How Doctors Think — with Dmitry Sokolov, MD
How Doctors Think explores health, performance, and longevity through clear, evidence-based conversations with clinicians, researchers, and other domain experts.
Hosted by Dmitry Sokolov, MD, the podcast examines how physiology, habits, and judgement shape real-world outcomes — especially in high-stakes areas such as productivity, surgery, recovery, metabolic health, and long-term performance.
It also explores uncertainty and the real-life problems faced by highly successful professionals in a rapidly changing world, shaped by accelerating AI and wider social and economic instability.
How Doctors Think — with Dmitry Sokolov, MD
Your Coffee Stopped Working Years Ago
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Your morning coffee stopped working years ago. You adjusted so gradually that you never noticed the moment it stopped giving you something and started preventing you from losing something. That distinction – between a substance that enhances performance and one that prevents withdrawal – is one most professionals never examine.
Caffeine's primary action is adenosine receptor antagonism. Adenosine accumulates during waking hours and produces the sensation of sleep pressure. Caffeine blocks the receptors and the signal is temporarily masked. But with chronic daily exposure the brain upregulates those receptors – it grows more of them and increases their sensitivity. After months of regular use, the morning coffee is not enhancing cognitive performance above the natural baseline. It is restoring performance to approximately where it would have been if you had never started.
Withdrawal is not caused by residual caffeine. It is caused by the adapted brain, now with excess receptors and no stimulant to block them. Days 3 to 5 are cognitively debilitating enough that most people interpret the experience as evidence they cannot function without caffeine, and the cycle resumes. By week 2, receptor downregulation has begun and a different quality of cognition becomes available. Almost nobody reaches week 2.
You can find a companion essay for this podcast episode at dmitrysokolovmd.com.
Your morning coffee stopped working years ago. You adjusted so gradually that you never noticed the moment it stopped giving you something and started preventing you from losing something. That distinction between a substance that enhances your performance and a substance that prevents withdrawal is one that most professionals never examine. Because coffee, tea, caffeine appears to us all essential. In the morning, locked in focus and ultimately making it through the day feels impossible without it. I want to walk through what is actually happening, pharmacologically, physiologically, and psychologically, in the daily rhythm of a highly functioning adult who has been using caffeine for a decade or more. Because it's not just a coffee habit, it's a cycle that has a cost almost nobody accounts for. Responsibility changes how our brain allocates energy. Early in a career, cognitive demand is episodic. You work and then you recover. Performance is followed by rest. But somewhere between 35 and 45 hits the time when a structural shift occurs. You stop having tasks and become the person the tasks depend on. Your decisions now affect employees, patients, clients, children, and mortgage, aging parents. And the brain responds to this not as stress or anxiety, but as permanent vigilance. And the difference matters immensely. Stress and anxiety anticipate threat, vigilance anticipates obligation. Your nervous system is no longer preparing for danger, it is preparing to be needed continuously without a defined endpoint. The biological consequence is subtle but measurable. You stop waking up restored because your brain never fully exits monitoring mode. Your sleep still occurs, but recovery decreases. And gradually, a small rational adjustment appears. Morning caffeine no longer feels like stimulation, it feels like normalization. You're not trying to feel energized, you're trying to feel baseline. Then the afternoon arrives. Around 1 to 3 p.m., we get this specific experience. Not sleepiness, but rather decision resistance. You can work, but you cannot initiate demanding thinking. So the second caffeine appears, not for energy, but for executive function. And by evening, you end up not alert, but wired. And while alert is a state of readiness, wired is a state of inability to stop. The engine is still running, but you need it to stop because tomorrow starts in seven hours and the cycle begins again. So what does a responsible professional do at 9 p.m. when the caffeine is still circulating and the nervous system will not stand down? They reach for the break. Magnesium-3N8, apigenin, ashvagandha, glycine, L-theanine, melissa lavender oil, GABA, melatonin of desperate. An entire pharmacological counter operation designed to suppress the arousal that the morning pharmacology created. Just think about what this actually is. You're not managing your health, you're running a stimulant sedative cycle. Full accelerator in the morning, full brake in the evening, every single day. And instead of cruising in a car built for endurance, you're torturing a high performance engine from one set of traffic lights to the next, flooring it off the line, then slamming the brakes 200 meters later, and then wondering why the machine is wearing out. The evening supplement stack is not wellness, it's damage control. And it exists because the morning and daytime caffeine disrupted the very system the evening stack is trying to restore. The person doing this is not irresponsible. They're intelligent, often medically literate, sometimes following protocols recommended by the people they respect. But the logic is circular. You take the stimulant because you're tired, and you're tired because the stimulant degraded the recovery that would have prevented the tiredness. The mechanism behind this is well understood, and it is worth knowing because it changes how you interpret your own experience. Caffeine's primary action in the brain is adenazine receptor antagonism. Adenazine is a neurotransmitter that accumulates during waking hours and produces the subjective sensation of tiredness and sleepiness, what neuroscientists call sleep pressure. Caffeine blocks adenazine receptors, primarily A1 and A2A, thus preventing adenosine from binding. The result is temporary. You feel more alert because the sleep signal is being masked. But our brain adapts. With chronic daily caffeine exposure, even modest amounts, even green tea, the brain upregulates adenosine receptors. It grows more of them and increases their sensitivity. This is the tolerance mechanism. After weeks or months of regular use, the original dose of caffeine no longer produces the same effect, not because your coffee stopped working, but because now there are more receptors to block than when you started. And here is the part that matters. When you drink your morning coffee, you're no longer enhancing your cognitive performance above the natural baseline. Instead, you are restoring your performance to approximately where it would have been if you had never started using caffeine at all. The drug is not adding anything, it is preventing the withdrawal symptoms that it caused. This has been demonstrated in controlled studies. Habitual caffeine users who are tested after overnight abstinence show impaired cognitive performance, which caffeine corrects. But when compared to never users, their caffeinated performance is not superior. The boost is restoration, not enhancement. The entire subjective experience of caffeine helping you, the clarity, the focus, the sense that you cannot function without it, is a pharmacological illusion maintained by dependency. Now let's be careful here, because the scope is beyond the binary narrative. Caffeine is a tool. In acute intermittent use, before a specific demanding task, after a night of poor sleep, or during a period that genuinely requires supraphysiological alertness, it works. The ergogenic evidence is robust, reaction time improves, endurance improves, cognitive performance genuinely enhances. So the problem is not the molecule, the problem is daily chronic use, which converts a genuine performance tool into a dependency maintenance program. Most professionals are not using caffeine as a tool. They're using it as infrastructure. It's built into the architecture of the day so deeply that they have completely forgotten their actual baseline, the cognitive state they would inhabit without any pharmacological input. They literally don't know what their brain feels like unassisted. And the absence of this knowledge is what keeps the cycle running, because every time they skip caffeine, they feel terrible and interpret that feeling as evidence that they need it. There is a reason why most people never break the cycle, and it's not lack of willpower, it is genuinely medically alarmingly unpleasant nature of withdrawal. Caffeine's half-life varies considerably between individuals, anywhere from 1 to 9 hours with most people in the 3 to 7 range. What this means in practice is that the drug itself is cleared from your bloodstream within a day or two at most. But withdrawal symptoms are not caused by residual caffeine. They're caused by the adaptive changes in your brain, the upregulated adenosine receptors that persist well beyond caffeine elimination. So when caffeine is removed, adenosine suddenly has excess receptor access. The result is exaggerated adenosine signaling, profound sleepiness, cognitive slowing, impaired working memory, difficulty finding words, difficulty sustaining attention. Days 3 to 5 and until the end of the first week are typically the worst. And this cognitive impairment can be severe enough to feel pathological. I have experienced this personally, and I will tell you honestly that on day 4 of caffeine cessation, the experience resembled what I imagine early cognitive decline feels like. Word finding difficulty, impaired concentration, pervasive fog that does not respond to sleep hydration or any other intervention. It is functional suppression, not neurodegeneration, but it is frightening if you don't know what it is. Then by day 6-7, adenosine receptor downregulation begins. The brain starts recalibrating. And by the end of week 2, most people report something unexpected, not just the absence of withdrawal, but a quality of cognition they don't recognize. More stable, less volatile, steady attentional baseline rather than the peak and trough pattern they had accepted as normal. Sleep deepens and morning alertness returns without pharmacological assistance as the system resets. But almost nobody reaches week two because days three to five are so unpleasant that they interpret the experience as evidence they cannot function without caffeine. The withdrawal confirms the dependency and the cycle resumes. I stopped caffeine after years of daily use. My own vehicle was green tea, chosen for the EGCG, the L-theanine, the slower absorption curve. But by the end, I was getting jitters without meaningful performance benefit, and my tool had now become my problem. The withdrawal was exactly as I have described. Days 3 to 5 were cognitively debilitating. I was aware enough of the pharmacology to know it was temporary, but I still found it difficult not to reach for the kettle. But by the end of week 2, the quality of my sleep had changed in a way I had not anticipated. And by week 3, I realized I had never, in decades of daily caffeine use, actually known what my own cognitive baseline felt like or what it was capable of without assistance. Now I'm not telling you to stop using caffeine altogether. That would be a simplistic position on a nuanced question, and this channel doesn't do simplistic positions. Some people will use caffeine intermittently, strategically, as a genuine tool, and that is a rational, defensible approach. I still use it this way. On the rare occasion when I had 90 minutes of sleep after a night shift, and my commitments of being a husband, a father, a responsible adult don't pause just because I'm tired. On those days, caffeine is doing exactly what it was designed to do, bridging a genuine deficit once without creating daily dependency. At the same time, some people will continue with daily use because the trade-off is acceptable to them and they manage the sleep impact adequately. So both these are legitimate decisions. What I'm suggesting is that if every day of your life requires a stimulant to start and a sedative stack to stop, the question worth asking is probably not which supplements to add to your evening routine, but why not try and take your feet off both pedals? Because underneath the start-stop cycle you're sustaining is a baseline you've never met. And the only way to meet it is to quit and to survive the two weeks it takes for your brain to remember what it was before you started helping it.