DOPAMINE NATION:

Finding Balance in the Age of Indulgence

Anna Lembke, MD
Professor of Psychiatry and Medical Director of Addiction Medicine
Stanford University School of Medicine
Dakota Medical Foundation Summit
August 15, 2023
 Disclosures
• I do not receive any funding, fees, stock options, or other
compensation from companies that make, market, or disseminate
medical products.
• I have been retained as a medical expert witness in federal, state, and
county opioid litigation against opioid manufacturers, distributors,
and pharmacies.
 Learning objectives
• The Pleasure-Pain Balance: How It Works

• The Plenty Paradox: The Mismatch between our Primitive Wiring and
the Modern Ecosystem

• What to Do About It: Abstain, Maintain, Seek out Pain

The Pleasure-Pain Balance
 The reward circuit

Image from Dopamine Nation: Finding Balance in the Age of Indulgence,

Dutton Penguin Random House, 2021
Dopamine as a human neurotransmitter

Image from Dopamine Nation: Finding Balance in the Age of Indulgence,

Dutton Penguin Random House, 2021
Dopamine as a universal currency

Image from Dopamine Nation: Finding Balance in the Age of Indulgence,

Dutton Penguin Random House, 2021
Dopamine and movement

Copyright@2006 Nature Publishing Group, Nature Reviews

 The Pleasure Pain Balance

Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 The opponent-process mechanism

Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 The opponent-process mechanism

Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 Neuroadaptation

Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 Changing the hedonic setpoint

Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
The dopamine-deficit state

Volkow ND, et al, Behavioural Pharmacology

2002;13:355–366
Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 The balance remembers

Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 The developing brain

Paul M. Thompson, Ph.D. Laboratory of Neuro Imaging, UCLA,

NIMH/UCLA
 The Plenty Paradox:
Overabundance is itself a stressor caused
by the mismatch between our primitive
wiring and the modern dopamine-rich
ecosystem
In 2021, adults in the U.S. spent on average eight hours
and five minutes with digital media each day.
What to Do About It
Three levels of intervention
• Individual/Family

• Community

• Legislature
Individual/Family
• Abstain

• Maintain

• Seek out pain

Abstain
 Maintain (Self-Binding)
• Space:
• Delete apps
• Physically separate from the phone (leave it at home)
• Create tech free spaces (bedrooms)
• Time
• Digital intermittent fasting (dopamine fasting)
• Create tech free times (meals)
• Schedule time for mindless scrolling?
• Meaning
• Be intentional about how to use the device before going on the device
• Assert neurological freedom: Hide the Like-button, turn off alerts and notifications,
go grayscale
• Values-Based Internet Use: No lying or hiding use (radical honesty) “Can I see your
phone?”
Seek out pain? The science of hormesis

Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,

Dutton Penguin Random House, 2021
Image from Lembke, Anna. Dopamine Nation: Finding Balance in the Age of Indulgence,
Dutton Penguin Random House, 2021
 Hormesis: Paying for our dopamine up front
by unplugging and doing things that are hard
• Exercising • Making music/playing an
• Taking ice cold water plunges instrument
• Intermittent fasting • Reading a hard book
• Praying • Talking to the barista, shopkeeper,
storekeeper instead of ordering
• Meditating with the App
• Cooking (unplugged) • Walking or biking instead of driving
• Gardening (unplugged) • Writing a thank-you note
• Caring for pets (unplugged) • Reaching out to old friends,
• Spending time with children parents, grandparents
(unplugged) • Telling the truth
• Being in nature • Saying we’re sorry
Dealing with boredom!!!
 ReSet Your Tech Life
• 1 Go on a digital fast Don’t touch your phone – or any screens – for 24 hours. The aim is to
interrupt your physiology and reset dopamine reward pathways. In truth, 24 hours is probably not
enough, but it may make you realize how addicted you are.
• 2 Optimize your chance of success by setting a date and time for going cold turkey. Tell people
you’ll be out of contact and make plans for what you’ll do in this time. Trust me: it will feel very
long. Time slows when we stop chasing dopamine.
• 3 Anticipate the symptoms of withdrawal: anxiety, irritability, insomnia, dysphoria, craving. Just
know these are time limited and with continued abstinence will lessen or go away entirely.
• 4 When you get intense cravings to check your phone, take a cold bath, do 20 sit-ups or clean the
closet. In other words, rather than switch addictions to something else that makes you feel good,
invite pain as a way to reset the balance.
• 5 When the fast is over, plan how to reintegrate digital devices without letting them take over
your life. Write down the ways your fast made you feel better and keep it with you; before even
opening your device again, make a list of what you plan to do and set a time limit; use strategies
such as turning off alerts and deleting apps.
Community/Legislature
• Access (least difficult)

• Design

• Content (most difficult)

Access
Access
• The Chinese government limiting access of children to videogames:
• Uses facial recognition software to verify
• Holds the companies that make and profit from the games responsible
• Probably only possible in an authoritarian government
• But consider our drinking and cigarette laws

• State of Louisiana limiting access of children to pornography

websites:
• Site visitors required to verify they’re over 18 before accessing Pornhub and
other pornographic sites
• Uses digital ID service to verify. Doesn’t identify who you are.
Design
• Stop promoted content
• The AI algorithms learn what we’ve liked before and then send more potent,
novel versions of the same
• Leads to extreme content, usually negative
• Leads to polarizing communities
• Stop the streaks and ranks and other quantitative comparisons that
drive overuse
• Make it easier for users to opt-out, de-subscribe, de-finance, etc
• Make it easier for parents to monitor use
• Require companies to share their user data and be responsible for
harmful use (California SB 680)
 Thanks for listening
[email protected]