 slows it down. The famous 17th century physician Thomasidnam said this about pain. 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 because it's thought to kindle the brain for the brain for future 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 20 American children takes a psychiatric drug on a daily basis. The use of antidepressants like Paxil, Prozac, and Cilexa is rising in countries all over the world, with the United States topping the list. 110 people per 1,000, ticks an antidepressant, followed by Iceland, 106, 1000, Australia, Canada, 86,000, 1000, Denmark, 85, slash 1,000, Sweden, 79, slash 1,000. Among 25 countries, Korea was last, 13, slash 1,000. Antipressant Use rose 46% in Germany in just four years, and 20% in Spain and Portugal during the same period. 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 dollars in 2011, up 19.5% from the previous year. Prescriptions of stimulants, Adderall, Ritalin, and the United States doubled between 2006 and 2016, 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, clonipin, valium, also addictive, are on the rise, perhaps to compensate for all those stimulants we're taking. Between 1,996 and 2013 in the United States, the number of adults who filled a benzodiazepine prescription prescription increased by a stimulant prescription increased. by 67% 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. seeking to distract ourselves from the present moment to be entertained. As Aldis 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 1,900ate-S classic Amusing-im 1,980S 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 and 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, Instagraming, YouTubeing, 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 open-mouthed. open-mouthed. 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 more connected to yourself to yourself to yourself to others and to yourself. 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 new thought to form without which were 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. 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 my school.

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+ 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. 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 15-hour days, and ran 30 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'd 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 aid event for anxiety before presentations. From 2008 to 2018, I was taking up to 30 milligrams of Adderall a day, 50 milligrams of Ambien a day, and 3 to 6 milligrams of 8 of 8 of a day. 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 vitamins, Adderall, Ambien, and Adevin, 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 at her all. He did it pretty well. So then what happened? I got tired of it. Tired of taking upers 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 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 Adevan and until he was no longer suicidal. It took two weeks. He was discharged. He was discharged. 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 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 expectancies saw similar decreases in self-reported happiness scores, including Belgium, Canada, Denmark, France, Japan, New Zealand, and Italy. Researchers interviewed nearly 150, 50, 50,000 people in the United States. in 26 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 1,90 and 2. 2017. The highest increases in new cases were seen in regions with the highest socio-demographic 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 have grown, complex regions. pain syndrome, fibromyalgia, interstitial cystitis, myofacial pain syndrome, pelvic pain syndrome, and so on. When researchers asked the following question to people in 30 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. 34 percent of Americans said they felt pain often or very often compared to 19% of people living in China, 18% of people living in Japan, 13% of people living in Switzerland, and 11% 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 Neuroscientific advances in the last 50 to 100 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. 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 pre-synaptic neuron.

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+ 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 was first identified as a neurotransmitter in the human brain in 1957 by two scientists working in 1957 by two scientists working independently, Arvid Carlson and his team in London, Sweden, and Kathleen Montague based outside of London. Carlson went on to win the Nobel Prize and Physiology or Medicine. Dopamine is not the only Eurotransmitter 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 tigamental area, the nucleus. Accumbents 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's reward pathway. 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. Ampetamine, the active ingredient in the street drug speed, ice, and Shaboo, as well as in medications like Adderall that are used to treat attention deficit disorder, increases the release of dopamine by thousand percent. By this accounting, one hit off a myth pipe is equal to 10 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 of 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, an 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 grimlands hopping on the pain side of the balance to counteract the weight on the pleasure side. The grimlands 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 1,970, social scientists... Richard Solomon and John Corbett called this reciprocal relationship between pleasure and paying the opponent process theory. Any prolonged or repeated departures from hedonic or effective 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 regulating systems. Yohan Wolfgang von Gerda, Ewald Herring, 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 after image. The perception of green gives way in succession to the perception to the perception of the perception of the perception of the perception of red. Red. When Green is turned on, Red can't be, and vice versa. Tolerance, neuro-adaptation. 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 recreate those good feelings or try not to let them fade away. The simple solution is to keep eating or playing or watching or reading or reading. 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 a substance to the other substance to the other 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 it. After math 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. 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 grimlands camped out on the pain side of the balance and flatable 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 2000. 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

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+ 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 Algeses, means sensitivity to pain. What's more? When these patients tapered off opioids, many of them experienced improvements in pain. Neuroscientists, Norfolkau, and colleagues have shown that heavy, prolonged consumption of high dopamine substances eventually leads to a dopamine deficit state. Folkau 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-based-shaped area of the brain associated with reward and motivation lights of 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-based region of the brain contains little or no red, indicating little or no dopamine transmission. transmission. As Dr. Focal 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 myths and go home. effects of addiction on dopamine receptors receptors 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 anedonia, which is the inability to enjoy pleasure of any kind. 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-imposis 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 Coob calls this phenomenon dysphoria-driven relapse where in a return to using is driven not by the search for pleasure but by the desire to alleviate physical and psychological suffering of protracted protracted withdrawal. Here's the good news. If we wait long enough, our brains usually read up 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 every day, simple rewards. Going for a walk watching the sun rise. Enjoying a meal with friends. People, Places, and Things. The pleasure-paying balance is triggered not only by re-exposure 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 Q-dependent learning, also known as classical Pavlovian, conditioning. Conditioning. Ivan Pavlov, who won the Nobel Prize in Physiology or Medicine in 19-4, 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, a condition queue a condition 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 condition Q, e.g. a buzzer, metronome, light, well before the reward. It self is ingested, e.g. cocaine injection. The pre-reward dopamine spike in response to the condition Q, explains the anticipatory pleasure we experience when we know good things are coming. craving. Right after the condition Q, 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. drug. My colleague Rob Malinco, 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 shoot. I 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 dopam 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 Q induced craving translate to our pleasure pain balance? The balance tips to the side of pleasure, a dopamine mini spike, an anticipation of future reward, immediately followed by a tip to the side of pain, a dopamine mini deficit, and the aftermath of the Q. dopamine many deficit in the aftermath of the Q. 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, 5 TH edition as addictive disorders. Studies indicate that dopamine release as a result of gambling links to the unpredictability 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.

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+ In a 2010 study, Jacob Leonard and his colleagues measured the dopamine release and 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 of losing and winning was nearly identical, 50% representing maximum uncertainty. Gambling disorder highlights the subtle distinction between reward and 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 strong when they win a phenomenon described as lost. 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 to high dopamine reward. 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. 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,ed, the rats stopped running. variable lifetime for 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 rat's 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 to cannabis 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 brains were working. 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 portrayed 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 linked 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 neural networks. This means that although the brain changes are permanent, we can find new synaptic-synaptic pathways to create healthy behaviors The future holds tantalizing possibilities for ways to reverse the scars of addiction. Vinson Parkoli 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 the 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 starts with a problem. 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, 1,904-1,976, 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 steady 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 29-year-old construction worker who walked into the emergency room after landing foot first on a 15-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 with fentanyl with fentanyl with fentanyl, fentanyl, 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

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+ 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, hipocampled tattoos to last a lifetime. The phylogenitically uber ancient neurological machinery for processing pleasure has remained large 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. The ultimate seekers, the ultimate seekers, have responded too much. 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 Finnekain who studies diabetes in the setting of chronic sedentary feeding said we are cacti in the rainforest. 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 21st 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 reward weary world? Part 2. Self Binding Dopamine fasting. I'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-lend 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 in the morning in the morning. Using my wax pen is the only thing that gets me out of bed. Your wax pen? Yeah, I've ate now. I used to do blunts and bongs, sativa in the daytime and endica before bed. But now I'm into concentrates. Wax, oil, buddier, shatter, scisser, dust, quisso. I mostly use a vague 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 over-consumption. 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 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 and dopamine stands for data. I begin by gathering the simple facts of consumption. In Delilas 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 fair 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 1,960S, when recreational weekends only used 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 and 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 non-functional. I mean even more non-functional than I am now. And 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, and attention, 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 neting my grief and grief. never having another baby, something I wanted and my husband did not, creating attention in our marriage and in our sex life that hadn't existed before. Peace 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... 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. except the mountain.

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+ 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. 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 donut tastes good in the moment but we are less aware that eating a donut 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 outweighs 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. 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, 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 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 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? Hmm. 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 10 years from now? No.. No way. She shook her head vigorously. How about five years from now? No, not in five years either. How about a year from now? Paws. Chuckle. I guess you got me there, document. 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 hope that quitting smoking would take on a new urgency. It seemed to have worked. The endopamine 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. effect between our substance use and the way we're feeling. To put it in terms of the pleasure paying balance, fasting from dopamine allows sufficient time for the grimlands 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 Fokau, showing that dopamine transmission is still below normal two weeks after 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, for weeks is often sufficient. Mark Shucket 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 of depressive disorder. Shuckett, 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 Mark, a gifted teacher, at a series of conferences on addiction in the early 2000 S. The depressed men in Shuckett study went into the hospital for four weeks, during which they received for four weeks, during which time they received no treatment for depression other than stopping alcohol. After one month of not drinking, 80% 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, 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% 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 for life-threatening withdrawal if they were to quit all of a sudden, as in cases of severe alcohol, benzodiazepine, Xanax, valium, or clonopin, or opioid dependence, and with

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+ 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 grimlands 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 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. 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 is separate from your thoughts, emotions, and sensations, including pain.. This practice is sometimes called mindfulness called mindfulness, mindfulness, 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-the Milky-way.-way. as we start 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 you, 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 to getting to know our brainss and our brains, 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 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 who. As a result of their mental illness 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. I 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 depended 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. 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 are 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 to gradual relaxing of my mental balance, and in 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 didn't. it. And you're not going to believe this, duck, 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 that motivated you. Because you. 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...

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+ 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. 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. of shocked. The eye 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. End stands for Next Steps. As my visit with Delilaf 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 missed 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 end 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 non-risky 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. Lila's, we strategize together for how to achieve it. 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, 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 seeing with non-caloric drugs like cocaine or whether the real driver is the genetic predisposition position of the genetic predisposition of the 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 over-consumption 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, 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 In the fall of 2017, after a year of abstaining from compulsive sexual behaviors, Jacob relapsed. He was 65 years old. The trigger was a trip to Eastern Europe to see his family, complicated by his current wife and his children from 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 mailed me from overseas to let me know he was struggling. 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 U.S. open. I lie there flipping through the channels, feeling depressed, thinking about my family and my family and my wife, and how everyone is angry at me. 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 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. You are electrical stimulation machine? Yes, he said sadly, only barely meeting my eyes. The problem is when you start, you can be an ecstasy for...

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+ 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 20 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 and repair them and use all day. On Friday night I call my sponsor and go to a sexaholic's anonymous anonymous 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 understanding. Then any time you get the idea or urge or cravingving or cravingiving to use, to use, 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 converge the mundane and the metaphysical. Nothing was too low or too high for my consideration. Tilling 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 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 over-consumption. Self-binding is not primarily a matter of will, although personal agency plays some part. openly recognizes the limitations of will. The key to creating effective self-binding is first to acknowledge the loss of voluntists 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 slash or avoiding pain is nearly impossible to resist. In the throes of desire, there is 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. 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 repurposed strategies I learned 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 asked 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? to your drug of choice. I have even used self-binding in my own life to manage problems of compulsive over-consumption. 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. predictions. 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 slash or geographical distance between ourselves and our drug drug of choice. 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 called hotels beforehand to ask them to remove the minibar. I called 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 70s with a scholarly a booming voice, and a penchant for talking in soliloquies, so much so that he made a model 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. 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. 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. 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 lock and open the drawer. to try to dismantle the lock and open the drawer. He worked with laser focus and determination.

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+ But he couldn't open the drawer. Every tool he tried failed to penetrate the lock. Then the answer dawned on him like a not 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. 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 K-safe kitchen safe might have done the trick. About the size of a bread box and made of. In order to give you clear plastic, the case 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 is 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 Naltrexon is used to treat alcohol and opioid addiction and is being used for a variety of other addictions as well, from gambling to over-reading to shopping. Naltrixon 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 flat lining of pleasure with Naltrexone. One patient said to me, now Trixon 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 run as high. We worked around this by having him take now Trixon half an hour before entering a risky drinking situation, such as a happy hour. This now Trixon, 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 38-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 naltrixon implant to block the effects of heroin. 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 with no feeling. I did not think about stopping stopping because I still had money because I still had money. 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 dysulfuram. Dysulfuram interrupts alcohol metabolism leading to the accumulation of acetaldide, which in turn causes a severe flushing reaction, nausea, vomiting, elevated blood pressure, and an overall feeling of malaise. Taking Dysulfuram 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 disulfuram, 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 disulfuram like reaction to alcohol without the drug. These individuals have historically had lower rates of alcohol addiction. 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, di-sulfuram is fallible. My patient Arnold had been drinking heavily for decades, a problem that only got worse after he got worse 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 Dysulfuram 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 got a whiskey and 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 disulfurium 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 gastrod banding, sleeve gastectomy, and gastric bypass. These surgeries effectively create a smaller stomach and slash 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. of the stomach or small intestine. The sleeve gastricomy surgically removes part of the stomach to make it smaller. Gastric bypass surgery rerutes 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.

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+ 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 to 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-sized 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 for. 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 then 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. and candy fiction. The simple act of having to go to the library or 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 will consume only on holidays on holidays. only on weekends, never before Thursday, never before 5, 0 p.m. and so on. Sometimes, rather than time per se, we bind ourselves based on milestones or accomplishments. We'll wait till our birthday or as soon as we complete an assignment or after we get our degree or once we get to promotion. When the clock has run down or we've crossed a self-designated finish line, the drug is our reward. and George Coob have shown that rats give an unlimited access to cocaine for six hours per day gradually increased their lever-pressing over time to the point of physical exhaustion and even death. Increased self-administration under extended access conditions, six hours, has also been observed with methamphetamine, nicotine, heroin, and alcohol. However, rats who have access to cocaine for only one hour per day use steady amounts of of cocaine over many consecutive days. That is, they don't press the lever for more drug per unit time with each consecutive day. This study suggests that by restricting drug consumption to a narrow window of time, we may be able to moderate our use and avoid the compulsive and escalating consumption that comes with unlimited access. Just tracking how much time we spend consuming, for example, by clocking our smartphone use, is one way to become aware of and thereby mitigate consumption. consumption. When we made conscious use of objective facts like how much time we're using, we are less able to deny them and therefore in a better position to take action. However, this can get very tricky very fast. Time has a funny way of getting away from us when we're chasing dopamine. One patient told me that when he was using methamphetamine he convinced himself that time didn't count. He felt as though he could stitch it back together back together later without anyone realizing a piece a piece that a piece had gone missing piece had gone a piece had gone missing. I imagined him floating in the night sky, big as a constellation, sewing together a rent in the universe. High dopamine goods mess with our ability to delay gratification, a phenomenon called delay discounting. Delay discounting refers to the fact that the value of a reward goes down the longer we have to wait for it. Most of us would rather get $20 today than a year from now. Our tendency to overvalue short-term rewards over longer term ones can be influenced by a many factors. One of those factors is consumption of addictive drugs and behaviors. Behavioral economist and Lion Bredeville Jensen and her colleagues investigated the discounting in active heroin and amphetamine users compared with ex-users and with matched controls, individuals matched for gender, age, education level, etc. The investigators asked the participants to imagine they had a winning lottery ticket worth 100,000 Norwegian- norwegan croner and okay. approximately $14,600.00. They then asked participants if they would rather have less money right now, less than $100,000 in OK, or the full amount a week from now. Of active drug users, 20% said they wanted the money right now and would be willing to take less to get it. Only 4% of former users and 2% of matched controls would have accepted that loss. Segarate smokers are more likely than matched controls to discount monetary monetary reward. that is, they value them less if they have to wait longer for them, the more they smoke, and the more nicotine they consume, the more they discount future rewards. These findings hold true for both hypothetical money and real money. Addiction's researcher warned Kay, Bickel and his colleagues asked people addicted to opioids and healthy controls to complete a story that started with the line. After the awakening, Bill began to think about his future. In general, he expected to. Opioid addicted steady participants referred to a future that was on average nine days long. Healthy controls referred to a future that was on average 4.7 years long. This striking difference illustrates how temporal horizons shrink when we're under the sway of an addictive drug. Conversely, when I ask my patients what was the deciding moment for them to try to get into recovery, they'll say something that expresses a long view of time. As one patient told me who had been snorting heroin for the past year, I suddenly realized I'd been using heroin for a year, and I thought to myself, if I don't stop now, I may be doing this for the rest of my life. Reflecting on the trajectory of his whole life, rather than just the present moment, allowed this young man to take a more accurate inventory of his day-to-day behaviors. The same was true of Delilah, who was willing to abstain from cannabis for four weeks only after imagining herself still smoking 10 years hence. In today's dopamine-rich ecosystem, we've all become primed for immediate gratification. We want to buy something, and the next day it shows up on our doorstep. We want to know something, and the next second the answer appears on our screen. Are we losing the knack of puzzling things out, or being frustrated while we search for the answer, or the answer, or... or having to wait for the things we want. The neuroscientist Samuel McChaseh.

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+ and his colleagues examined what parts of the brain are involved in choosing immediate versus delayed rewards. They found that when participants chose immediate rewards, emotion and reward processing parts of the brain lit up. When participants delayed their reward, the prefrontal cortex, the part of the brain involved in planning and abstract thinking became active. The implication here is that we are all now vulnerable to prefrontal cortical atrophy as our reward pathway has become the dominant driver of our life. In addition to high dopamine goods is not the only variable that influences delayed discounting. For example, those who grow up in resource-poor environments and are primed with mortality cues are more likely to value immediate rewards over delayed rewards compared to those who are similarly primed and grow up in resource-rich environments. Young Brazilians living in favelas, slums, discount future rewards more than age matched university matched university students. Any wonder that poverty is a risk factor for addiction, especially in a world of easy access to cheap dopamine? Another variable contributing to the problem of compulsive over-consumption is the growing amount of leisure time we have today, and with it the ensuing boredom. The mechanization of agriculture, manufacturing, domestic chores, and many other previously time-consuming, labor-intensive jobs has reduced the number of hours per day people spend working, leaving more time for leisure for more time for leisure. A typical day for the average laborer in the United States just before the Civil War, 1,861,1865, whether in agriculture or industry, consisted of working 10 to 12 hours a day, 6 and a half days per week, 51 weeks per year, with no more than two hours a day spent on leisure activity. Some workers, often immigrant women, work 13 hours a day, 6 days a week. a week. Others labored in slavery. By contrast, the amount of leisure time in the United States today increased by 5.1 hours per week between 1,965 and 2003, an additional 270 leisure hours per year. By 2040, the number of leisure hours in a typical day in the United States is projected to be 7.2 hours, with just 3.8 hours of daily work. The numbers for other high income countries are similar. Leisure time in the United States differs by education and socioeconomic status, but not in the way you might think. In 1965, both the less educated and more educated in the United States enjoyed about the same amount of leisure time. Today, adults living in the U.S. without a high school diploma have 42 percent more leisure time than adults with a bachelor's degree or higher, with the biggest differences in. biggest differences in. Leisure time occurring during weekday hours. This is due in large part to under employment among those without a college degree. Dopamine consumption is not just a way to fill the hours not spent working. It has also become a reason why people are not participating in the workforce. Economist Mark Agiar and his colleagues wrote in an article aptly titled Leisure Luxuries and the labor- Younger Men, ages 21 to 30, exhibited a larger decline in work hours over the last 15 years than older men or women. Since 2004, time used data show that younger men distinctly shifted their leisure to video gaming and other recreational computer activities. Writer Eric Jay, Ianelli briefly alluded to his own history of addiction as follows. Years ago, and what now seems like another life, a friend said to me, your entire existence can be reduced to a three-part cycle. One, get fucked up. Two, fuck up. Three, damage control. We hadn't known each other very long, probably two months at most, and yet he had already witnessed enough of my regular blackout drinking, just one of the more obvious manifestations of addiction self-perpetuating vortex to have got my number. With a rice mile, he went on to hypothesize more generally, and, I suspect. only half jokingly are bored or frustrated problem problem problems solvers who instr problems solvers who instinctual, contrived Houdini like situations from which to disentangle themselves when no other challenge happens to present itself. The drug becomes the reward when they succeed and the consolation prize when they fail. When I first met Muhammad he was a river of words. His thumb could barely keep up with his brain, which was teeming with ideas. I think I may have a little addiction problem, he said. I liked him immediately. and flawless English with a slight Middle Eastern accent. He told me his story. He came to the United States from the Middle East in 2007 to study undergraduate math and engineering. In his home country, drug use of any kind risked harsh punishment. After arriving in the United States, it was liberating for him to be able to use drugs recreationally without fear. To begin, he restricted drug and alcohol use to the weekends, but within the year, he was smoking cannabis daily and could see that his grades and his friendships suffered suffered as a relationship suffered as a relationship suffered. result. He told himself I'm not going to smoke again until I complete my undergraduate degree, get accepted to a master's program, and get funded for PhD. True to his promise, he did not smoke again until he completed a Stanford Master's Program in mechanical engineering and got funding for PhD. When he resumed smoking, he pledged to limit himself to weekends only. A year into his PhD, he was smoking every day and Here into his PhD, he was smoking every day, and by the end of his second year, he set new rules for himself, 10 milligram joints while working, 30 milligram joints when not working, and 300 milligram joints only on special occasions. To get really fucked up. Muhammad failed his qualifying exam, the culmination of his PhD studies. He took it a second time and failed again. He was about to be terminated from the program, but managed to convince his profession to convince his professor. to give him one last try. In the spring of 2015, Mohammed committed to abstaining until he passed his qualifying exam, however long it took. For the next year, he abstained from cannabis and worked harder than ever before. His final report was over 100 pages long. It was, he told me, one of the most positive and productive years of my life. That year he passed his qualifying exams, and the night after his exam, cannabis over to help him celebrate. At first, Muhammad declined. But his friend said, there's no way someone is smart as you can be addicted. Just this once, Mohammed told himself, and then not again till graduation. By Monday, not again till graduation became no marijuana on days that I have classes, which became no marijuana on days that I have hard classes, which became no marijuana on days that I have exams, which became no marijuana before nine. Mohammed was smart. So why couldn't he figure out that every time he smoked he wouldn't be able to stick to his self-imposed time limits? Because once he started using

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+ cannabis, he wasn't governed by reason, he was governed by the pleasure-paying balance. Even one joint created a state of wanting not easily influenced by logic. Under the influence, he could no longer objectively evaluate the immediate rewards of smoking against their long-term counterparts. Delayed discounting ruled his world. In Mohammed's case, chronological self-bindinging went only so far, and cannabis in moderation was unlikely ever to be an option. likely ever to be an option. He would have to, and eventually did, find another way. Categorical self-binding. Jacob came to see me again a week after his relapse. He hadn't used for the entire week. He put his machine in a garbage can that he knew was being carted away the same day. He also put his laptop and tablet away. He went to church for the first time in years and prayed for his family. Not thinking about myself, and my problems was a good change. I also stopped shaming myself. Mine is a sad story, but I can do something about it. He paused. But I'm not feeling good, he said. I see you on a Monday, and by Friday I think about killing myself, but I know I won't do it. It's the come down from using, I said. Let your feelings crest over you like a wave. be patient, and with time, you will feel better. And the weeks and may be better. months that followed, Jacob was able to maintain abstinence by limiting not just access to pornography, chat rooms, and. Ten units, but also to lust in any form. He stopped watching television, movies, YouTube, women's volleyball competitions, pretty much anything that presented for him a sexually provocative image. He skipped over certain types of news articles, for example, articles about Stormy Daniels, the stripper who allegedly had an affair with Donald Trump. He put his shorts on before shaving in front of the mirror in the mornings. To see his own nakedness was itself a trigger. I played with my own body for a long time. I can't do that anymore, he said. I must avoid anything that might entertain my attic mind. Categorical self-binding limits consumption by sorting dopamine into different categories, those subtypes we allow ourselves to consume and those we do not. not. This method helps us to avoid not only our drug of choice, but also the triggers that lead to craving for our drug. This strategy is especially useful for substances we can't eliminate altogether, but that we're trying to consume in a healthier way, like food, sex, and smartphones. My patient Mitch was addicted to sports betting. He had lost a million dollars gambling by the time he was 40. participating in Gambular's anonymous was an important part of his recovery. Through his involvement in gambler's anonymous, he learned that it wasn't just betting on sports he had to avoid. He also had to abstain from watching sports on TV, reading the sports page in the newspaper, surfing sports-related internet sites, and listening to sports radio. He called all the casinos in his area and had himself put on the no-admit list. By avoiding substances and behaviors beyond his drug of choice, Mitch was able to use categorical binding to mitigate the risk of reason for his risk of reason for his events. to sports betting. There's something tragic in touching about having to ban yourself. As for Jacob, hiding the naked body, his and others, was an important part of his recovery. Concealing the body as a way to minimize the risk of engaging in forbidden sexual concourse has long been a part of many cultural traditions continuing to the present day. The Quran says a female. Modesty and tell the believing women to cast down their glances and guard their private parts and not expose their adornment and to wrap a portion of their head covers over their chests and not expose their adornment. The Church of Jesus Christ of Latter-day Saints, LDS Church, has issued official statements on modest dress for its members such as discouraging short shorts and short skirts, shirts that do not cover the stomach, and clothing that does not cover the shoulders or is low-cut in the front or the back. Categorical self-binding fails when we inadvertently include a trigger in our list of acceptable activities. We can correct mistakes like these with a mental sifting process based on experience. But what about when the category itself changes? The well-worn American tradition of dieting vegetarian, vegan, raw vegan, gluten-free, Atkins, Zom, ketogenic, paleolithic, grapefruit is one example of categorical self-binding self-binding. to sue these diets for varied reasons, medical, ethical, religious. But whatever the reason, the net effect is to decrease access to large food categories, which in turn limits consumption. But diets as a form of categorical self-binding are threatened when the category changes over time as a result of market forces. More than 15% of North American households use gluten-free products. Some people are gluten-free because they have celiac disease and auto-imic disease and auto-imic disease wherein the ingestion of gluten leads to damage in the small intestine. But growing numbers of people are gluten-free because it helps them limit consumption of high-calorie, low-nutrition carbohydrates. The problem? Around 3,000 new gluten-free snack products were introduced in the U.S. from 2008 to 2010 and bakery products are the single highest-grossing packaged good category in the gluten-free market today. free market today. In 2020 the gluten-free products value in the US alone was estimated at 10.3 billion dollars. A gluten-free diet which previously had effectively limited consumption of high-calorie processed foods such as cakes cookies, crackers, cereal, pastas, and pizzas now no longer does. For those who were using the gluten-free diet to avoid gluten this might be good news. But for those who were benefiting from This might be good news. But for those who were benefiting from gluten-free as a category to limit consumption of bread, cakes, and cookies, the category no longer serves. The evolution of the gluten-free diet illustrates how attempts to control consumption are swiftly countered by modern market forces. Just one more example of the challenges inherent in our dopamine economy. There are many other modern examples of previously taboo drugs being transformed into socially acceptable. often in the guise of medicines. Cigarettes became vate pens and ZYN pouches. Heroin became oxygen. Cannabis became medical marijuana. No sooner have we committed to abstinence than our old drug reappears as a nicely packaged, affordable new product saying, hey, this is okay. I'm good for you now. Deifying the demonized is another form of categorical self-binding. Since prehistoric times, humans have elevated mind altering drugs to sacred categories to be used during religious ceremonies, rights of passage, or as medicines. In this context, only priests, shamans, or other designates who have received special training or have been invested with special authority are allowed to administer these drugs. For more than 7,

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+ years, hallucinogens, also known as psychedelics, magic mushrooms, Iowaska, Paeote, have had sacramental uses across diverse cultures. When hallucinogens became popular and widely available as recreational drugs in the counterculture movement of the 1,960 S, however, harms multiplied, leading to LSD being made illegal in most parts of the world. Today there is a movement to bring hallucinogens and other psychedelics back into use back into use. but only in the pseudo-secret context of psychedelic assisted psychotherapy. Especially trained psychiatrists and psychologists are now administering hallucinogens and other potent psychotropic agents. Salasibin, ketamine, ecstasy, as mental health remedies. Administering limited doses, one to three, of psychedelics interspersed with multiple sessions of talk therapy over many weeks has become the modern equivalent of shamanism. the modern equivalent of shamanism. The hope is that by limiting access to these drugs and by making psychiatrists gatekeepers, the mystical properties of these chemicals, a sense of oneness, transcendence of time, positive mood, and reverence can be leveraged without leading to misuse, overuse, and addictive use. Some people need neither shaman nor psychiatrist to imbue their drug of choice with the sacred. In a now famous Stanford Marshmallow experiment, at least one child in the experiment managed the sacred entirely on their own. The Stanford Marshmallow experiment was a series of studies led by psychologist Walter Mitchell in the late 1,960 S. at Stanford University to study delayed gratification. Children between the ages of three and six were offered a choice between one small reward provided immediately a marshmallow or two small rewards, two small rewards. if the child could wait for approximately 15 minutes without eating the first marshmallow. During that time, the researcher left the room and then returned. The marshmallow was placed on a plate on a table in a room that was otherwise empty of distractions, no toys, no other children. The purpose of the study was to determine when delayed gratification develops in children. Subsequent studies examined what kinds of real-life outcomes are associated with the ability or lack thereof, or lack thereof, delay gratification. The researchers discovered that of approximately 100 children, one-third made it long enough to get the second marshmallow. Age was a major determinant, the older the child, the more able to delay. In follow-up studies, children who were able to wait for the second marshmallow tended to have better SAT scores and better educational attainment, and were overall cognitively and socially better adjusted adolescents. adolescence. One detail of the experiment that is less well known is what the children did during those 15 minutes of struggling not to eat the first marshmallow. The researchers observations reveal a literal embodiment of self-binding. The children cover their eyes with their hands or turn around so that they can't see the tray. Start kicking the desk or tug on their pigtails or stroke the marshmallow as if it were a tiny stuffed animal. Covering eyes and turning away is turning away is and a physical self-binding. Tugging on pigtails suggests using physical pain as a distraction. Something I'll talk about later at length. But what of stroking the marshmallow? This child, instead of turning away from the desired object, made it a pet, far too precious to eat, or at least to eat impulsively. My patient Jasmine came to me seeking help for excessive alcohol consumption up to 10 beers every day. As part of the treatment I advised her to remove all alcohol from her home as a self-binding strategy. She mostly took my advice with a twist. She removed all alcohol save one beer which she left in her refrigerator. She called it her totemic beer which she regarded as the symbol of her choice not to drink, a representation of her will and autonomy. She told herself that she only needed to focus on not drinking that one beer rather than the more daunting task of not drinking any beer from the vast quantity available in the world. This metacognitive sleight of hand, transforming an object of temptation into a symbol of restraint, helped Jasmine abstain. Half a year into his second attempted recovery, I met Jacob in the waiting room. It had been several months since I had seen him. As soon as I laid eyes on him, I knew he was doing well. It was the way his clothes fit him, the way they hugged him, the way they hugged. his body. But it wasn't just his clothes. His skin fit him too, the way it does when a person feels connected to themselves and the world. Not that you'll find that in any psychiatry textbook. It's just something I've noticed after decades seeing patients when people get better, everything holds together and has a rightness. Jacob had a rightness to him that day. My wife is back in my life. He said once we were in my office. We still living separately separately separately. but I go to Seattle to see her and we spend two wonderful days. We are going to spend the Christmas together. I'm glad, Jacob. I am free of my obsession. I am not compelled to behave in a certain way. I am free to make decisions again about what I will do. I've got almost six months since my relapse. If I just keep doing what I am doing, I think I'm going to be okay. Better than okay. I smiled. I smiled back. The extraordinary lengths to which Jacob went to avoid anything likely to incite sexual desires seen downright medieval to our modern sensibilities, just one step removed from a hair shirt. Yet far from feeling constrained by his new way of living, he felt liberated. Released from the grips of compulsive overconsumption, he was again able to interact with other people and the world with joy, curiosity, and spontaneity. He felt a certain dignity. As Emmanuel Kant wrote in the metaphysics of morals, when we realize that we are capable of this inner legislation, the natural man feels himself compelled to reverence for the moral man and his own person. Binding ourselves is a way to be free. Chapter 6. A Broken Balance? I'm hoping, Chris said, sitting in my office, adjusting his backpack, pushing back the hair that had fallen into his eyes, jingling his knee. his eyes jingling his knee I would learn over the ensuing years that he was always in motion that you will continue my buprenorphine. It's been helpful. Actually that's an understatement. I'm not sure I'd be alive without it and I need to find. Someone who can prescribe it for me. Buprinorphine is a semisynthetic opioid derived from the baean, distilled from the opium poppy. Like other opioids, Buprinorphine binds to the opioid receptor, providing immediate relief from pain and opioid craving. In the simplest terms, it works by bringing the pleasure pain balance back to a level position so that someone like Chris can stop battling craving and get back to living his life. The evidence is robust that Buprinorphine decreasesens illicit illicit illicit opioid use. reduces the risk of overdose and improves quality of life.

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+ But there's no glossing over the fact that Buppronorphine is an opioid that can be misused, diverted, and sold on the street. For people who aren't dependent on stronger opioids, Buppronorphine can create a euphoric high. People on Buppronorphine experience opioid withdrawal and craving when they stop or decrease the dose. In fact, I've had some patients tell me that the withdrawal from Buppronorphine, is far worse than anything they experienced with heroin or OxyContinotin. tell me your story, I said to Chris, and then I'll let you know what I think." Chris arrived at Stanford in 2003. His stepfather drove him up from Arkansas in an old borrowed Chevy suburban. The SUV, packed full of Chris's belongings, stood out among the shiny new B&Ws and Lexus's crowding the entrance to student housing. Chris didn't waste time. He organized his dorm room with meticulous precision, starting with his CD collection, which he arranged for in alphabetical order. He studied the course catalog and settled on creative writing, Greek philosophy, and myth and modernity in German culture. He dreamed of becoming a composer, a film director, and author. His plans, like those of his fellow students, were grand. This would be his illustrious Stanford beginning. Once classes began, Chris did well in all the expected ways. He studied hard. He got excellent grades. He studied hard. He got excellent grades. But on another level, he was not thriving. He attended his classes alone, studied in his room or the library alone, played the piano in the common room of his dorm alone. That favorite campus buzzword, community, eluded him. Most of us looking back on our early college days will remember struggling to find our people. Chris struggled more. It's hard to say, even now, exactly why. He's a good-looking young man. Thoughtful. Afible. Eager to please. Perhaps it had something to do with being that poor kid from Arkansas. His solitary campus existence continued into his sophomore year until he met a girl at his part-time campus job. His chiseled features, soft brown hair and wiry, muscular build had always attracted attention. He and the girl, a fellow undergraduate, kissed and Chris fell instantly in love. When she told him she had a boyfriend, he decided it didn't matter. He wanted to be with her and repeatedly sought her out. When he didn't give up, she accused him of stalking her and reported him to their mutual boss. As a result, he lost his job and was reprimanded by school administration. Without a job or a girlfriend, he decided there was only one solution, he would kill himself. Chris wrote a parting email to his mother, Ma, I wore clean underwear. He borrowed a knife, took his CD player and a carefully selected CD and made his way to Roblefield. It was dusk, and his plan was to swallow a bottle of pills, cut his wrists, and time his death with the setting son. Music was important to Chris and he chose his final song with care. PDA by Interpol, a New York indie post-punk revival band. PDA is rhythmic and pounding. The lyrics are hard to make out. The last stanza goes like this, this, sleep tonight, sleep tonight, sleep tonight, sleep tonight, sleep tonight. Something to say, something to do, nothing to say, there's nothing to do. Chris waited till the very end of the song, then pulled the sharp edge of the knife across each wrist. Trying to kill yourself by slitting your wrists in an open field turns out not to be a very effective strategy. Half an hour later, the blood on his wrists had congealed, and he was sitting in the dark, watching people walk by. sitting in the dark watching people walk by. He went back to his dorm room, made himself vomit up the pills, and called 911. The paramedics came and took him to Stanford Hospital, where he got admitted to the psych ward. His stepfather was the first to visit him. His mother planned to come too, but was unable to board the plane. She had a long-standing fear of flying. His biological father, whom he saw several times per year, also showed up, also showed up. His father looked stricken when he saw the red, raised incisions on Christopher's wrists. Chris stayed on the psychiatric ward for a total of two weeks. During that time, he mostly felt relieved to be in a contained, controlled, and predictable environment. A representative from Stanford University came to visit him on the unit and informed him that, under the circumstances, he would be forced to take a medical leave from Stanford until he recovered sufficiently to be able to return. and discretion of the university. Chris went back to Arkansas to live with his mother and stepfather. He got a job waiting tables. He discovered drugs. In the fall of 2007, Chris returned to Stanford. Before he could enroll for the fall quarter, he needed to meet with the head of student mental health. And his resident dean to update them on his progress and present a convincing argument for re-enrolling. for re-enrolling. The day before his meeting, he stayed with a girl he had known at Stanford. He hadn't known her well, but she was troubled too, so Chris felt more comfortable asking if he could crash at her place for a night or two while he got himself squared away with the university. The night before his interview, Chris stayed up doing coke and reading Freud's civilization and its discontent. By morning he concluded he was too messed up to meet with a bunch of college administrators. He flew home the same day. Chris spent the next year shoveling dirt, spreading mulch, and mowing lawns in 100 plus degree weather for the University of Arkansas. He liked the physicality of it, the way that moving his body distracted him from his thoughts. He got promoted to Arborist, which mostly involved sheving tree trunks and branches into a wood chipper. composing music, score after score, while smoking cannabis, which had become indispensable to him. Chris returned to Stanford again the next fall. No in-person meeting was required this time. Chris showed up to his dorm jack-reacher style, nothing but a toothbrush in his pocket and a laptop in his hand. He slipped on his mattress in his clothes, no sheets. He willed himself to be structured, something he recognized he would need to be successful he would need to be successful to be successful to be successful. he would need to be successful. As part of his new mindset he changed his major. He would study chemistry now. He also vowed to quit smoking cannabis but his resolve lasted only three days before he was back to smoking daily, hiding out in his room, trying to time it for when his roommate, whom he remembered merely as some Indian guy, wasn't around. At midterm time, Chris reasoned that since he'd most of his steady time high, he should be high for his midterms. Something about state-dependent learning that he'd read about in his psychology class. He made it to the second question before realizing he didn't know the material and was unable to complete the exam. He stood up and walked out, throwing his test in the garbage on the way. He was on a plane home the next...

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+ day. Leaving Stanford the third time felt different for Chris. It was tinged with hopelessness. When he got home, he had no ambition at all, not even to continue composing music. He began drinking heavily, in addition to smoking cannabis. Then he tried opioids for the first time, which was easy to do in Arkansas in 2009, when opioid manufacturers and distributors were pumping millions of opioid paying pills into the state. year, doctors in Arkansas wrote 116 opioid prescriptions per 100 persons living in Arkansas. While taking opioids, everything Chris thought he had been searching for suddenly seen just within reach. Yes, he felt euphoric, but that wasn't the key. The key was he felt connected. He began calling relatives and other people he knew, talking, sharing, confiding. The connections seemed real as long as he was doped, but disappeared as he was doped, but disappeared as he was dope but were off. Drug manufactured intimacy, he learned, didn't last. An intermittent pattern of opioid use followed Chris to his next attempt at matriculating at Stanford. When he returned in the fall of 2009, now his fourth attempt, he was chronologically and geographically marginalized from his undergraduate peers. He was five years older than the average sophomore. He was placed in graduate student housing, where he shared a two-bedroom apartment with a graduate student with a and particle physics. They had little in common and worked hard to stay out of each other's way. He developed a routine that revolved around studying and drug use. He had given up on the idea of trying to quit. He had come to think of himself as a confirmed drug addict. He smoked cannabis alone in his bedroom every day. Every Friday night he went up to San Francisco alone to get heroin. A single shot on the street cost him. cost him $15. A $15. for a rush that lasted 5 to 15 seconds and an afterglow that persisted for hours. He smoked more cannabis to ease the come down. Midway through the first quarter, he sold his laptop to buy more heroin. Then he sold his coat. He remembered being cold as he wandered the streets of the city. He tried once to make friends with two British students in his language class. He told them he wanted to make a movie with them in it. with them in it. He had begun to take an interest in photography and sometimes wandered the campus taking pictures. They seemed initially charmed but when he told them his idea for the movie to film them speaking in American accents while eating they demurred and avoided him thereafter. I guess I've always been odd like that. Odd ideas. That's why I don't ever want to tell people what I'm thinking. Through it all, Chris went to class and got as, except one be in the interpersonal basis of abnormal behavior. He went home at Christmas and didn't return. In the fall of 2010, Chris made one last half-hearted attempt to matriculate at Stanford. He rented a room off campus in Menlo Park and declared yet another new major human biology. A few days in, he stole paying pills from his landlady and got a prescription for Ambien, which he crushed and injected. He made it five miserable months, then left Stanford with no hopes this time of ever returning. Back home in Arkansas, Chris spent his days getting high. He would shoot up in the morning, and when it wore off hours later, he would lie in his bed in his parents' home, willing time to pass. The loop seemed endless and inescapable. of 2011, Chris got caught by police stealing ice cream while intoxicated. He was offered jail or rehab. He chose rehab. On April 1, 2011 and rehab, Chris was started on a medication called Bupprenorphine, better known by the trade named Suboxone. Chris credits Bupprenorphine with saving his life. After two years of stability on Bupprenorphine, Chris decided to make one final attempt at returning to Stanford. In 2013, he rented a bed in a trailer home from an elderly Chinese man. He couldn't afford anything else. In his first month on campus, he came to me looking for help. Of course, I agreed to prescribe Bupernorphine for Chris. Three years later he graduated with honors and went on to get a PhD. His odd ideas, it turned out, were well suited to the laboratory. In 2017, he married his girlfriend. his girlfriend. about his past and understood why he took Buppronorphine. She sometimes lamented his robotic lack of emotion, especially his apparent lack of anger when she felt anger was warranted. But basically, life was good. Chris was no longer overwhelmed by craving, rage, and other intolerable emotions. He spent his days in the laboratory and rushed home after work to see his wife. They were soon expecting their first child. One day in 2019, I said One day in 2019, I said to Chris during one of our monthly sessions, you are doing so well and have been for so long, have you thought about trying to get off of Booprenorphine? His answer was definitive. I don't ever want to get off of Booprenorphine. It was like a light switch for me. It didn't just prevent me from doing heroin. It gave my body something I needed and couldn't find anywhere else. Medications to restore a level balance? I've thought often about what Chris said that day, about Bupprenorphine giving him something he couldn't find anywhere else. Had prolonged drug use broken his pleasure-paying balance such that he would need opioids for the rest of his life just to feel normal? Perhaps some people's brains lose the plasticity necessary to restore homeostasis even after prolonged abstinence. Perhaps even after the grimelens dismount, their balance remains permanently waiting permanently waiting permanently waiting, to the side of pain. Or was Chris saying that opioids corrected a chemical imbalance he was born with? When I went through medical school and residency in the 1,990S, I was taught that people with depression, anxiety, attention deficit, cognitive distortions, sleep problems, and so on of brains that don't work the way they're supposed to. Just like people with diabetes have a pancreas that doesn't secrete enough insulin. My job, according to the theory, is to replace the missing chemical so people can function normally. This messaging was widely disseminated and aggressively promoted by the pharmaceutical industry and found a receptive audience in doctors and patient consumers alike. Or maybe Chris was saying something different still. Maybe he was saying that Bupprenorphine made up for a deficit not in his brain, but in the world. Maybe the world let Chris down, and Bupprenorphine was the best way he could function so best way he could function normally he could function normally can function normally as a good. see to adapt. Whether the problem was in Chris's brain or in the world, whether it was caused by prolonged drug use or a problem he was born with, here are some of the things I worry about in using medications to press on the pleasure side of the balance. First, any drug that presses on the pleasure side has the potential to be addictive. David, the college student who got hooked on prescription prescription stimulants, is living proof that getting stimulants from a diagnosed medical condition.

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+ condition does not confer immunity to the problems of dependence and addiction. Prescription stimulants are the molecular equivalent of street methamphetamine, ice, speed, crank, Christina, no-dows, scooby-snacks. They cause a surge of dopamine in the brain's reward pathway and have a high potential for abuse, a direct quote from the food and drug administration's warning for Adderall. Second, what if these drugs don't actually work the way they're supposed to or worse yet make it, make. symptoms worse in the long run. Although Bupernorphine was working for Chris, the evidence for psychotropic medications more generally is not robust, especially when taken long term. Despite substantial increases in funding in four high-resourced countries, Australia, Canada, England, and the US for psychiatric medications like antidepressants, Prozac, angiolytics, Xanax, and hypnotics, Ambien, the the prevalence of mood and anxiety symptoms in these countries. has not decreased, 1,990 to 2015. These findings persist even when controlling for increases in risk factors for mental illness such as poverty and trauma, and even when studying severe mental illness such as schizophrenia. Patients with anxiety and insomnia who take benzodiazepines, Xanax and clonopin, and others sedative hypnotics daily for more than a month may experience worsened anxiety and insomnia. who take opioids daily for more than a month are at increased risk not only for opioid addiction but also for worse and pain. As mentioned earlier this is the process called opioid induced hyperalgesia that is opioids making pain worse with repeated doses. Medications like Adderall and Ritalin prescribed for attention deficit disorder promote short-term memory and attention but there is little or no evidence for long-term complex cognition improved scholarship or higher good. grades. As public health psychologist Gretchen Lafiever Watson and her co-authors wrote in the ADHD drug abuse crisis on American College. Campuses, compelling new evidence indicates that ADHD drug treatment is associated with deterioration in academic and social emotional functioning. Recent data show that even antidepressants previously thought not to be habit-forming may lead to tolerance and dependence and possibly even make depression worse over the long-term. a phenomenon called Tartive Dysforia. Beyond the problem of addiction and the question of whether or not these drugs help, I've been plagued by a deeper question. What if taking psychotropic drugs is causing us to lose some essential aspect of our humanity? In 1993, the psychiatrist Dr. Peter Kramer published his groundbreaking book Listening to Prozac, in which he argued that antidepressants make people better than well. But what if Kramer got it wrong? What if instead of making us better than well, psychotropic drugs make us other than well? I've had many patients over the years who have told me that their psychiatric medications, while offering short-term relief from painful emotions, also limit their ability to experience the full range of emotions, especially powerful emotions like grief and awe. One patient who seemed to be doing well on antidepressants, told me she no longer cried at Olympics commercials. at Olympics commercials. She laughed when she talked about it, happily forfeiting the sentimental side of her personality for relief from depression and anxiety. But when she couldn't even cry at her own mother's funeral, the balance for her had tipped. She went off antidepressants and a short time later experienced a wider emotional amplitude, including more depression and anxiety. She decided the loaves were worth it were worth it to feel human. Another patient of mine who tapered off high dose OxyContin, which she'd taken for over a decade for chronic pain, came back to see me months later with her husband. It was my first time meeting him. He tired of so many doctors over so many years. My wife on Oxy, he said, stopped listening to music. Now off of that stuff she enjoys, music again. For me, it feels like I got back the person I married. experiences with psychotropic medication. Restless and irritable from childhood I was, for my mother, a difficult child to raise. She struggled to help me temper my moods and in the process felt bad about herself as a parent or at least that's my interpretation of the past. She admits she preferred my brother, docile and biddable. I preferred him too and he effectively raised me when my mother threw up her hands in frustration. In my 20s I started on In my 20s, I started on Prozac for chronic low-grade irritability and anxiety diagnosed as atypical depression. I felt better right away. Mostly, I stopped asking the big questions, what is our purpose? Do we have free will? Why do we suffer? Is there God? Instead, I just sort of got on with it. Also for the first time in my life, my mother and I got along. She found me pleasant to be around, and I enjoyed being more pleasing. I fit her better. When I went off Prozak some years later in anticipation of trying to get pregnant, I reverted to my old self, cranky, questioning, restless. Almost immediately, my mother and I were at odds again. The very air in the room. to crackle when we were both in it. Our relationship decades later is marginally better. We do best when we interact least. This makes me sad because I love my mom and I know she loves me. But I don't regret going off Prozac. My non-Prozac personality, although not a good fit for my mom, has allowed me to do things I never would have done otherwise. Today. today, I'm finally okay with being a somewhat anxiousous, slightly depressed skeptic. needs friction, a challenge, something to work for or fight against. I won't widdle myself down to fit the world. Should any of us? In medicating ourselves to adapt to the world, what kind of world are we settling for? Under the guise of treating pain and mental illness, are we rendering large segments of the population biomeklemically indifferent to intolerable circumstance? Worsh yet have psychotropic medications become a means of social control of the poor, especially of the poor, or not yet? unemployed and disenfranchised. Psychiatric drugs are prescribed more often and in larger amounts to poor people, especially poor children. According to the 2011 data from the National Health Interview Survey of the CDC's National Center for Health Statistics, 7.5% of American children between the ages of 6 and 17 took a prescribed medication for emotional and behavioral difficulties. Poor children were more likely to take psychiatric medication. than those not living in poverty, 9.2% versus 6.6%, boys were more likely than girls to be medicated. Non-Hispanic whites were more likely than people of color to be medicated. Based on the extrapolation of Georgia Medicaid data to the rest of the nation, as many as 10,000 toddlers may be receiving psychostemulent medications like Ritalin.