“Well, I did it! And you’re not going to believe this, Doc, 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 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 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, rushing off to do it.
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. I’m honestly kind
of shocked.”
—
The
i 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.
N
Stands for Next Steps
As my visit with Delilah 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 miss 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
n 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, nonrisky 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
Delilah’s, we strategize together for how to achieve it. Through a gradual
process of trial and error, 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, and continue to use heavily 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 seen with noncaloric drugs like cocaine; or whether the real driver is the
genetic predisposition of 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 overconsumption, 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
(homeostasis) and renew our capacity to experience pleasure in many
different forms.
