Addiction broadly defined is the continued and compulsive consumption of a substance or behavior (gambling, gaming, sex) despite its harm to self and/or others. What happened to me is trivial compared to the lives of those with overpowering addiction, but it speaks to the growing problem of compulsive overconsumption that we all face today, even when our lives are good. I have a kind and loving husband, great kids, meaningful work, freedom, autonomy, and relative wealth— no trauma, social dislocation, poverty, unemployment, or other risk factors for addiction. Yet I was compulsively retreating further and further into a fantasy world.

In an attempt to find a less addictive opioid painkiller to replace morphine, chemists came up with a brand-new compound, which they named “heroin” for heroisch, the German word for “courageous.” Heroin turned out to be two to five times more potent than morphine and gave way to the narcomania of the early 1900s.

In 2014, a middle-aged patient walked into my office sucking on a bright red fentanyl lollipop. Fentanyl, a synthetic opioid, is fifty to one hundred times more potent than morphine.

By contrast, doctors today are expected to eliminate all pain lest they fail in their role as compassionate healers. Pain in any form is considered dangerous, not just because it hurts but also because it’s thought to kindle the brain for future pain by leaving a neurological wound that never heals. The paradigm shift around pain has translated into massive prescribing of feel-good pills. Today, more than one in four American adults— and more than one in twenty American children—takes a psychiatric drug on a daily basis.

Researchers interviewed nearly 150,000 people in twenty-six countries to determine the prevalence of generalized anxiety disorder, defined as excessive and uncontrollable worry that adversely affected their life. They found that richer countries had higher rates of anxiety than poor ones. The authors wrote, “The disorder is significantly more prevalent and impairing in high-income countries than in low- or middle-income countries.” The number of new cases of depression worldwide increased 50 percent between 1990 and 2017. The highest increases in new cases were seen in regions with the highest sociodemo-graphic index (income), especially North America.

Dopamine may play a bigger role in the motivation to get a reward than the pleasure of the reward itself. Wanting more than liking. Genetically engineered mice unable to make dopamine will not seek out food, and will starve to death even when food is placed just inches from their mouth. Yet if food is put directly into their mouth, they will chew and eat the food, and seem to enjoy it.

Right after the conditioned cue, brain dopamine firing decreases not just to baseline levels (the brain has a tonic level of dopamine firing even in the absence of rewards), but below baseline levels. This transient dopamine mini-deficit state is what motivates us to seek out our reward. Dopamine levels below baseline drive craving. Craving translates into purposeful activity to obtain the drug.

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 Dr. Tom Finucane, who studies diabetes in the setting of chronic sedentary feeding, said, “We are cacti in the rain forest.” And like cacti adapted to an arid climate, we are drowning in dopamine.

Addictions researcher Warren K. Bickel and his colleagues asked people addicted to opioids and healthy controls to complete a story that started with the line: “After awakening, Bill began to think about his future. In general, he expected to . . .” Opioid-addicted study participants referred to a future that was on average nine days long. Healthy controls referred to a future that was on average 4.7 years long. This striking difference illustrates how “temporal horizons” shrink when we’re under the sway of an addictive drug.

For example, those who grow up in resource-poor environments and are primed with mortality cues are more likely to value immediate rewards over delayed rewards compared to those who are similarly primed and grow up in resource-rich environments. Young Brazilians living in favelas (slums) discount future rewards more than age-matched university students. Is it any wonder that poverty is a risk factor for addiction, especially in a world of easy access to cheap dopamine?

Patients with pain who take opioids daily for more than a month are at increased risk not only for opioid addiction but also for worsened pain. As mentioned earlier, this is the process called opioid-induced hyperalgesia, that is, opioids making pain worse with repeated doses.

In particular, those behaviors that seem excessive, gratuitous, or even irrational in existing religious institutions, such as wearing certain hairstyles or certain clothing, abstaining from various foods or forms of modern technology, or refusing certain medical treatments, are rational when understood as a cost to the individual to reduce free riding within an organization. You might think that religious organizations and other social groups that are more relaxed, with fewer rules and strictures, would attract a larger group of followers. Not so. “Stricter churches” achieve a larger following and are generally more successful than freewheeling ones because they ferret out free riders and offer more robust club goods.

Lessons of the Balance

1. The relentless pursuit of pleasure (and avoidance of pain) leads to pain.
2. Recovery begins with abstinence.
3. Abstinence resets the brain’s reward pathway and with it our capacity to take joy in simpler pleasures.
4. Self-binding creates literal and metacognitive space between desire and consumption, a modern necessity in our dopamine-overloaded world.
5. Medications can restore homeostasis, but consider what we lose by medicating away our pain.
6. Pressing on the pain side resets our balance to the side of pleasure.
7. Beware of getting addicted to pain.
8. Radical honesty promotes awareness, enhances intimacy, and fosters a plenty mindset.
9. Prosocial shame affirms that we belong to the human tribe.
10. Instead of running away from the world, we can find escape by immersing ourselves in it.