The “Addict” in All of Us: The Surprising Places Where Addiction Exists, Dr. Anna Lembke, MD | Bottom Line Advocator With Sarah Hiner

Key Takeaways

  • The three C’s of addiction: control use, compulsive use, continued use despite harm to self or others
  • Addiction isn’t about how often you use or how much you use, it’s about whether you use even though the drug has impacted relationships, health, or any important aspect of life
  • You can be addicted to substances or behaviors
  • Trends in addiction are changing – it’s happening later in life and equally among men and women
  • COVID-19 has split people with addiction into two camps: (1) those thriving because shutdowns afforded less opportunity for use and abuse ; (2) those who have relapsed possibly because of loss of control, fear, anxiety, or financial stress
  • If you struggle with addiction or addictive tendencies it’s helpful to structure your day – lack of structure and trigger to stress then vulnerability then addictive behavior
  • Al-anon and Co-dependents Anonymous are both organizations for people with loved ones who struggle with addiction


Anna Lembke, MD,a psychiatrist, assistant professor and Chief of Addiction Medicine at Stanford University School of Medicine in California. She has published more than 50 peer-reviewed articles, chapters and commentaries, and is the author of Drug Dealer, MD: How Doctors Were Duped, Patients Got Hooked, and Why It’s So Hard to Stop.

On this episode of Bottom Line Advocator, host Sarah Hiner speaks with addiction specialist Dr. Anna Lembke (@drugdealermd) to discuss the impact of COVID-19 on addiction, risk factors for addiction, and how to address addiction in yourself or loved ones.

Host: Sarah Hiner (@sarahiner)

What Is Addiction?

  • “Addiction is the continued compulsive use of substance or behavior despite harm to self or others” – Dr. Anna Lemke
  • Addiction is marked by the three C’s: control use, compulsive use, continued use despite harm to self or others
  • Addiction isn’t about how often you use or how much you use, it’s about whether you use even though the drug has impacted relationships, health, or any important aspect of life
  • Culture plays a huge role in how we perceive the drug and how comfortable we are with its use

How Does Addiction Start?

  • Most people who try a substance or behavior will not become addicted
  • The natural history of addiction is similar regardless of the substance of addiction
  • Addiction trajectory: tried it once and felt something positive, used it again to have fun or solve a problem (e.g., boredom, need help sleeping, etc.)
  • Dopamine is our pleasure neurotransmitter
  • When we do something positive or pleasing, we initially get more dopamine
  • Drugs or things that are addictive release a lot more dopamine than things that are not addictive
  • When the brain gets a hit of dopamine, it down-regulates dopamine and gets into a deficit state – so you look to reinforce that good feeling again
  • The reward system is good in a state of scarcity, the problem is we live in a land of plenty

Age & Gender Trends In Addiction

  • It used to be that people would present with addiction in teen years – in the past 20-30 years, addiction age has shifted to older adults
  • Sometimes people have been able to use drug of choice in moderation but increased gradually and became addicted
  • Historically, the majority of people with substance use disorders were men – now it’s almost 1:1 across genders
  • Men have more “process addictions” such as gaming, gambling, porn

Nature, Nurture, Neighborhood

  • The risk factors can be categorized into nature, nurture, and neighborhood
  • There is a heritable risk or addiction – about 50-75% is based on genes
  • People with a biological parent or grandparent with alcohol abuse are at elevated risk (4x) of addiction
  • Once you become addicted to something, you’re more likely to become addicted to another substance or behavior
  • Innate/nature risks for addiction: genetics, emotional dysregulation, inability to delay gratification, co-occurring psychiatric disorders
  • Nurture risks for addiction: people who experience childhood trauma, children with parents who implicitly/explicitly condone substance use
  • Neighborhood: people who live in areas where drugs are sold on the corner are more likely to become addicted because it’s easier to get access and widely available
  • With normalization, use goes up

Dichotomous Personalities Of Addiction

  • What we assume could be a trigger for someone might actually be helpful in terms of addiction, whereas someone else may respond differently
  • Some individuals with addiction thrive and do much better in periods of high stress and uncertainty
  • Some individuals with addictive tendencies struggle in times of peace and joy
  • People with addiction tend to need some friction in their lives

Impact Of COVID-19 On Addiction

  • The pandemic has triggered addiction struggles in people who have previously recovered, those who have previously been able to avoid it, and those who have never had any issues
  • In people who already have substance use disorder, there have been two groups: (1) people doing better as a result of shelter in place – less likely to go out, get invited places with temptation, less shopping which can trigger purchases
  • The second group (2) individuals who had been in recovery and relapsed – this group likely dealt with financial stressors, anxiety, feeling out of control, depression
  • About 10% of the U.S. population will experience a substance abuse disorder at some point in their lifetime

COVID-19 And Drug Overdose

  • It’s misleading to make a blanket statement that drug overdose deaths increased in 2020
  • The reality is that timespan looks at May 2019 – May 2020 which is only a few months into the pandemic
  • It is true that this period marks the highest ever recorded drug overdose deaths, but difficult to parse out effects of pandemic alone
  • Once 2020 data is analyzed, we will have a more comprehensive picture of the effect of COVID-19 on drug overdose
  • Note, this podcast was released February 2, 2021

Non-Drug Addictions

  • Addiction doesn’t just mean drugs – you can be addicted to food, television, internet, gaming, porn, etc.
  • People in the United States are drinking more alcohol sheltering in place during COVID-19  
  • During the pandemic, the benchmarks we use for orienting our lives have been lost – work, school, hobbies have been derailed
  • Many people also don’t have to go to work or work from home so there’s a tendency to sleep later, wake up later
  • We’re also spending more screen time which triggers addiction to video games, online, social media
  • Potential correlates of non-drug addiction: fear, anxiety, depression, loss of control, loss of structure  
  • Food is manufactured to be reinforcing so you can’t have just one
  • Potato chips are manufactured to be palatable – they have salt, fat, and sometimes sugar added
  • There is a biochemical aspect to sugar and carbohydrate addiction

Steps To Take If You Struggle With Addiction/Addictive Tendencies

  • Structure your day: lack of structure contributes to stress, which contributes to vulnerability and addiction
  • Reach out for help
  • Go to a meeting and listen to other stories
  • Articulating to someone is often a turning point: identify trusted friend or family member to confide in about behavior
  • Even if you aren’t sure you meet criteria for addiction, you can set up a consultation with someone to discuss it and strategize to reign in behaviors you may be worried about

How To Handle People With Addiction In Your Life

  • People with addiction get good at leading a double life to hide the problem
  • Signs to look for: changes in appetite, weight, loss of interest in former activities
  • An addicted person can convince themselves that behavior is normal and denial takes over
  • It can be difficult but talk to the person directly in an intentional way
  • Don’t place blame, use language like “I feel scared when I see you up until 3 am playing video games and unable to wake up for work the next day” – and then let the other person respond
  • Al-anon and Co-dependents Anonymous are both organizations for people with loved ones who struggle with addiction
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