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[RUSH TRANSCRIPT BELOW] “We’re living in this strange day and age when we’ve essentially bio-hacked all of the things that we do and really come to organize our lives around our little rewards, right? So, we wake up in the morning, we reach for our phones, we have our cup of coffee, we have our favorite muffin.”

Dr. Anna Lembke is a psychiatrist, professor, and medical director of addiction medicine at Stanford University. She’s the author of “Dopamine Nation: Finding Balance in the Age of Indulgence.”

“This is, of course, the great paradox, that although we want to avoid pain, our efforts to avoid pain actually lead to more pain,” she says.

How have technology and modern living led to mass overconsumption in America?

Views expressed in this video are opinions of the host and the guest, and do not necessarily reflect the views of NTD.

RUSH TRANSCRIPT
Jan Jekielek:

Anna Lembke, it’s such a pleasure to have you on American Thought Leaders.

Thank you for having me. I’m excited to be here.

I’m going to read something that I think might sound controversial. One of the biggest risk factors for getting addicted to any drug is easy access to that drug. In a world where harm reduction policies for drug abuse are the norm, this seems like a very controversial thing to say.

It is surprisingly controversial in this day and age, and yet it’s very evidence-based. For example, if you look at opioids, it’s very clear that if you have a region in which opioids are readily available, either because of porous borders and being imported illegally or through doctors prolifically prescribing them to patients in pain, as we had here in the first decade of this century, what you see very quickly thereafter is rising rates of addictive use and overdose deaths. Likewise, when the supply retracts because doctors start prescribing less or because borders are shored up, addictive use and related deaths and other harms go down.

This is really true for almost any substance and behavior. I wouldn’t even say almost; this is true for all substances and all addictive behaviors. When you have easy, ready access to any drug or behavior, you’re more likely to engage in that behavior, your brain is more likely to be changed from that frequent engagement, and you’re more likely to trip over into addictive, maladaptive use.

Your book, Dopamine Nation, made me aware of how many things that you don’t think of as drugs, because of the nature of our technology and society, and our attitudes in general, have effectively become like drugs.

Right. This is what I call the drugification of modern life. Almost everything that we eat, that we engage in, including traditional drugs like cocaine, heroin, nicotine, and alcohol, has all become more accessible, more potent, more novel, and more bountiful, and those factors make them, in essence, more addictive. Even healthy behaviors—things like playing games, connecting with other human beings, or exercising—have become drugified through the application of technology, again made more accessible, more potent, more novel, and more bountiful. So we’re living in this strange day and age when we’ve essentially biohacked all of the things that we do and really come to organize our lives around our little rewards.

We wake up in the morning, we reach for our phones, we have our cup of coffee, we have our favorite muffin, we drive to work, we listen to whatever we want to listen to. Throughout our day, we work and then take a series of breaks; we scroll on our phones. At the end of the day, we look forward to going home and eating some kind of delectable food, binging on Netflix, eating cupcakes, smoking pot, or drinking. I just think intoxicants have been around since the beginning of human time, but the extent to which they are readily accessible at the touch of our fingertips, the extent to which they’re incredibly potent, easy to obtain, cheap, and really free—when you look at digital media—all this means that we’re sort of constantly bombarding our brains with these small and large rewards.

This is just a normal part of our reality now, and it’s acceptable. It’s morally acceptable in our society to create technologies to basically manipulate or addict people as part of what we do—through things put into food. Another example is how marijuana has changed into something completely different today than it was even 20 years ago, just because of the potency and the impact. People experience psychotic breaks from it.

Right. I shop, therefore I am. We’ve really reached this kind of tipping point where, in a successful capitalist system—not to denigrate capitalism; it’s a fine system in many ways—but in any successful capitalist system, we would all be the ultimate addicts. So we have really organized modern life around consumption, and optimizing our consumption. At the same time, many of us living in wealthy nations have our basic survival needs met. We’ve got machines doing our work, so we have more leisure time than ever before in the history of humanity. We have access to more luxury goods and more disposable income.

All of that combined means that we’re living in the kind of perfect storm for all of us to become addicted. More and more, those of us who thought we would be immune to this problem are actually experiencing the addiction pattern in our own lives, whether it’s being addicted to our phones and digital media or to our drugified food supply with the addition of salt, fat, sugars, and flavorants, which lights up the same reward pathway as drugs and alcohol.

I think it’s fair to say that many, many modern people are struggling with some form of compulsive overconsumption. We can really look to people with severe addiction in recovery as modern-day prophets for the rest of us because they’ve had to figure out how to manage their compulsive behaviors as a matter of life or death. For those of us with more minor addictions, it may not be life or death, but it certainly affects our quality of life.

Looking to the recovery world, how people get into recovery and how they think about their consumptive behaviors—plus we now have surgical interventions to help us manage our appetites, right? People are, for the first time in human history, getting their intestines rerouted so that they don’t eat so much food. We’ve got medications that we’ve invented that we take for appetite control of all sorts. This means that the boundary of the problem of addiction is now extending much further and including many more of us as we’ve changed our ecosystem—the world we live in—through science, technology, and progress to make the world more addictogenic and drugified, making us all more vulnerable to this problem.

It’s a combination of consumption almost as a virtue, but also pain avoidance as a top goal. You make the very strong case that this is a really bad idea.

First, we have to begin with empathy for ourselves because we evolved over millions of years to reflexively approach pleasure and avoid pain, right? It’s so deeply hardwired; it’s conserved over millions of years of evolution across species. We pull our hands away from a hot stove, and we approach mother’s milk. If that weren’t there, we wouldn’t be here either. The problem is that through human action, we’ve now created an environment where we no longer really have to work very hard to get those rewards that we need to survive. We’re largely insulated from painful experiences, right?

Our lives are very, very comfortable. We can micro-adjust the temperature in any given room to suit our comfort levels, right? So we’ve really eliminated hardship. We’ve exponentially increased pleasures, and this kind of ecosystem is not well suited to our ancient reward pathways, which were really evolved for a world of scarcity and ever-present danger. So it’s this mismatch that we’re grappling with now.

You document how pain is actually a really important part of being able to experience pleasure.

Yes, so we have an innate tendency to want to avoid pain. On the other hand, pain avoidance and the pursuit of pleasure lead to more pain. This is, of course, the great paradox. Although we want to avoid pain, our efforts to avoid pain actually lead to more pain. If you look at every major philosophy or religion in the world, they essentially come down to similar messages that we have to face struggles, that suffering is a part of life, and that suffering gives us really valuable information that helps us make our lives better. But this kind of ancient wisdom has largely been forgotten.

We have lots of narratives that tell us the opposite—that if we’re uncomfortable in any way, there must be something wrong with our lives or wrong with our brains, or we need to go get treatment or go on an antidepressant. We are led to believe that we should be experiencing this kind of constant euphoria; otherwise, we’re doing something wrong. I think this is really a misleading narrative because it’s also contrary to our biology.

Our biology essentially says that no matter what we pursue pleasure-wise and no matter how much we avoid pain, our brains will recalibrate or neuroadapt to a new hedonic or joy set point, such that we’ll constantly need more pleasure over time to get the same effect, and more minor injuries will, in turn, be painful. What philosophy and religion have been trying to teach us for millennia, I think neuroscience is now corroborating.

Something that is a massively underreported issue in our society, is the ubiquitous on-demand availability of hardcore pornography. Tell me why that is problematic.

It’s a problem on so many levels. First of all, pornography is highly addictive. What happens when people initially view these images and typically masturbate to them is that, over time, they’ll need more potent images, perhaps more deviant images, and they’ll find themselves escalating to engaging with images that are outside their values, maybe even illegal, right? But they need that higher potency over time to get the same effect. When they try to stop, they really can’t. So this is the addiction cycle.

Addiction is broadly defined as the continued compulsive use of a substance or behavior despite harm to oneself and/or others. You might ask, “What harm is there in pornography?” But you’re potentially harming the people whose images are being used. Certainly, we see that people are harming, in many instances, their own relationships because they spend more and more time engaging with these images.

Obviously, when children engage with these images, they are trying to process a video or photograph that they can’t possibly contextualize. If that becomes their definition of what sex should look like, you’ve got young people going out into the world with a very distorted sense of the meaning and purpose of sexual encounters. So on many levels, it’s very dangerous and destructive.

A lot of people ask, “Can you really get addicted to pornography?” I can tell you, if you could be a fly on the wall in my clinical setting, you would see people who come in having lost everything because they can’t stop watching pornography, even when they want to. They’ve lost their jobs, their families, and they’ve ended up in jails and prisons because they’ve broken the law in pursuit of more deviant forms of pornography.

In many instances, at heart, these are wonderful human beings. They’re good people, but their reward pathways have essentially been hijacked by this repetitive behavior of engaging with these images, engaging in sex with these images, or, in many instances now, with real people on the other end. It’s not just still images. It’s videos, live chat, and live streams. It’s very, very destructive and devastating for folks.

It’s this weird subculture that I learned about from your book. But the flip side is that one character, Jacob, that we revisit constantly throughout, so far seems to have had a happy ending.

Yes, Jacob was a patient of mine. He came to see me for a very serious sex addiction involving initially pornography but eventually escalating to live chats and eventually him building his own masturbation machine that he let people in live chat rooms control, which meant that he was really putting his life at risk. He had escalated so far in this addiction that, even though he knew it was life-threatening, he still couldn’t stop, even after repeatedly trying to stop many times over.

It’s an extreme example, but I think we can learn a lot by looking at these extreme cases, especially when folks with this kind of extreme addiction can get into recovery. They can stop that behavior, get their lives back, their jobs back, their joy back. I think it becomes a model for the rest of us with our minor addictions, which may not meet that level of danger or impairment, but are on that same spectrum.

Many of us have this issue with smartphones and maybe food. I certainly do. Your book made me reflect on the fact that I think I am significantly affected in at least two areas. But here’s the thing, right? Using the smartphone, and I guess I’m kind of asking you to do a little therapy on camera here, but the thing with the phone is that there’s a lot of really important stuff coming through there, legitimately. I have to deal with it, and in some cases, it’s incredibly important. So I feel I need to have it by me, and then I’m responding to things. You find yourself deviating into really interesting stuff on the X platform, which is genuinely fascinating, but probably not the highest priority at this moment, right?

But in some cases, it is, because I’m a news guy and I need to know what’s going on. Upon reflection, I can see I’m picking the things that are easy instead of the more challenging ones. For example, I have this huge resistance to communicating when there’s a significant chance of not getting the response back that I want. Okay, so that’s just a lifelong issue. But I think it fits into this because you end up picking the things that are quick and manageable. But then again, that’s also reasonable, because I can knock these things off my to-do list. I would expect there’s more than one person like me out there. What does someone like me do?  In the end, it’s all of us. How do you deal with that?

Yes, right. It’s so embedded in so much of our lives and has become necessary to function in the modern world. We look at Jacob and his masturbation machine, and that seems so wildly extreme. We use not just tools, but a kind of auto-stimulation to meet our intellectual needs, emotional needs, sexual needs, and physical needs. In that process, many things are happening that are not good. One of which is that, in turning to our phones to meet these fundamental needs, we’re no longer turning to each other.

We see this in every aspect of life. Just walk around any neighborhood in the evenings when people used to roam, go for walks, go to the park, or stop by to see a neighbor. The streets are empty now. We have to really stop and look at this and say, “Okay, where are all the people?” They’re inside in their separate rooms auto-stimulating on their smartphones.

There was an incredible art project where someone created a scene of people doing what you’re talking about, but in public. You can isolate yourself unbelievably, even among a whole group of people. The artist took photos of people engaging with their phones, but then erased the phones from the artwork. It was shocking. The point of the painting is that nobody was looking at anybody else. Nobody was interacting with anyone else. You get the sense that these people are completely isolated from each other, because, in fact, that’s the case.

Right. You also see this in families with young children. We, as a society, need to be very alarmed about this. You see young children standing next to a parental figure on their phone, the child tugging at the parent’s clothing, unable to get their attention. That is no different than having a parent who is intoxicated and checked out on alcohol or any other drug. We are not present for others when we are entranced by our phones. This will have devastating generational repercussions for all of us. We really need to pay attention to this. This is such an important topic.

The other thing I would say, in addition to how it’s adulterating our ability to connect with each other because we’re just connecting with the device, is that it’s also impairing our ability to create new things. Now, I know a lot of creation is happening online—creation and creativity—and that’s great. But I can tell you that the numbers show it is a small minority of people who are creating the metaverse content. The vast majority of us are just consuming this content. In this constant mode of reactive consumption, two things are happening.

Number one, we are not creating; we’re consuming. And number two, we’re not allowing our brains time to rest, recover, consolidate, and process this incredible flow of information. That’s stressful and that’s exhausting. People wonder why, with all this leisure time and freedom and options and material goods, are people so stressed out? It doesn’t make sense, right? People are more stressed out than maybe during famine or war.

It’s because we’re constantly overstimulating ourselves. We’re not letting our brains rest in between. The other thing that’s happening, as you alluded to, is that these devices are now procrastination generators. There are a lot of hard and annoying things that we all have to do in our lives, from taking out the garbage to responding to annoying, unpleasant emails, to writing thank-you notes to people we have delayed writing to. You name it.

And yet, the likelihood that we will engage in those mundane but important and necessary tasks is greatly decreased if we have that device available to distract ourselves, to avoid the pain of doing that mundane task, and really to get lost. Because once we go on the device, we forget. We completely forget what we were meant to do or what else we have to do. We’re sort of lost again in this kind of transportative experience that feels really good but is probably not good for us.

There’s an example of a woman you asked to step away from smoking marijuana, because you figured out that a month is the right amount of time to give someone the opportunity to reflect on what life would be like without that substance.

That’s a great way to phrase it, by the way. I love that you phrased it that way because a lot of people don’t appreciate that I’m not saying taking a dopamine fast for a month will cure your addiction. I’m not saying that, but you’re right. It’s the amount of time on average it takes for people to sort of have that “aha” moment and say, “Wait a minute,” then look back at their using self, and say, “I don’t really want to continue to live like that.”

Please explain to us how dopamine fits into this whole picture, because it’s the centerpiece.

Yes. Dopamine is a neurotransmitter. It’s a chemical that we make in our brain. Neurotransmitters allow for fine-tuned control of the electrical circuits that make us who we are. Dopamine is essential for the experience of pleasure, reward, and motivation. It’s not the only neurotransmitter involved in that process, but it’s the final common pathway for all reinforcing substances and behaviors. So neuroscientists have come to use it as a kind of common currency for measuring the addictive potential of a variety of different substances and behaviors.

For example, experiments in rats that measure dopamine levels at baseline and then see how much dopamine increases in response to certain substances or behaviors find that food, or chocolate in particular, increases dopamine firing by 55 percent above baseline. Sex is about 100 percent, nicotine about 150 percent, all the way up to cocaine and amphetamines at 1,000 percent above baseline. Indeed, that tracks with animal behavior. If you put a rat in a cage with a lever to press for cocaine, that rat will press that lever until exhaustion or death.

Now, human beings aren’t rats, so it’s not that what happens to rats in a cage will happen to every single human. There’s also the important concept of inter-individual variability and drug of choice. What releases a lot of dopamine in your brain might not release a lot of dopamine in my brain and vice versa. But in general, the concept holds true that intoxicants or things that are highly reinforcing, including behaviors, tend to release dopamine in those nucleus accumbens brain reward circuitry structures. The more dopamine released, and the faster dopamine is released, the more likely we are to want to engage in that substance or behavior again and again.

One important misconception here is that it’s not that dopamine is bad or that we’re addicted to dopamine per se. It’s that dopamine is a chemical signal, and we’re always releasing dopamine in the reward pathway at a kind of baseline tonic level. It’s the fluctuations in dopamine above and below that baseline that then motivate certain types of repetitive behaviors, especially to take action to get our drug of choice.

What is the relationship between pain and dopamine?

We know that pain and pleasure are co-located in the brain. In the simplest explanation, they work like opposite sides of a balance. When we do something pleasurable, that releases dopamine, and our balance or teeter-totter tilts to the side of pleasure. The first and most important rule governing this balance is that it wants to remain level, or what neuroscientists call homeostasis, such that we will work very hard—our brains will work very hard—to restore homeostasis after any deviation from neutrality. The way our brains do that is by tilting an equal and opposite amount to whatever the initial stimulus is. If we do something pleasurable that releases dopamine, our brain responds by down-regulating dopamine transmission, for example, by reducing postsynaptic dopamine receptors, so that we get back to not just baseline firing of dopamine but actually below baseline.

I often talk about that as these neuro-adaptation gremlins hopping on the pain side of the balance to bring it level again. But they like it there, so they don’t get up as soon as we’re level. They stay on until we’re tilted an equal and opposite amount to the side of pain. It’s that come down, that hangover, that moment of craving which drives us to reach for more of whatever that substance is.

In a world of plenty where we’re surrounded by as much of whatever we like at the touch of our fingertips, it’s very hard to resist the urge not to reach for more. The problem is that with repeated exposure, we essentially end up in a chronic dopamine deficit state. You might imagine that as these gremlins camped out on the pain side of the balance. We’ve essentially changed our hedonic or joy set point.

Now, we’ve entered an addicted brain where we need more of the drug in more potent forms, not to get high, but just to level the balance and feel normal. When we’re not using, we’re walking around with the balance tilted to the side of pain, experiencing the universal symptoms of withdrawal from any addictive substance or behavior, which are anxiety, irritability, insomnia, depression, and craving. This is why people find it so difficult to stop compulsive overconsumption once they’ve entered that dopamine deficit state.

Because the fastest way to get out of that state and restore homeostasis is to reach for more of our drug, we get into this very deceptive loop where more of our drug feels good, not just because it’s dopamine-releasing, but because now we’re trying to get out of pain, right? When we’re not using, we’re in more pain. So we can get into this very confusing, tail-chasing situation where we don’t recognize the ways in which the substance is actually contributing to pain. Because in the short term, it’s alleviating pain.

This is such a critical explanation. How many people functioning in this kind of environment with phones and computers are not experiencing this reality? It’s almost everybody at some level, unless they have some very unusual non-addictive personality or balance of neurotransmitters.

Yes, I think anybody who can manage their consumption of their smartphone or other digital media with ease is either a very rare subset of individuals for whom this medium is not particularly potent and compelling. Since the medium is invented by our own brains, there aren’t going to be very many people like that because it’s so cognitively and emotionally engaging.

They are making it intentionally addictive from what we know.

Exactly. It was invented to be enchanting, and they’ve more than succeeded in that. So I think you’re looking at the vast majority of the population struggling with compulsive overuse of smartphones and digital media and trying to figure out how to limit use. And yet, we can—and we must—with intention do that, both through our individual efforts to manage our consumption and through top-down policies. Holding the companies that make addictive digital media accountable for the harms and getting schools to rethink how they’ve integrated technology because it’s gone far too far. Now, you can’t participate in the average American public high school without a QR code function.

Except for the ones where Jonathan Haidt’s work has actually taken hold and they’ve removed them entirely, which is really impressive and represents huge changes.

Yes. Jonathan Haidt’s work is amazing, but he didn’t invent banning smartphones. There were schools early on, mostly private schools, starting with a few on the East Coast, but also in other parts of the world, that saw early on—our kids are not connecting with each other. They’re not paying attention to learning. They’re not flourishing because of these devices. They banned the devices and saw huge improvements in social, emotional, and cognitive well-being.

Now, formalizing studies of this is very difficult because it’s a lot of apples and oranges. You’re comparing one school that banned smartphones with another that didn’t. Did the first school really ban them, or did they just say, “Hey, don’t use them?” So there’s a lot of confusing data out there, and when you tease it apart, you realize the methodology is flawed. But what we see just experientially and phenomenologically, when schools ban smartphones, kids do better.

Jonathan Haidt has been instrumental in spearheading that work, advocating for getting smartphones out of schools, K-12, or at least through middle school, bell to bell. It can’t just be per class because then kids, in between classes and at lunchtime, aren’t interacting. It’s really got to be a top-down policy, which also greatly reduces FOMO, or fear of missing out, one of the main reasons that kids, particularly teens who are so socially sensitive, feel they can’t get off their phones even if they want to because they’re so worried they’ll miss out on something important.

Is it reasonable to approach this in a meaningful way without changing our societal idea that pain is terrible, and we should do everything to prevent people from having it? What do you think?

Yes, we definitely need a cultural shift on this point. Interestingly, we have a kind of very exercise-sports-oriented, extreme fitness culture. Getting back to this pleasure-pain balance, it turns out that if we intentionally press on the pain side to do things that are hard, those gremlins will actually hop on the pleasure side, and we can get our dopamine indirectly by paying for it upfront. That’s called hormesis. Hormesis is a Greek term that means to set in motion.

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