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

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Episode 339.

339 is the area code serving the Boston, Massachusetts area.

1939, The Wizard of Oz premiere.

True story, whenever I climax with a woman,

I scream out,

Surrender Dorothy!

Or,

I'm melting.

I'm melting! Go melting go go go welcome to the 339th episode of the prop g pot what's happening the dog is howling he's busy he's like one of those belgian malinois dogs it is not unless it's working all the time, like roaming property or defending someone. I, except I'm not like that, but I basically have the tasks of a Belgian, of a Belgian Malinois.
And that is, I have so much shit going on today. I flew in last night from Barcelona, got in late, came here, took an edible, crashed for like five hours.
Now I'm up. I'm at the Fauna Hotel, which I love.
Even though it's not really my design aesthetic, it's like a very handsome, wealthy, metrosexual Buenos Ayrin exploded into a hotel, which I think is pretty much the owner of this hotel. And then I got to do this, and I'm going to this conference, this 0100 conference to host a lunch.
And I got to bomb up to Palm Beach where I'm doing a speaking gig. Then I'm on a plane to New York and, you know, wash, rinse, and repeat.
But anyways, I'm in Miami. It's absolutely beautiful.
Isn't it good to know what I'm up to? Thank God I know where he is. Thank God I know what's going on here.
Anyways, what are we going on? Today's episode, we speak with Dr. Anna Lemke, professor of psychiatry at Stanford University and author of the bestselling book, Dopamine Nation, Finding Balance in the Age of Indulgence.
We discuss with Dr. Lemke the rise of addiction in the digital age from drugs to social media and why our brains are wired to create more.
Plus, Dr. Lemke shares practical solutions to help build a healthier relationship with pleasure.
I really enjoyed this conversation. You occasionally interview somebody, especially, and it's so rewarding when you interview someone in the sciences or the public health field, and you get the sense they genuinely care, that they want to figure this stuff out, they want to help people.
And she highlighted something, we did this interview, I think about a week week ago about a lot of young men or just a lot of men have addictions to porn. And there's a lack of peer-reviewed research on it because very few academics want to be known as the porn professor.
And just literally after she highlighted what an issue it has become for many of her patients, I have had no joke, three men come up to me and start talking to me and we start talking about addiction. And they look around and in the very self-conscious they say, well, I have an addiction problem.
And we start talking and I'm pretty straightforward. I said, what's your addiction problem? And all three times it's been porn.
And I want to learn more about it because it's something that I don't think we talk a lot about. And there's very little peer-reviewed research.
And as we think about men, especially young men, and the access to this type of porn, I've often said that the nicest thing in my life is getting to raise children with a competent partner. That, you know, it's just, if you can figure that out, if you can find someone who you share values with that you're aligned with around money and that quite frankly, you want to have sex with and you are blessed with healthy children, that's kind of the whole shooting match, or at least that's what I've decided as a whole shooting match.
Every, everything else for me was just like a means to an ends. And I was sated.
I always wanted more and more money, more experiences, more relevance, and I'm still on this fucking hamster wheel, and it's the reason why I'm here speaking to you right now. Is that fair? Is that fair? Anyways, let's misstep the faena.
But if I had been a young man and had access to porn, I'm not sure any of that would have happened. Why is that? No that? No joke, part of the reason I used to go on campus and probably the only reason I got a 2.27 GPA from UCLA and not a 1.87, at which point I wouldn't have graduated, I wouldn't have gotten a job at Morgan Stanley, I wouldn't have gotten into a high school of business, wouldn't have met my co-founder of Profit, wouldn't have started businesses and, you know, 30 years later, 35, be at the Faena.
And that is because I would go on campus and go to class because I was hoping deep down or something in the back of my mind was that I was going to meet a strange woman, establish a rapport with her, and at some point have sex with her. That was very motivating for me.
And that sounds crass, but I don't think there's anything wrong with wanting to mate. And what I tell young men is the following.
I tell them, look, I consume porn, but I've tried to, for the last 10 or 15 years, when kind of porn came on the scene, and I think it's really good advice, especially for young men, try and modulate your use. Because some of that desire, some of that wanting to meet people such that you can make your own bad porn is key.
You don't want to extinguish those flames of desire because those flames of desire can actually result in good things. They make you want to be more successful.
They make you want to be in better shape. They make you want to develop a rap.
They make you want to figure out a way to make someone else laugh. They make you want to have a plan such that you're more attractive, such that you might, in fact, be able to get out there and establish your own romantic relationships.
Anyways, what's the bottom line and the advice I would give to anybody, but especially young men?

Look, most people consume porn.

Is that true?

Most men, I think, consume porn.

I get it.

But try and modulate your use and try and figure out a way to develop the mojo, the desire, and the skills that you can get out there and start making your own bad porn.

So with that, here's our conversation with Dr. Anna Lemke.
Dr. Lemke, where does this podcast find you? I am physically sitting in my office here at Stanford University.
This is where I treat patients and do my work. Sounds good.
So let's bust right into it. In your best-selling book,

Dopamine Nation, published back in 2021, you argued that constant access to stimulation is rewiring our brains. Four years later, has anything changed or any additional observations between then and now? I would say that the four years that have elapsed have really, unfortunately just seen an acceleration in this problem.
I guess the good news is that people are talking about it more, more aware of it. I think the groundswell really started with parents concerned about their kids.
But I think in general, the average person is now, you know, more aware of and concerned about their consumption of digital media. Something that I'm especially concerned about is the father of a 14 and a 17-year-old, especially with a 14-year-old, and my colleague Jonathan Haidt talks a lot about this, is that the rewiring is especially, or I guess the more appropriate term would be the wiring of the brain as children are going through puberty, that that can be especially damaging.
Are we about to flush into the economy or society millions of essentially dopa addicts that if they don't find it on their screen, they're going to find it elsewhere? Yeah, it's a great question. I think it's important to emphasize that we are constantly rewiring our brains, wiring just really being a metaphor for neurons and the plasticity of neurons and the way that we're constantly making new connections between neurons.
Every single experience that we have rewires our brain in some way. So, you know, the fact that we're spending enormous amounts of time online by the latest report, I think it was Pew surveys came out and said that about 50% of teenagers now report being continuously online during the waking hours.
Of course, that is rewiring our brain. the question is to what end right because we have to adapt to any environment we're always

rewiring our brains but are we now rewiring our brains in a way that is ultimately not good for us as individuals, not good for societies, not good for humanity? And I mean, I would say, I think I'm a little bit more measured than Jonathan Haidt about this, although I totally respect him and his work. I would say, yes, there is a lot to be concerned about here, but that I'm ultimately optimistic that we will both self and other regulate.
What do I mean by that? I'm already seeing people who are beginning to say, you know what, this isn't good for me or this isn't good for my family. Even teenagers themselves forming these groups and saying, let's get off social media together.
Let's try to do things that we can do in real life, you know, with each other. Other regulate because it can't just be left up to the individual.
This is far too powerful a transformation to just say, well, you know, it's up to you to figure out how to moderate your consumption of digital media. We have to get smartphones out of schools, bell to bell.
We have to hold the companies accountable. We have to legislate, particularly to protect kids.
Talk about the different types of addiction. There's obviously addiction to screen, and there's drugs, there's alcohol, there's pornography, there's gaming.
Is there any way to sort of stack rank these addictions? And I was always told, I'm pretty open on my podcast, I love marijuana. I loved it in college.
I took kind of a 20-year break because I was working my ass off, and I've started using it again, and I enjoy it. And I actually think it's additive to my life.
But I remember people was telling me that it was a gateway drug to more serious addictions. If you were to sort of stack rank different types of addictions in terms of what is the most dangerous or what perhaps is a gateway to other things, any thoughts about sort of the hierarchy or the waterfall of different types of addiction? Great question.
I have become pretty much convinced over the course of my career that it depends on the person and their unique wiring and their drug of choice. For one given individual, traditional drugs like alcohol, cannabis, opioids, nicotine may not hold much appeal, but social media may indeed be the drug that overpowers them and leads to a very serious and devastating addiction.
Furthermore, people are variably vulnerable to addiction, period. Some people are much more vulnerable than others and can get addicted to a lot of different substances and behaviors.

Other people, you know, getting addicted is something that probably won't happen to them to a significant degree. And again, the uniqueness of the wiring, although I have argued that we're all more vulnerable to addiction now than before because of the drugification of our environment.
I think we also have to take into consideration that when we're thinking broadly about danger,

it's not just the addictiveness of the drug, like nicotine is very addictive for many people, but also the lethality of the drug. So opioids is something that can kill even when the dose is just a little bit beyond what the dose is for the desired effect.
That's not true in the short term for nicotine or cannabis, right?

Which can do significant harm in people who are addicted and use heavily,

but it usually takes a long time, many, many years of exposure.

You know, in your case, you know, somebody who loves marijuana,

who gave it up for a period of time is now using it and just basically finds it enjoyable.

You know, great. It's nice if that can be an enjoyable part of a person's life.
Intoxicants in various forms have been around since the beginning of time. the one thing that I would caution about always is just that we're not always the best self-observers

around whether or not our enjoyment is really leading us to, our short-term enjoyment is really leading to long-term enjoyment or is interfering, you know, in ways that we can't see. Just because these drugs tend to interfere with our insight in terms of what they're doing to us.

And often they can be causing harm or we can be getting addicted and really not see it.

I've observed something and I'd love to get your thoughts on it.

I go to a lot of conferences where there's a lot of young, successful people,

whether it's South by Southwest or I go to this event called Summit.

And I've noticed over going to these events for the last 20 years,

Thank you. of conferences where there's a lot of young successful people whether it's south by southwest or i go to this event called summit and i've noticed over the lot going to these events for the last 20 years that young people are not drinking and but it's not as if they've gone healthy or healthier they the aspirational set likes to think they've discovered a new technology and that they're innovators and now they're all doing doing ketamine, not all, a lot of them have substituted or traded out alcohol for ketamine, ecstasy slash molly, 2C, which I guess is a mix of ketamine and molly, even to the point where they would roam around these conferences with their own concoction using eyedroppers and different means of, I mean, it's just staggering to me.
I was on, I went to this thing called Summit at Sea and it was on a cruise ship and I went up and ordered a drink and the bartender said, Jesus, someone's actually ordered me a drink. And this is amongst a crew doctor of wealthy young people who would generally there'd be a the bar.
And the one I missed was mushroom chocolates. And I imagine there's a lot of edibles in there too.
I've just seen an enormous, and if you look at, it's having such weird knock-on effects. In London, 40% of nightclubs have closed since pre-pandemic because kids aren't drinking.
And some of that is they don't have the money anymore, but they're swapped out. They're under the impression that it's healthier or less bad for you.
And they'd rather do mushroom chocolates and have one drink or molly, and they see alcohol as old technology. I'm curious if you see, if this is just anecdotal evidence, or if see real evidence of this, and what your thoughts are around addiction and what it means for society when we're no longer two martini lunches, we're maybe doing a little bit of ketamine and trying to get on with our day.
What do you see going on here? Yeah. Well, I mean, I'm really torn because on one level, as an addiction psychiatrist, I'm thrilled that people are taking more seriously the harms of alcohol, which we've known for, you know, many thousands of years.
Of course, again, alcohol in moderation, the healthiest people being those who drink no more than one to two standard drinks per week, and the threshold being— Per week. per week, right? Per week.
So if we're taking the healthiest people on the planet. Oh, doctor.
I was almost entirely sure you were going to say per day. I know.
I know. I know.
But let me qualify that. Let me qualify that.
So that's a J-shaped curve that shows that people who drink one to two standard drinks per week are the healthiest. But it's probably because there are confounds there.
Like those are people who do a lot of things in moderation. They eat in moderation.
They exercise in moderation. They're even healthier than people who don't drink at all.
But that's not because alcohol itself is good for us. It's because in that non-drinking cohort, you get people who are what we call sick quitters who used to drink heavily and now are on the liver transplant list.
But what we do know is that beyond two drinks per week, and again, these are large epidemiologic catchment studies. One given individual is going to have their own trajectory, but beyond two drinks a week, you get to a threshold in women where more than seven drinks per week and men, men, more than 14 drinks per week, where you start to see a significant increase in all-cause morbidity and mortality, whether it's risk of cancer, risk of accidental death or trauma, risk of pancreatitis, liver disease, you know, dementia, or what have you.
So that's why we generally recommend that men have no more than 14 standard drinks per week and no more than four on a given occasion, women no more than seven per week and no more than three on a given occasion. But in general, through most of my career, it's been an uphill battle trying to convince people that alcohol is not good for them when consumed in excess, excess being as I just defined it with the 14 or 4.
There's been a huge sea change in the last five years where all of a sudden people seem much more aware of the dangers of alcohol, much less inclined to consume it recreationally because they're concerned with the dangers. This maps perfectly with what we know about perceived dangers in use.

When people perceive that a substance is dangerous, they're less likely to use it,

less likely to use it in excess, less likely to get addicted.

The huge shift along with that, I think, is twofold.

One, what you've already identified, the incredible surgence of designer drugs in all their various forms, including plant medicines, hallucinogens, psychedelics, where people really misperceive the dangers, think they're much safer than they actually are, and also have become equated with having some kind of actualization experience or spiritual growth experience. So you've got the combination of people thinking they're not dangerous.
Why? Because they've been heavily promoted as not dangerous, including the studies that promote their use. For example, the use of psilocybin as a treatment for depression.
Those studies systematically ignore harms, don't document harms. And the lay press has picked that up.
That has legs. And now people think, oh, you know, hallucinogens, psychedelics, they're not addictive, they're not harmful, and I might have a spiritual awakening.
So that's what's happening there. I think the other piece of it, too, that can't be ignored is that we are narcotizing ourselves with digital media.
So where we might go drink and get together with others, which in some sense, at least it was more social, you know, now, you know, I can speak for myself. I'm like in my bedroom watching one YouTube video after another, and it feels very pleasant.
And yet I know it's not good for me. We'll be right back.
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slash Scott terms and conditions apply only on LinkedIn ads. So, and I don't know if the producer warned you, but basically I use these podcasts and the guests as a vehicle to talk about me.
You know what? Go for it. I love it.
It's so much more interesting for me because I get to like, you human being. And I have one of the top domain experts in the world.
On yourself or on something? I'm teasing you. On addictions.
And I'm fascinated with addictions. And I want to talk about a couple of addictions I think I have.
And you talk about whether they're actually clinically diagnosed addictions and what to do about them. And then I want to talk about the advice I give to young men and what I'm getting right and wrong.
Because what I realize is I have a series of principles that I lecture young men about, and I don't know. I think I'm right, but I want to know what I don't know.
So the first is, I believe that everyone has a certain amount of addictions. That's not true.
Some more than others. But I think almost everybody has some level of something they do that is probably if they did less it would probably be better for them across their life whether it's addictions to shopping the affirmation whatever it might be and i'm addicted to the affirmation of strangers i care too much about what other people who i don't know will never know think and sometimes that gets in the way of my relationships with people who do, I should care about.
Someone will say something mean about me or insult my work on a social media platform, and it inhibits my ability to be close to my loved ones that weekend. I see that as an addiction, an addiction to the affirmation of others and strangers.
And I think that might be something that plagues, quite frankly, a lot of successful people or insecure people. And then I would also argue I have an addiction to money, that I'm very blessed and I got kind of enough money to live well or be economically secure.
And I still, almost every waking hour, spend a decent amount of that time thinking about how to get more money, even when I should probably, and I talk myself into believing it's for me and my family, but it's really just an addiction. I've spent so long trying to dig out of economic insecurity that I've become addicted to more, specifically more money.
So addiction to the affirmation of others, addiction to money. Are those clinically diagnosed addictions and how should I be thinking about them? Wow.
Those are really good ones that I don't get asked about very often. So thank you for your honest self-disclosure.
Let me go back a little bit to your first comment, this idea that everybody has something that they do more of than they wish they did. I mean, and that's been true since the beginning of time.
We know going all the way back to what Aristotle called wide-eyed incontinence. Incontinence is actually a term we use in medicine to talk about when people can't hold their bladder.
But Aristotle talked about wide-eyed incontinence. I see the thing that I am doing.
I have wide eyes when I'm seeing it. I want to stop doing as much of it as I'm doing, and yet I am unable to.
And so I agree with you that that is true for all of us in varying degrees. And it's because of the way we are wired over, you know, many, many, many thousands of years of evolution to reflexively approach pleasure and avoid pain, because that is what ensured our survival

in a world of scarcity and ever-present danger, which is the world that we lived in for most of

human existence. As civilization has progressed, we have managed to use our big brains to

apply technology. It's not right.
Now we've drugified everything. We've made it more potently

rewarding, more easily accessible, more abundant, more novel. And so now we're all struggling with

Thank you. Now we've drugified everything.
We've made it more potently rewarding, more easily accessible, more abundant, more novel. And 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, the 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. And 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.
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 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 that scale. So 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. Getting 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% increase in calls to hotline pathological gambling centers because people are losing everything in the face of, you know, their parlays having to do with whether or not the referee is going to touch his hat five times during the game.

So, yeah, I mean, this is sort of human nature 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 that our brains need to be doing, and turned it into a drug. Yeah, it's part of thought.
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 that we used to get from being social to, as you referenced, getting that hit with a low cost, low entry, low risk activity like YouTube or what have you?

Can you get it?

I 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. 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. How 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 moderate manageable pornography use to immoderate unmanageable addictive use and destroying lives, like losing their families, their jobs, engaging in illegal activity. Since 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. 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, glucinogens. 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 were just addicted to alcohol and not anything else. We 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 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.
I 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 and I decide to end it.
And 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 people. 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. The ball's going to 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 worrying too much here, that we're gonna 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.
Your thoughts? Yeah, so it's funny that you, I thought for sure you were going to say online pornography because I would probably put, in terms of risks to men living in the world today, I would probably put that above online gambling, but 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, you know, 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? So 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? And the risks, I usually classify into nature, nurture, and neighborhood. So nature, 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. Co-occurring psychiatric disorders put people at risk because of a kind of a self-medication myth and cycle.
We 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 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 um yeah i mean gambling is everywhere i there 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.
There 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. And 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, like, 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.

Huge, 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. You 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.

It 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. Yeah.
You sound like my son. Well, I think I sound like, I sound like most sons in their head and I think I just articulate 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 have gone to four or three or two because it just might have 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 want to take these risks.
I want to 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. I 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? Absolutely.
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.
I mean, this is a huge issue right now. of and and and by the way i think your your point here about it being so widespread that we can

hardly even call it it's like an endemicemic disease. 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. I 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.
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 and profit from these media are not remotely being held responsible for what's going on.
I mean, this is really endemic proportion problems. And 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, you know, it's ambiguous and it's painful, you know, because of all the ways in which we're all so complicated.
So yeah, this is a huge problem. We're like, 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.
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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. Many 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? Because 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 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. So after school programs.
Not even after school, during school. How can we do that? Get smartphones out of schools, bell to bell.
Create, give hands-on, bring back what happened to, I mean, I didn't like, you know, auto shop, 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 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. And 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. Yeah.
We age get a lot of things. Yeah.
Like, we recognize that kids have vulnerable brains 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. So 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. Yeah.
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. Again, 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 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 we should look for as potential warning signs for something going wrong with our kid.
Last 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. They 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.
So, 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.

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

Adder 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 30 super impressive in the ad tech market making you know 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 having real, it's yielding real benefits, especially with young men. And 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 though, who knows, like go on Craigslist and get whatever. But 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 was putting myself in an environment where i'd have a greater likelihood of being able to ask a woman out.
And show me someone who can ask a woman out or handle the rejection or be successful at it. I'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 or task rabbit 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 non-profit whatever it might be and and this is what we're going to do and this is what we're going to recommend if you're a young man right now.
I 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 be interested in 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, would you like to have coffee? And 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.
The 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, specifically 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.
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