Dopamine Nation and the Age of Digital Drugs — with Dr. Anna Lembke

25:08And so now we're all struggling with this problem of compulsive overconsumption, which is, you know, really making us unhappy. This idea of the affirmation of strangers. So it's very clear that we are also wired over evolution to want to connect with people. You know, being in a tribe is what ensures that we will find mates, steward scarce resources, protect ourselves against predators, and that wiring works through our dopamine reward pathway. We know that oxytocin, the love hormone, binds to dopamine-releasing neurons in the reward circuitry to release dopamine, which is our pleasure-reward neurotransmitter.

25:47The more that dopamine is released and the faster that it's released, the better it feels. And this is healthy and normal and wonderful until you have drugified human connection, which is exactly what the internet and social media and digital media has done. So you're somebody who's relational. You care about what other people think of you. We all do, by the way, to varying degrees. But, you know, most of us, if not all of us, care what other people think that's so deeply ingrained. But now you live in a world where you can have instant affirmation or its opposite at scale, hundreds to thousands to millions of people, right, quantified with likes and shares and on and on.

26:35And now you really have a very potent drug, which when it's going well is incredibly reinforcing, much more so than some nice compliment my husband might give me. Like, that's not as exciting as my book is number one on Amazon, right, with a whole bunch of reviews and people telling me that I'm great. and it's very easy to get get caught up in that so yes i think we can get addicted to the affirmation of strangers i think that the internet and social media has become the drugification of social affirmation making us all more vulnerable to that problem and my intervention for that problem would be the same as for people addicted to drugs and alcohol which would be to abstain from social affirmation venues, especially when you're dealing with them at scale.

27:24So try to avoid those types of situations where you would be exposed to like all of the love because ultimately what happens with that huge surge of dopamine is that our brain compensates by down-regulating dopamine transmission, not just to tonic baseline levels, but actually below baseline, we go into a dopamine deficit state. That is the addicted brain. Now we need more of our drug in more potent forms, not to get high and feel good, but just to sort of level our balance, go back to baseline and feel normal. And we're in a constant state of craving. Plus, we're experiencing the universal symptoms of withdrawal from any addictive substance, which are anxiety, irritability, insomnia, dysphoria, and craving.

28:06Getting more of our drug temporarily relieves that, but it doesn't last very long and actually makes the problem worse. And in terms of money, I mean, there's so much evidence that monetary gain lights up the same reward pathway as drugs and alcohol. It's why we're seeing a huge, huge increase in online pathological gambling. Sports betting has been made legal in many states in the nation, And with it, like a 300 to 500 percent increase in calls to hotline pathological gambling centers because people are losing everything in the face of, you know, their their parlays having to do with whether or not the referee is going to touch his hat five times, you know, during the game.

28:51So, yeah, I mean, this is sort of human nature, like writ large, because we live in an ecosystem that has taken all of these things that are, in some fundamental way, healthy and good for us and something that our brains need to be doing and turned it into a drug. yeah in spite of thought i i believe that one of i'm constantly saying something as a crisis i overuse the word crisis but i do think we have a crisis of loneliness do you think you can be addicted to loneliness or that we just fill in the dope what we used to get from being social to as you reference getting that hit with a low cost low entry low risk activity like youtube or what have you, can you get a...

29:38I have to force myself. It takes me almost as much discipline to get out and be around other people as it is to drink less. I have become, as I've gotten older, addicted to being alone. And I just find it easier, comforting, whatever happens. And I know it's bad for me. Could you say a certain level of deciding to be alone, maybe more than it's healthy, could that be classified as an addiction? Drugs in all their forms are the great human replacement. Addiction is a disease of loneliness. Even if we have a lot of great people in our lives, if we get addicted, we will isolate and we will use our drug to replace that human connection.

30:31So, and I say that because we sometimes talk about loneliness as the cause of addiction, but more often than not, what I see is that the addiction causes the loneliness. That because we're able to use this drug or this device or this behavior to meet our physical, emotional, sexual needs, we are no longer seeking out other people. And it's an enormous problem. because not only are more people in the United States actually physically living alone than ever before, but more people than ever before are endorsing loneliness. So this is a huge problem. And again, the antidote is to do the thing that's painful and difficult in the short term because in the long term, it will make us feel better and it will make our lives better.

31:25How have you seen the patients and the research you see come through your office and across your desk? Which addictions or types of addictions have you seen increase and decrease? So in terms of our patient population, the most common addictions for years have been the usual suspects, alcohol, nicotine, cannabis, and then starting in the early 2000s, opioids, prescription opioids, segueing to heroin and illicit fentanyl. starting in the early 2000s we saw the very first signal of typically middle-aged men coming in with sex pornography and compulsive masturbation addiction and almost universally endorsing that it was the advent of the internet and then explicitly the mobile devices the smartphones that led them from you know moderate manageable pornography use to uh immoderate unmanageable addictive use and destroying lives like losing their families, their jobs, engaging in illegal activity.

32:31Since that time, we've just seen an increase in escalation in people presenting with digital media addictions, video games, social media, online gambling, online shopping, the internet more broadly, a kind of diffuse addiction to the internet. so that's what we're really seeing increasing um you know we're here in northern california so cannabis is huge we're also seeing a lot of as we talked about sort of designer drugs psychedelics hallucinogens like nobody uses they used to call they used to like let's say 25 30 years ago they had this term white glove alcoholics these were folks who like they were just addicted to alcohol and not anything else.

33:12We never see that anymore. Everybody's using a whole bunch of stuff. It's a real sort of polypharmacy festival. I coach and work with a lot of young people, specifically I think a lot about young men. And the addiction I see emerging that I don't think is getting enough attention that just feels like a ticking time bomb to me is online gambling. and the reason I think of it as being so dangerous is my mother was a docent at the Bellagio in Vegas and so she used to come home with all these facts about gambling addiction and she told me and you can confirm or deny this that it has the highest suicide rate because you can get in so deep if if I develop an addiction to meth or alcohol it generally becomes pretty visible to the people around me and they intervene and try to do something.

34:06I can get so deep with gambling and nobody knows. And then I get in so deep, I've spent my kids' college fund, mortgage the house. My spouse doesn't know what I've done. I see no way out. I decide to end it. And I see, I've just seen these stats that 50 % of college males bet on the Super Bowl. and I see occasionally I'm in a scenario where I'm with a bunch of young men and they're all on their phones and I think, oh, that's natural. I know kids are on the phones. They're all gambling on the game they're watching and they're not doing 100 bucks, Liverpool will beat Arsenal. They're gambling every seven minutes.

34:49The ball's gonna turn over. What you were saying about the ref and I know these companies and the people architecting these algorithms they will figure out who's going to lose their money and encourage them to bet more. And the ones who actually know what they're doing, they will block out of the platform. So it's a guaranteed loss of income. And I like to gamble. I think it's fun. I go to Vegas, I gamble, but I assume it's consumption. I assume I'm going to lose it all. It strikes me that we might, and tell me if I'm being just, I don't know, hyperbolic or inflammatory or, I don't know, exaggerating or just, you know, worrying too much here, that we're going to have hundreds of thousands of young men, and my sense is young men, and again, I'd like you to validate and nullify this, are much more prone to gambling addiction than women, who enter the world with massive financial hangovers and shame because of the constant presence of gambling apps.

35:52Your thoughts? Yeah. So it's funny that you, I thought for sure you were going to say online pornography, um, because I, I would probably put in terms of risks to men living in the world today, I would probably put that above, um, online gambling, but I, I would make online gambling a close second. And this, you know, it's very hard to get actual data on this. but this is sort of based on my clinical impression and what I'm seeing. Of course, I've seen treatment seekers, but yeah, this is an enormous problem. I always like to start by emphasizing the vast majority of people who gamble will not get addicted to gambling, and that's true for any drug, right?

36:35So most people will be able to moderate their use. But as with drugs and alcohol, about 20, well, 10 to 20 percent of folks who consume will develop an addiction. An addiction is a brain disease, a very serious and potentially life-threatening one. And until you've either experienced it yourself or seen it in somebody you care about deeply, it's really hard to imagine how people could get to a place where they would sacrifice everything in pursuit of their drug. But that's exactly what happens. and so what is the vulnerability there what is the difference you know and and the risks i usually classify into nature nurture and neighborhoods so nature you some people are inherently more vulnerable than others but as we've talked about drug of choice matters if you meet your drug of choice and it's gambling you may never get addicted to alcohol but gambling may just be the end of you um co-occurring psychiatric disorders put people at risk because of a kind of a self-medication myth and cycle.

37:37We know that trauma contributes to the risk of addiction. That's the nurture part of it. But also neighborhood is really key. And this is, again, the ecosystem that we live in. The easier it is to get your drug of choice, the more of it you'll use, the more you'll change your brain, and the more likely you will be to develop a very serious addiction. So yeah, I mean, gambling is everywhere. where there's enough data to verify your impression that it's more men than women, although women also struggle with it. The same is true for online pornography. More men than women develop an addiction to that, although women do develop pornography and sex addictions.

38:21There are some addictions where women are more vulnerable than men, like online shopping and social media. But in terms of gambling and pornography, definitely men are more vulnerable. And I absolutely agree with you that this is a huge and largely unseen problem, complicated, as you say, by the shame issue, where for gambling addiction, there's still so much about, in our culture, about being a man who becomes wealthy and successful as sort of our modern day hero, that if you're somebody who's, you know, not done that or, you know, God forbid, gotten into financial trouble, very, very hard to come forward and ask for help.

39:06And frankly, the same is true with sex and pornography addiction. We have this prevailing cultural, I believe, false notion that all men are sexual predators. And so to come forward, you can only imagine the shame of somebody having to come forward and say, I'm addicted to sex or I'm addicted to pornography or I watch, you know, these types of pornographic images and they're stimulating for me. Very shameful, very hard. I've had patients come in and like on their, you know, come in and say they had a problem with like some drug, which wasn't even their problem. It was pornography and it took them four visits to be able to admit it.

39:44Huge, huge problem here. And again, access, ease of access, quantity. It's all, you know, all at the touch of our fingertips, which just makes it very, very difficult for us as humans who are reflexively wired to approach pleasure and avoid pain to withstand the lure of these incredibly potent drugs. There are professors and academics such as yourself looking at gaming. I found it really difficult to find anybody with deep domain expertise or peer-reviewed research around porn. And my assumption is that professors don't want to be known as professor porn, that there's actually shame in the academic community.

40:23You don't want to be that guy or gal. It's like, well, why did you decide to do that, professor? It's the second largest category, I think, on the internet. And relative to the size of it, there's a ridiculous scant amount or dearth of research around it. I had thought that, or some of the stuff I'd read, is that it's a small population consuming a disproportionate amount of porn that most men, young men, and young women are able to modulate it. My fear around it has always been that, just being very transparent, one of the reasons I went on campus every day at UCLA was, one, because I knew I was supposed to go to class, but two, the prospect that I might meet someone who over the medium or long term would decide to have sex with me.

41:10You sound like my son. Well, I think I sound like most sons in their head, and I think I disarticulate it. And if I'd had porn available at home, I'm pretty certain I wouldn't have been on campus five days a week. I might've gone to four or three or two because it just might've been, I mean, the reality is I wanted sex so badly and my hormones were raging so much that I was willing to take social risk and go out and try and meet people. And by the way, I think that's really healthy to think I wanna take these risks. I wanna meet people in hopes that I can have a coffee, invite to a party, establish a relationship, and at some point along the way, maybe have those types of physical encounters.

41:53I think that is really, really healthy. And I worry that, and curious to get your take, that it's not the hardcore addicts that are screwing up America around this stuff. It's that it just decreases across an enormous population of young men, their willingness to establish connections with others. that we're evolving, we're maturing a new species of asexual, asocial males that never get categorized or clinically diagnosed as addicts, but are just alone their whole lives and never develop these skills? Is there a low-level form of, I don't even want to call it addiction, but avoidance or replacement theory that could be even more damaging than what we think of as traditionally diagnosed addiction?

42:43Absolutely. And there are data to support this. So young people are having, for all our liberated sexual mores, young people are having less sex today than ever before. and many young men will report that they feel like the social landscape out there when it comes to dating and having sex is so uncertain and such a landmine that they just end up staying home watching pornography and masturbating and for folks who are vulnerable to that as their drug of choice it can evolve to the point where they literally cannot stop like with any drug they need more potent forms over time. So pornography becomes chat rooms, chat rooms become, you know, meeting in person, prostitutes, child pornography.

43:32I mean, this is a huge issue right now of, and by the way, I think your point here about it being so widespread that we can hardly even call it, it's like an endemic disease. You know, it's not even like a rare disease. I have had, in the last little bit of, like the last month, two mothers call me who are in desperation because their sons have been identified as viewers of child pornography. Now, these are teenage boys who are watching teenage girls and who now are facing potential felony. So I just think that the whole system is not set up for the degree to which this behavior has become so widespread, so normative.

44:28I mean, we can't be convicting all of these young men of felonies, and I'm not by any means endorsing child pornography or teen pornography. You know, my personal opinion is that none of it's good for so many reasons. But the issue is we have a court system who is now looking to convict an 18-year-old boy for viewing pornography of a 17-year-old girl and facing, like, being a lifetime sex event. Our legal system has clearly not caught up with what is happening, and the corporations that make in profit from these media are not remotely being held responsible for what's going on. I mean, this is really endemic proportion problems.

45:15And yeah, in terms of creating, you know, it's kind of a, I mean, I talk about the smartphone as our masturbation machines, and I mean that, like, in every sense of the word. That's what they are. We're using the internet and these devices to meet all of these needs that used to require other people. and part of what connects people together is our interdependency, our mutual need. If we didn't need other people, we wouldn't bother to do the work to go interact with them because it's a heck of a lot of work and it's complicated and it's ambiguous and it's painful because of all the ways in which we're all so complicated.

45:55So yeah, this is a huge problem. We're creating a generation of mole people as in mole the animals who never go out and never leave their little hidey holes. Super scary. We'll be right back.

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49:26We're back with more from Dr. Anna Lemke. I want to move to solutions. And I'm sure you get calls from government officials in D.C. and Sacramento who ask for your advice on this stuff. I think most of this, if I could think of one thing to try and set a context that would reduce addiction, it would be third spaces. And that is trying to get as many young people as often as possible in the company of other young people and in the company of potential mentors, friends, and mates. I was in Israel after October 7th at the Nova Music Festival site or memorial, and I met with a battalion of IDF soldiers, and there were these young, extraordinary, fit, 120 kids, 19 to 21, outdoors, in the company of each other.

50:14Many of them go on to start businesses together, lifelong friends. A lot of them meet their spouses outdoors, serving in the agency of something bigger than themselves. And I thought, I just don't think nearly as many of these young adults are going to end up addicts. And I thought, how can we do this a million times in different ways, whether it's continuing education, softball, league, church, nonprofit, like third spaces. If I could do one thing, it would be third spaces. What is the one thing, your thoughts on that, and what is the one or two things you would want to do to set up a context of success and addiction avoidance?

50:55Because we are creatures innately designed to approach pleasure and avoid pain, we need to create spaces where we have access to healthy sources of pleasure and a sufficient challenge to make that interesting enough for us that we creatures who need a certain degree of friction find it interesting, and also spaces that limit our access to unhealthy sources of pleasure, unhealthy dopamine, as in the instant pleasures of the various intoxicants we've been talking about. So I love the idea of third spaces, but, you know, it sounds a little rarefied like it would be for the elite and the wealthy. We have the potential to create those third spaces in the public school system where kids spend the vast majority of their lived hours.

51:47So after school programs. Not even after school, during school. How can we do that? Get smartphones out of schools, is bell to bell. Create, give hands-on, bring back what happened to, I mean, I didn't like, you know, Autoshop, but at least we had it, you know. I mean, let's have more art, more hands-on stuff. Let's have writing classes where they're not allowed to use chat to GTP and they get real, you know, not to say that we should never use those tools, but everything's gone online in the schools. It's all digitized. We're learning everything by watching somebody else do something. Kids need to do.

52:29And schools are the place, the default place to make that happen, which means getting the digital drugs out of their hands during school time hours. I'm also a huge believer in age verification. We have to recognize that digital media is a drug for the vulnerable. The vulnerable include a kid with a developing brain. We cannot have five-year olds on iPads for eight hours a day. What do you think that number is? Is it 16? Is it 12? What is it? I think it's at minimum, at minimum 13. And even then, I think there has to be a lot more in terms of guardrails. So we really need real age verification, like the real deal, you know where you have like a third party site you register and i know there's a lot of problems with that in terms of people's privacy but i'm sorry we make a lot of sacrifices to protect the vulnerable few as we should do in our society and we already don't let kids drive cars buy firearms go into casinos and gamble buy cigarettes buy alcohol buy drugs we already join the military yeah we age get a lot of things yeah like we we recognize that kids have vulnerable grains and that their frontal lobe isn't fully connected and that, you know, if we just let them run amok, we would have many fewer kids on the planet and we would, you know, we got to protect our kids.

53:50So that's what I think. Do you have kids, doctor? I do. Yeah. And what advice would you have? I find it difficult sometimes to discern between normal adolescent behavior, which is abnormal, as far as I can tell. And when I should be worried, when I should think, okay, he takes his phone into the bathroom to watch TikTok and pretends he's in the bathroom for 10, 20 minutes. Okay, is this 14-year-old behavior or should I be worried? And as someone who's been a parent and what pieces of advice, I don't know how old your children are, but as it relates to addiction, are there any sort of unlocks or critical success factors or red flags in your child's behavior where you can help discern the difference between what you'll call, not necessarily behavior we shouldn't correct, you know, get out of the bathroom enough already, but where you probably think, okay, this is getting serious and might require professional intervention.

54:59Yeah. So there's no blood test or brain scan and diagnose addiction. We base it on phenomenology on what's called the DSM, the Diagnostic and Statistical Manual of Mental Disorders, which briefly summarized is the four C's, control, compulsions, cravings, and consequences, especially continued use despite consequences. The problem is that a lot of kids use substances, engage in addictive behaviors, and don't have obvious consequences. So it's very hard to tell at that age because they're young, they're resilient, and they're good at hiding it. So although you won't find these criteria in the DSM, I think a warning sign to look for, unless there are obvious signs of unraveling, but if you've got a kid who isn't obviously unraveling, but you're kind of wondering, is look for lying and other antisocial behavior.

55:52Again, you won't find that in any psychiatric diagnostic manual, but I think those are very important soft signs of something going wrong with the kid or in the family. Now, all people lie. The average adult tells one to two lies per day. These tend to be small little lies about, you know, hiding our own selfishness and foibles, and teenagers definitely lie. But if you get a kind of a more significant systematic lying about where I've been, who I was with, what I was doing, or even just kind of antisocial behavior, rudeness, hostility, rage, these are the things that I think, you know, we should look for as potential warning signs for something going wrong with our kid.

56:35Last question, doctor, and you've been very generous with your time. Very curious to get your thoughts and take on GLP-1 drugs. GLP-1 drugs are super exciting. I'm really glad they're here. They don't work for everyone all the time because we're all unique and we have these unique brains. But the more tools we have to stop the kind of addiction chatter that happens for some people, the better. As you know, GLP-1 agonists are FDA approved to treat diabetes and obesity. They modulate stomach emptying, slow down the gastric flow, and make people feel more full. But they also work on the brain's reward pathway.

57:15They modulate dopamine release or reward neurotransmitter. And there is very active research now looking at their use broadly in addictions. For most alcohol addiction, but also there's some preliminary evidence for benefit with nicotine addiction, with opioid use disorder, which is really interesting. as well as behavioral addictions like gambling and sex. We are using them off-label occasionally in our clinic for treatment refractory alcohol use disorder. This is folks who have tried everything for their alcohol addiction, and we're getting some good traction in a few of our folks. Other folks try it and don't find it that helpful.

57:52So, you know, nothing is going to be like the miracle drug. I don't think GLP-1s will either, but they're exciting new development, and they can be very effective for food addiction and potentially other addictions as well. Dr. Anna Lemke is a professor of psychiatry at Stanford University School of Medicine. She's also the author of the bestselling book, Dopamine Nation, Finding Balance in the Age of Indulgence. I really enjoyed this conversation and you're doing such important work and you have such a nice vibe about you. You just reek of credibility and I can see why you're having such an impact because I find myself just hanging on every word because I get the sense that you are really, I don't know, a good actor trying to just call balls and strikes.

58:38Really appreciate your good work and enjoy the conversation, doctor.

58:58Adder of happiness. I am starting, I had a bit of a gap, but I'm starting to coach young men again. And I actually had a kid come up to me last night. this guy in his early 30s, super impressive in the ad tech market, making real good money, and kind of stalking me and asking me to be his mentor. And finally, I just said, dude, you don't need my help. And who I'm trying to focus on are, quite frankly, young men who are struggling. And I've actually taken on a couple men my age who are trying to reinvent themselves who are struggling. But I'm doing this exercise, and it's yielding real benefits, especially with young men.

59:34And that is, I was just struck by the stat I read that over half of men ages 18 to 24 have never asked a woman out in person. They'll swipe right, right? They'll email somebody or whatever it might be, or they'll, who knows, like go on Craigslist and get whatever. But there's very, the majority of men, 18 to 24, have not asked a woman out in person. and that just rattled me and made me so upset and sad. When I think about 18 to 24 for me, it was putting myself in an environment where I'd have a greater likelihood of being able to ask a woman out. And I show me someone who can ask a woman out or handle the rejection or be successful out.

1:00:21I'm going to show you someone. Anyone who's good in a bar is good in a boardroom. I think it's a key skill for young men. And so the exercise I've been doing, and I talk a lot about this, is one, we're going to get fit. Two, we're going to start making a little bit of money, no matter what it is, Lyft driver, TaskRabbit. Three, we're going to put ourselves in a context, in an environment with strangers regularly, in the context of something bigger than you, whether it's a church group, softball league, nonprofit, whatever it might be. And this is what we're going to do. And this is what I'm going to recommend if you're a young man right now.

1:00:57I need you to approach a stranger and express interest in friendship or exploring a romantic relationship. And those are weird words. You would never say that. Hey, what are you doing this weekend? Do you want to get together, go to a bar, watch the game? Hi, would you lay on your wrap or develop your wrap or lack thereof? Would you mention grabbing coffee or grabbing a drink? what have you. And that's not the win. That's not the exercise. The win is I need you to get to know. And unfortunately, that happens a lot, right? And that is, I want you to go up to someone, do your best, try, say hi, and shoot, would you like to have coffee?

1:01:33And then call me the next day. And this is what's going to happen. Most of the time, the answer will have been a no. It's usually a polite no, but it's usually a no. And then I'm going to say, how are you? And this is what you're going to tell me. You're going to say, well, I'm upset. I'm bummed. But Yeah, on the whole, I'm fine. That's the victory. That's the payoff. Because here's the thing. No is the way to success. Specifically, your willingness to put yourself in a room where you get no's. If you're not getting no's, it means you're in the wrong room. And you miss all the shots you don't take.

1:02:09The number of no's. No's are your path to yes and success. So here's the victory. You express an interest in friendship. You express an interest in a romantic relationship and you get to the no. And that's the victory because you find out, you find out you're fine, they're fine, and it hurts a little less the next time you get to a no. Whether it's inquiring about a job you're not qualified for, whether it's expressing interest in lunch with someone who might be able to mentor you or help you, whether it's expressing interest in someone that you are physically and romantically attracted to. The reason I'm staying, I get to live the life I lead, and I get to partner with someone who is much higher character and much hotter than me, was no.

1:02:52Specifically, my willingness to get to a shit ton of no's and then mourn and move on and get through them. What is the key to success? No. This episode was produced by Jennifer Sanchez. Our intern is Dan Chalon. Drew Burrows is our technical director. Thank you for listening to the Prop G Pod from the Vox Media Podcast Network. We will catch you on Saturday for No Mercy, No Malice, as read by George Hahn. And please follow our Prof G Markets pod wherever you get your pods for new episodes every Monday and Thursday.