In Dopamine Nation, psychiatrist and author Dr Anna Lembke writes about “finding balance in the age of indulgence”. The following edited excerpt examines the abundance of high-reward, high-dopamine stimuli in the modern world, and how this has affected our tolerance for pain and threshold for pleasure.
Imagine our brains contain a balance – a scale with a fulcrum in the center. When nothing is on the balance, it’s level with the ground. When we experience pleasure, dopamine is released in our reward pathway and the balance tips to the side of pleasure. The more our balance tips, and the faster it tips, the more pleasure we feel.
“Dopamine Nation: Finding balance in the age of indulgence” is published by Headline (United Kingdom) and Penguin Random House (United States)
But here’s the important thing about the balance: it wants to remain level, that is, in equilibrium. It does not want to be tipped for very long to one side or another. Hence, every time the balance tips toward pleasure, powerful self-regulating mechanisms kick into action to bring it level again. These self-regulating mechanisms do not require conscious thought or an act of will. They just happen, like a reflex.
Once the balance is level, it keeps going, tipping an equal and opposite amount to the side of pain.
In the 1970s, social scientists Richard Solomon and John Corbit called this reciprocal relationship between pleasure and pain the opponent-process theory: “Any prolonged or repeated departures from hedonic or affective neutrality…have a cost”. That cost is an “after-reaction” that is opposite in value to the stimulus. Or as the old saying goes, ‘What goes up must come down’.
Tolerance (neuroadaptation)
We’ve all experienced craving in the aftermath of pleasure. Whether it’s reaching for a second potato chip or clicking the link for another round of video games, it’s natural to want to re-create those good feelings or try not to let them fade away. The simple solution is to keep eating, or playing, or watching, or reading. But there’s a problem with that.
When our balance is tilted to the pain side, we crave our drug just to feel normal (a level balance)
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, we need more of our drug of choice to get the same effect.
Needing more of a substance to feel pleasure, or experiencing less pleasure at a given dose, is called tolerance. Tolerance is an important factor in the development of addiction.
With prolonged, heavy drug use, the pleasure–pain balance eventually gets weighted to the side of pain. Our hedonic (pleasure) set point changes as our capacity to experience pleasure goes down and our vulnerability to pain goes up.
I became acutely aware of this effect of high-dopamine addictive substances on the brain’s reward pathway in the early 2000s, when I started seeing more patients coming in to clinic on high-dose, long-term opioid therapy (think OxyContin, Vicodin, morphine, fentanyl) for chronic pain. Despite prolonged and high-dose opioid medications, their pain had only gotten worse over time. Why? Because exposure to opioids had caused their brain to reset its pleasure–pain balance to the side of pain. Now their original pain was worse, and they had new pain in parts of their body that used to be pain free.
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.
A pleasure–pain balance tilted to the side of pain is what drives people to relapse even after sustained periods of abstinence. When our balance is tilted to the pain side, we crave our drug just to feel normal (a level balance).
The balance is only a metaphor
In real life, pleasure and pain are more complex than the workings of a balance.
Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death
With prolonged and repeated exposure to pleasurable stimuli, our capacity to tolerate pain decreases, and our threshold for experiencing pleasure increases.
By imprinting instant and permanent memory, we are unable to forget the lessons of pleasure and pain even when we want to: hippocampal tattoos to last a lifetime.
The phylogenetically uber-ancient neurological machinery for processing pleasure and pain has remained largely intact throughout evolution and across species. It is perfectly adapted for a world of scarcity. Without pleasure we wouldn’t eat, drink, or reproduce. Without pain we wouldn’t protect ourselves from injury and death. By raising our neural set point with repeated pleasures, we become endless strivers, never satisfied with what we have, always looking for more.
But herein lies the problem. Human beings, the ultimate seekers, have responded too well to the challenge of pursuing pleasure and avoiding pain. As a result, we’ve transformed the world from a place of scarcity to a place of overwhelming abundance.
Our brains are not evolved for this world of plenty. As I once heard Dr Tom Finucane, who studies diabetes in the setting of chronic sedentary feeding, say, “We are cacti in the rain forest”. And like cacti adapted to an arid climate, we are drowning in dopamine.
The net effect is that we now need more reward to feel pleasure, and less injury to feel pain. This recalibration is occurring not just at the level of the individual but also at the level of nations. Which invites the question: How do we survive and thrive in this new ecosystem? How do we raise our children? What new ways of thinking and acting will be required of us as denizens of the twenty-first century?
This text was extracted from Dopamine Nation by Anna Lembke, which is published by Headline (United Kingdom) and Penguin Random House (United States). It was edited for the SSA website by Natalie Davies.
Dr Anna Lembke is professor of psychiatry at Stanford University School of Medicine and chief of the Stanford Addiction Medicine Dual Diagnosis Clinic. A clinician scholar, she has published more than a hundred peer-reviewed papers, book chapters, and commentaries. She sits on the board of several state and national addiction-focused organisations, has testified before various committees in the United States House of Representatives and Senate, keeps an active speaking calendar, and maintains a thriving clinical practice.
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