Anna Lembke is an American psychiatrist, Program Director of the Stanford Addiction Medicine Fellowship, and Chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. In her recent bestselling book Dopamine Nation, Lembke compiles decades of research and expertise on addiction. She also tells personal anecdotes of patients from her clinical practice. As she sees it, their addiction experiences are not as distant from our lives as we might think. Instead, their stories are like those of a prophet, teaching us who we truly are. Living in a culture primarily motivated by high-dopamine rewards, it has become crucial that we all learn how to balance pleasure and pain.

Broadly defined, addiction “is the continued and compulsive consumption of a substance or behavior … despite its harm to self and/or others.” Several risk factors lead people to become addicts, such as poverty, trauma, unemployment, and biological predisposition. However, modern people’s most significant risk factors are “easy access” and “constant exposure” to addictive substances and behaviors. With the aid of technology, capitalism has created a loop of supply and demand, particularly motivated by dopamine. As people fall prey to different compulsive consumptions, our society has increased the supply, variety, and potency of addictive wellsprings—which puts all of us at risk. Historian David Courtwright labeled this phenomenon “limbic capitalism.” 

Innovative technologies, machines, and medical advancements offer the general public an increasing supply of potent substances, as well as new ways to consume them. For instance, the creation of the cigarette-rolling machine in 1880 ultimately gave way to the odorless and low-profile electronic cigarettes that target teenagers today. These e-cigarettes come in different flavors and supply high levels of nicotine in short bouts of inhalation. Another tragic example of this phenomenon is the opioid epidemic, aided by the pharmaceutical discovery of the pain-killer morphine and the invention of the hypodermic syringe. Today people can find and consume opioids in every imaginable form, from lollipops and pills to injections and nasal sprays. 

We are well aware of the increasing availability of drugs like cocaine, alcohol, and social media. But our dopamine-devoted economy constantly exposes us to new drugs in disguised ways. It is hard to find a place that is free of any addictive stimuli. Even hotel rooms offer “a bed, a TV, and a minibar”—an environment perfectly suited for pornographic and alcoholic benders. When it comes to addiction, we can no longer afford to point fingers or think only a few people are at risk. It can happen to all of us—we are all surrounded by old and new drugs, all the time, every day.

Dopamine is a neurotransmitter that makes us feel pleasure. The addictive potential of any drug or behavior is measured by how much and how fast it triggers a dopamine release in the brain. 

The region of the brain that processes dopamine also processes pain. Lembke uses the metaphor of a balance to explain how they work together. When dopamine is released, the balance tips to the side of pleasure; the more and faster it tips, the more pleasure we feel. However, the balance wants to remain level. It does not want to tip too much to either side, so the balance self-regulates. This built-in system that seeks to maintain a balance between pleasure and pain is called homeostasis and is present in every living organism.

Pleasure has a price. If the balance tips towards pleasure for a long time and very intensely, it tries to self-regulate and tips to the same amount on the side of pain. The more we engage in a pleasurable activity, the weaker and shorter the balance tips to the side of pleasure, and the stronger and longer the balance counters on the side of pain. In other words, if we expose ourselves to prolonged and dopamine-heavy experiences, our brains will feel painful stimuli more easily and have a harder time feeling pleasure. This lack of sensitivity to pleasure is called tolerance and makes us crave faster and stronger dopamine releases. But as mentioned, this eventually makes the balance tip harder to the side of pain and numbs us to pleasure even more. Indulgence actually causes pain.

The good news is that if we wait long enough, our brain (usually) recovers from the absence of the drug and restores a healthy balance. We become satisfied again by simple pleasures like talking to a friend and going for a walk in nature. The bad news is that addictions alter our brains forever by changing the size and shape of dopamine-producing neurons. This means that if a recovering addict uses cocaine after years of being sober, his brain will ask for the same dopamine load that he used previously. After just one exposure and regardless of how many years of abstinence, an addict's brain will respond to the drug as if he had never really been sober. 

Until fairly recently, the world was a place of scarce resources. Our brains adapted to function perfectly in that world. But we have transformed the world into a place of neverending pleasures. By overwhelming our brain's threshold sensibility for pleasure, we have exposed it to more pain.

Lembke recalls one of her patients named Kevin, a 19-year-old male who could not attend school, maintain a job, or help out at home. He was depressed, anxious, and unmotivated. When Kevin spoke about his life philosophy, Lembke was shocked. “I do whatever I want,” he said. If he wanted to play video games, he would play video games. If he craved coke, his dealer would deliver it to his house. If he wanted sex, he would find someone online and have sex with them. Kevin’s parents told Lembke that they feared they would “traumatize” their son if they did not treat him positively and with compassion. They actively protected their son from stress and discomforts. Lembke quickly saw that the cause of his psychological problem was not related to abuse or neglect, but to being a spoiled kid. 

Kevin’s problem was familiar to Lembke. It had to do with the confusion that individual happiness was synonymous with the “good life.” Modern culture values hedonism: the cultivation of all desires without restraint. Despite having every advantage in life—a loving family, a good education, financial prosperity, and good health—many of Lembke’s patients struggled to get out of bed. They used drugs to cope with unbearable emptiness and psychological pain. 

The cult of happiness has been reinforced by religion and even medicine. New religious trends implement a theology of “God Within,” which encourages people to increase their own comfort, happiness, and prosperity. These new religious sects have reduced moral responsibility to “compassion” and “kindness” but offer people no tools to face the real and profound problems of life. 

The medical industry has also joined the cult of happiness. Despite scientific data showing that painkillers slow down recovery, supplying opioids to patients is standard practice. Our values are twisted. We expect doctors to alleviate pain even to the detriment of our recovery. In 2012, enough opioids were prescribed for every single American to have a personal bottle of pills. That year, these feel-good pills caused more deaths than guns and car accidents. 

Painkillers, prosperity doctrines, hypersexuality, and videogames are only few of the things designed to help us escape the pains and discomforts of living. A swipe and a click on social media can quickly alleviate our loneliness. A line of coke can cure boredom. Smoking cannabis can drown our social anxiety. We think we are escaping pain, but in reality, we are making the pain worse. Easily adjustable behaviors such as smoking, physical inactivity, and diet cause 70 percent of global deaths. Despite living in times of increasing wealth, technological progress, and medical innovation, we are killing ourselves with drugs to avoid feeling miserable, bored, and lonely.

On one occasion, Lembke and her patient Michael discussed his recovery from addiction to cocaine. Michael always craved something that would boost his energy. When he found cocaine as a teen, he told himself he would only use it recreationally. By the time Michael was an adult, he was married and wealthy. But all throughout, he remained an avid user. At age 35, his marriage was suffering due to his addiction, and he resolved to look for help. For Michael, quitting was not hard. However, the feelings of sadness, anger, and shame that sobriety brought to the surface were unbearable. 

To keep himself busy, Michel began playing tennis. Due to withdrawal symptoms, he would sweat for hours after training, so the coach suggested he try cold showers. To Michael’s surprise, cold showers not only fixed the sweating but also improved his overall mood. After making them a daily habit, Michael reported feeling the same high that he felt with cocaine, but without any harmful effects. Eventually, Michael got his entire community into cold exposure. He would organize cold-water parties with his friends and their children. Whereas his cocaine use threatened his life and marriage, his love for cold exposure built community and made everyone happier. 

What occurs on the pleasure side of our brain’s balance also occurs on the pain side. If we push on the side of pain, our body strives for homeostasis, so it levels out on the side of pleasure. Exposure to pain desensitizes us to pain and makes us more responsive to pleasure. In the same way that seeking feel-good substances makes us unhealthy, intermittent and balanced pain exposure makes us healthy. Painful stimuli, such as cold, heat, radiation, and food restriction—in the right amount—improve body functionality. 

A study shows that ice baths increase dopamine concentration in the body by 250 percent. After a cold bath, dopamine levels remain elevated above normal for up to two hours. Another (more controversial) study suggested that the Japanese citizens partially exposed to radiation from the 1964 nuclear attacks had longer lifespans and lower cancer rates than those without radiation exposure. In rodents and monkeys, intermittent fasting and caloric restriction has been shown to reduce blood pressure and improve heart rate variability. The pain of exercise also has excellent benefits. At the cellular level, exercise deprives the body of oxygen and glucose and puts it in a state of toxicity (a state usually thought to harm an organism). However, these pain exposures at the cellular level lead to improved physical and mental health overall. 

Nevertheless, the pursuit of pain, like the pursuit of pleasure, has a dark side. Too much pain and we risk becoming addicted to it. Lembke also treated patients with these kinds of addictions. One of them ran compulsively even after acquiring bone injuries. Another cut her wrist, forearms, and thighs with a razor blade to alleviate mental angst. 

Self-imposed challenges and exposure to pain make us feel better in the long run, as long as we experience them in moderation. They can also help us stay away from harmful dopamine-based drugs. If we can cultivate the right amount of pain, we can heal our bodies and increase our joy. The perfect balance can be summed up in the famous quote by philosopher Friedrich Nietzche: “What doesn’t kill me makes me stronger.”

Telling the truth is crucial for recovery from addiction. Most of us are averse to telling the truth because we fear people will reject us if they know our weaknesses and flaws. Of course, this could not be further from the truth. In fact, sharing vulnerabilities is a very attractive quality. Letting others see our entire humanity (blemishes and all) makes people feel safe and invited to share theirs. Though we might have to face painful consequences at first, being radically honest with big and small things helps us become aware of our actions and form deeper relationships. When we speak the truth we invite ourselves and others to be less alone. 

Our inclination to lie is borne out of our desire to get rewards we have not earned, be they social, emotional, or economic. But when we tell the truth, we free ourselves from our dependency on immediate positive rewards and pursue what is healthy for ourselves and others in the long run. When we are radically honest, we promote human intimacy, which leads to a release of oxytocin and an increase of dopamine in the brain. 

In contrast, when we consume high-dopamine goods, we become numb to the good feelings we get from being connected to other people. Drugs numb us from the rewards we get from being close to others, leading to isolation and indifference. Experiments show that a rat will always try to save a fellow rat trapped in a plastic bottle—unless the free rat has consumed heroin. Then, the rat will be so occupied by compulsive cravings that it won’t care to save another rat. 

If we learn to be honest with ourselves about ourselves, we gain freedom and authenticity. Social media has made telling the truth about ourselves challenging. It has presented us with positive rewards for fabricating a false personae with no resemblance to reality. One of Lembke’s patients, Tony, had this kind of double life. According to social media, he exercised first thing in the morning, worked on his artistic ventures throughout the day, and had received numerous awards. In real life, Tony was bedridden and addicted to pornography. He had become suicidal and struggled to find a meaningful job. Lying is a form of defense against the demands or stressors the world imposes on us. In short, it is a way to avoid pain. If we do it enough, we will eventually feel detached and divided from ourselves. In psychiatric terms, this is known as depersonalization, and it often contributes to suicidal thoughts.

Fortunately, telling the truth to ourselves and others is contagious. In her practice, Lembke has noticed that patients who initiate a journey of recovery from addiction often create a chain of recovery for people around them who are also addicted. She has seen wives who quit drinking inspire their overeater husbands to pursue healthy diets, spouses who become sober influence their wives to cut out infidelity, and parents who kick cannabis motivate their kids to also quit.

Throughout the book, Lembke threads her own struggles with addiction. For her, it all began with the vampiric romantic saga Twilight. She thought it was perfect—equal parts thriller, romance, and fantasy. Enthusiastic, Lembke got her hands on every vampire romance novel she could find, eventually expanding her taste to werewolves, witches, soothsayers, mind readers, and so on. Once those stopped doing the trick, she began reading erotica. Things escalated when Lembke purchased a Kindle. Now she could quickly access steamy books in just a few clicks and hide them easily from her coworkers, patients, and kids. In her weakest moments, Lembke read erotica on her Kindle between sessions with patients. With time, she began skipping through the books to find the episodes of sexual tension and release where the hero and heroine would finally have sex. At 2 am one morning, Lembke found herself reading about sadomasochistic sex toys in her newly acquired book, Fifty Shades of Grey. 

The fantasy world of erotica had alienated her from her husband and kids, and it affected her sleep and performance in her clinical practice. To recover from her addiction, Lembke made a conscious effort to immerse herself in the world her addiction led her to neglect. She focused on the things she loved about her work. She focused her energy into building relationships with her patients. Eventually, Lembke re-established a dopamine balance and once again felt more satisfaction from her vocation than from badly-written pornographic fiction.

Another one of her patients, named Muhammad, used the same approach. After many failed attempts to stop using cannabis, Muhammad went on a hiking trip, hoping to find solace doing something he once loved. 

Without realizing it, Muhammad had walked into the same hiking trail he and his college friends would visit while intoxicated. Painful memories and the unbearable craving for cannabis began to hunt him as he hiked. At a particularly scenic viewpoint, where he and a friend used to smoke, Muhammad noticed a nearby plant. When he got closer, he saw a bug sitting on one of its leaves. He grabbed his camera and zoomed in. It was a beetle with hairy legs and a beautiful bright red shell. Captivated, he took picture after picture of the bug, and began hunting for more of the insects. Muhammad spent the remainder of his trek intensely focused on shooting close-ups of many different varieties of beetles. His cannabis longing waned.

To overcome compulsive behavior, Lembke compels you “to find a way to immerse yourself in the life you’ve been given.” Instead of trying to escape from discomfort and pain, she urges us to take a pause, find stillness, and turn around to the source of our fear. When we look our discomfort in the face, we should walk toward it (slowly) and resist all temptations to escape it. Our “hypermedicated, overstimulated, pleasure-saturated” culture will make this process difficult. Because what lies ahead is hidden, we will need to cultivate our faith and lean into the journey of our lives one step at a time, trusting the answers will be revealed in time. As we step into the unknown, this peculiar, lovely, and ample world will once again reveal itself to us. A world worth our attention and affection—full of beauty for our delight.