Dopamine Nation: Finding Balance in the Age of Indulgence

“But if we do that, you and I, we miss an opportunity to appreciate something crucial about the way we live now: We are all, of a sort, engaged with our own masturbation machines.”

Lembke’s use of the third-person here indicates that although Jacob’s problematic behavior is perhaps shocking, people shouldn’t see it as an opportunity to distance themselves from the way it happened. Addiction like Jacob’s can happen to anyone—when they least expect it and even against their will.

“I was struck by how much hotel rooms are like latter-day Skinner boxes: a bed, a TV, and a minibar. Nothing to do but press the lever for drug.”

Lembke uses analogy here to elaborate on her point that dopamine reward is seemingly always made available. In this case, the Skinner box, a term named after psychologist B. F. Skinner, is apt in that the hotel room actually resembles the confinement of the box that Skinner used to see how reward and punishment shape involuntary movements.

“I worry that we have both oversanitized and overpathologized childhood, raising our children in the equivalent of a padded cell, with no way to injure themselves but also no means to ready themselves for the world. By protecting our children from adversity, have we made them deathly afraid of it?”

Lembke editorializes somewhat here. She buffers the starkness of the claim implied in the last sentence of this passage by framing it as a question. This little bit of ambiguity helps her stay on a more generalized discussion of how modern society interacts with pain rather than having to defend a more definitive thesis.

“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.”

At various places throughout the text, Lembke discusses the American opioid epidemic. Here, she cites data as a means of supporting her point that modern medicine has gone overboard in the treatment of pain. Lembke lets the numbers presented speak for themselves.

“The reason we’re all so miserable may be because we’re working so hard to avoid being miserable.”

Lembke uses this comment at the very end of Chapter 2 to summarize it. She presents a paradox—a device she uses frequently throughout the text—to emphasize an irony inherent in pain avoidance in modern society.

“Neurotransmitters are like baseballs. The pitcher is the presynaptic neuron. The catcher is the postsynaptic neuron. The space between pitcher and catcher is the synaptic cleft. Just as the ball is thrown between pitcher and catcher, neurotransmitters bridge the distance between neurons.”

Lembke uses analogy here to provide a visual for the scientific terminology that describes the experience of pleasure or pain. Lembke uses analogy throughout the text to help make it more digestible for laypeople.

“What’s more, when these patients tapered off opioids, many of them experienced improvements in pain.”

This comment comes toward the end of Lembke’s discussion on tolerance. What it reveals is the inverse of what might be expected. Because sustained opioid use keeps the pleasure-pain balance pressed to the side of pain, when people come off the drug, their brains naturally seek the balance; hence some experience greater pain relief.

“The paradox is that hedonism, the pursuit of pleasure for its own sake, leads to anhedonia, which is the inability to enjoy pleasure of any kind.”

Again, Lembke uses paradox. In this instance, she’s referring to the limits of pursuing pleasure. It has a cost, and that cost yields a permanent return to the state that the pleasure seeking was attempting to avoid.

“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.”

Once again, Lembke subverts expectations. First, she draws attention to how people with addictions have generally been regarded over time. Then, she attributes to them the qualities of a sage.

“This framework is easily remembered by the acronym DOPAMINE.”

Lembke has developed a framework based on clinical experience. In the book, she uses the acronym to organize the discussion of the components of a successful recovery from addictive and compulsive behaviors. She lists and details each of these components—“Data,” “Objective,” “Problems,” “Abstinence,” “Mindfulness,” “Insight,” “Next step,” and “Experiment.”

“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.”

As she often does, Lembke presents a balanced view in this passage. She’s discussing gastric bypass surgery, and she points out that it’s a marvelous advancement in medicine but that it comes with a cost. In addition, the passage includes a critique of modern food culture, which—like much of what she discusses in the book—presents people with constant temptation.

“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 pain pills into the state. In that same year, doctors in Arkansas wrote 116 opioid prescriptions per 100 persons living in Arkansas.”

Lembke offers shocking information here but doesn’t embellish the data or express her outrage about a common practice during the height of the opioid epidemic in the US. The numbers she cites are astonishing, and her objective tone allows them to speak for themselves.

“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.”

This passage is the closest Lembke comes to an explicit criticism of the pharmaceutical industry. Here, she brings up the prevailing mindset to show how she differs. Her loosely veiled criticism is really a method to highlight the contrast between how medicine has evolved toward overprescription of medicine and her practice of treating the whole patient, through a program that includes therapy, in her approach to addiction treatment.

“Getting stimulants from a doctor for a diagnosed medical condition does not confer immunity to the problems of dependence and addiction.”

Lembke points out that getting prescription treatment for one thing can lead to a whole new series of problems relating to addictive behaviors. Often, patients who are prescribed highly addictive medicine—including stimulants, opioids, and benzodiazepines in particular—don’t fully realize the elevated increase in risk for addiction because their focus is on the ailment that led them to seek treatment in the first place. A doctor’s prescribing a drug doesn’t make it any less addictive.

“In medicating ourselves to adapt to the world, what kind of world are we settling for?”

Lembke poses a rhetorical question here to force people to consider the answer for themselves. In the context of the discussion in this section of Chapter 6, Lembke suggests that society shouldn’t settle for the kind of world that requires chemical supplements to help people deal with it.

“For most of human history, people bathed in cold water. Only those living near a natural hot spring could regularly enjoy a hot bath. No wonder people back then stayed dirtier.”

The passage highlights a relatively rare touch of humor. Because the subject allows it, she takes the opportunity to have a little fun. In addition, the comment provides a convenient transition into a brief discussion on evolutionary biology. Heated water piped into the home is a relatively new concept in the history of society and provides a far easier bathing experience than earlier civilizations had.

“With intermittent exposure to pain, our natural hedonic set point gets weighted to the side of pleasure, such that we become less vulnerable to pain and more able to feel pleasure over time.”

Lembke’s discussion on people who intentionally seek discomfort and pain generally shows how it can yield an increased sense of pleasure. However, like much else that ends in pleasure, seeking pain and discomfort can lead to compulsive behavior, as she’s apt to point out. Additionally, in extreme cases, oversaturation of pain-seeking behavior can lead to a state in which a person can feel pleasure only after pain.

“Exercise has a more profound and sustained positive effect on mood, anxiety, cognition, energy, and sleep than any pill I can prescribe.”

Lembke doesn’t preach that exercise is so good that people should do it more regularly. She simply states the fact and allows the message to settle without implying that some kind of judgment awaits should they not take the advice. Her tone once again is forthright but not pedantic.

“The question is, how does telling the truth improve our lives?”

The passage highlights another use of the rhetorical question, and the answer is subjective. There really is no definitive answer. After posing this question, Lembke points out that telling the truth can be difficult but that it’s important for people to do so as much as possible.

“The Odysseus myth highlights a key feature of behavior change: Recounting our experiences gives us mastery over them.”

Lembke alludes to Homer’s Odyssey earlier in the book and returns to it here to show how people can really gain mastery over their past only by being honest about it. Those who can’t honestly come to grips with the truth of their past miss the opportunity that authentic self-narration provides in the long run.

“Telling the truth draws people in, especially when we’re willing to expose our own vulnerabilities. This is counterintuitive because we assume that unmasking the less desirable aspects of ourselves will drive people away. It logically makes sense that people would distance themselves when they learn about our character flaws and transgressions. In fact, the opposite happens. People come closer.”

Lembke returns indirectly to the rhetorical question she posed earlier in the chapter (Quote 20). In this passage, she provides a rationale for why telling the truth is important: It sets people free from the burdens they impose on themselves by lying. Lembke points out how the concept is counterintuitive because people tend to think it’s wiser to avoid full self-disclosure rather than embrace it.

“The victim narrative reflects a wider societal trend in which we’re all prone to seeing ourselves as the victims of circumstance and deserving of compensation or reward for our suffering.”

Lembke only occasionally strays from her primary discussion to offer wider editorial commentary of social trends, as in this passage. Her point here isn’t so much to offer a social critique as to show how a victim mentality can pose a trap and lead to the overindulgence that can become addiction.

“When it comes to compulsive overconsumption, shame is an inherently tricky concept. It can be the vehicle for perpetuating the behavior as well as the impetus for stopping it.”

A recurring motif in the book is the idea that common perception tends to overlook nuance. This quote recalls Lembke’s discussion on opioid misuse and how it can lead to the reverse of the drug’s intent, or cause the effects that its use intends to subdue. In this case, shame can backfire: Depending on how a person experiences it, shame can result in increasing addictive behavior.