We live at a time when everything is available at every moment. Just on your phone, you can order lunch, bet on sports, read this story, watch porn, chat with a friend, chat with a stranger, chat with a large language model or buy a car. Dr. Anna Lembke says that all that convenience and abundance is making us less happy, and there is plenty of research to back her up: In the developed world, we are lonelier, more anxious and more depressed than ever.
Lembke is a psychiatrist who works at Stanford University’s Addiction Medicine Dual Diagnosis Clinic, where she sees patients dealing with all sorts of addictions, from opioids and alcohol to what she calls “digital drugs” that, she says, put us in a “trancelike state where we lose track of time.” In her best-selling book, “Dopamine Nation,” about the science behind addiction, Lembke argues that our brains are wired to constantly seek stimulation, and that modern life, with its never-ending stream of content and stuff, makes it nearly impossible to fight that urge.
At the same time, scientific breakthroughs in medical interventions and new cultural habits, like the decrease in alcohol consumption, hold some promise. My own experience reflects those recent changes. Addiction runs in my family. In 2020, my sister, who struggled with alcoholism for years, died of liver failure — something I shared with Lembke before our interview began. Her “death of despair” made me change my own behavior. After a lifetime of obesity, I started taking Ozempic, which curtailed my obsessive relationship with food. And two years ago, I stopped drinking alcohol. But while I feel physically great, losing weight and getting sober hasn’t stopped some other destructive behaviors, like online shopping, from creeping in. This is a dynamic Lembke is familiar with — both in her work and in her personal life. How to find balance in a world feeding us temptation, she says, is a struggle for us all.
You published “Dopamine Nation” in 2021 with the thesis that the overabundance of modern culture has us constantly stimulated by dopamine. And that has only accelerated since, I think. Generally speaking, have you seen things in your practice that weren’t there before? So, to put it in perspective from my clinical front-row seat: In the early 2000s, we were seeing a sudden increase in people addicted to the very same pills their doctors were prescribing to them for chronic and minor pain conditions, leading to our current-day opioid epidemic. But also, middle-aged men were coming in with severe internet-pornography addiction and compulsive masturbation. Primarily men who had been able to consume pornography in reasonable moderation without a lot of harm to their lives until the advent of the internet — and then especially, in the first decade of the 2000s, the smartphone. And that was probably our earliest signal for behavioral addictions. And then around 2012, 2013, we were seeing a bunch of teenage boys brought in by their parents primarily for internet-gaming disorders. Then roughly 2015, 2016, we started to see the earliest signal of social-media addiction, online shopping, a huge increase in online gambling addiction. And then what I would say I’ve seen primarily in the past five years is a sort of diffuse addiction to the internet. People will have their drug of choice, whether it’s shopping or social media or video games or pornography. But if that’s not available, they’ll switch to something else.
That timeline is — and I’m going to use the word — very sobering. Yeah.
How do you define addiction? Addiction is the continued compulsive use of a substance or a behavior despite harm to self and/or others. Importantly, there is no brain scan or blood test to diagnose addiction, and there won’t be for a very long time, if ever. We still base our diagnosis on what we call phenomenology, which is patterns of behavior that repeat themselves across individuals, temperaments, cultures, time periods, etc.
Is there a difference between addictive behaviors and being an addict? Oh, interesting.
My understanding has always been that addicts cannot control their compulsion, and then addictive behaviors are more habits that can be moderated or controlled. But I think what I’m hearing from you suggests that that’s not the right way to think about it. These issues are debatable, and the use of language is important. When I use the term addiction, I am talking about a form of psychopathology, which is a spectrum disorder. So there is mild, moderate and severe addiction. When we see severe addiction, we all recognize it. It’s obvious, right? People are struggling, they’re suffering, there are incredible consequences as a result of their use, and yet they can’t stop using without significant help. On the less severe end, it’s much harder to tell when we might cross over from healthy recreational and adaptive use of a substance or a behavior into unhealthy, maladaptive use. And often that’s a judgment call. And it’s also culturally informed. So, for example, when we think about something like work addiction: We live in a culture that absolutely celebrates workaholism. So we’re not really going to identify that as a problem typically.
As we’ve discussed, we’ve all become extremely attached to our phones. And phones do seem like the gateway to a lot of these new addictive behaviors. Online sports betting has exploded; pornography use, as you mentioned, is up even as actual sex is down. I was reading a study that said in 2024, Gen Z spent six to seven hours a day scrolling, on average. So I guess it seems that it’s more a systemic problem than an individual problem. I agree 100 percent. This is a collective problem. I see it as part of the Anthropocene, which is a term that’s been coined to describe the age we live in now, when human action is changing the face of the planet for the first time in history. Climate change is often included in this idea of the Anthropocene. But I think that the stressors of overabundance should also be included in that. In the richest countries in the world, we have more leisure time, more disposable income, more access to leisure goods than ever before. And as a result, we are all struggling to know what to do with all that extra time and money. And one would hope and think that we would be engaging in deep philosophical discussions, helping each other —
Sorry, I’m laughing. But instead what we’re doing is spending a whole lot of time masturbating, shopping and watching other people do things online. And essentially what’s happened is we’re spending more and more of our energy and creativity investing in this online world, which means that we are actually leaching our real-life existence of our energy and creativity. So when we try to re-enter the real world, it actually is more boring, because there’s less going on, because there’s nobody there.
You’ve called this the plenty paradox, right? Which is the more we have, the worse off we are, because we’re being bombarded all the time with dopamine-producing things, and that makes us actually feel worse. Yes, exactly. It seems to me we’ve crossed over some kind of abundance set point where we went beyond meeting our basic survival needs and now have so much access to so many pleasure-inducing substances and behaviors that we may actually be changing our brain chemistry such that we’re in a dopamine-deficit state. Now we need to keep using these highly stimulating drugs and behaviors, not to get high and feel good, but just to level the balance and feel normal.
Do you see us all as addicts now? No, I don’t. I think we all struggle with appetitive control in the modern world, but I do think it’s important to use this term addiction or as the D.S.M. defines it, a use disorder, for when we’ve crossed that threshold into self-and-other-harm that is on some level out of our control. So I don’t want to just say, “Everybody’s addicted.” But I do think that the problem of compulsive overconsumption has become something that all of us are probably struggling with in one form or another.
You have authority and expertise in this area, but you are also part of the Anthropocene era, and you are a human in this world and a mother. How do you navigate this for yourself and for your family? My family struggles with this as much as the next family. But one thing that we did that I am very grateful for, and my kids are grateful for, is that we did not have any devices in the home environment until our eldest started high school. When our daughter started high school, she came home and said, “I actually can’t function as a student unless we get connection to the internet,” and we realized that was true with the constantly changing high school schedules, all of the assignments online — there was no way to participate in high school life without connecting to the internet. And this was eight years ago. So we got internet connection, and really it was downhill from there.
I just want to pause here. You didn’t even have internet in your home? We did not have internet in our home, and I did not own a smartphone, if you can believe it, until about 2019, when I was forced through work to get one in order to be able to prescribe controlled substances using Duo Security. I want to emphasize: I’m not judging other people.
I get it! I’m just in awe. I have the kind of work that allowed me to do that. Most people do not have that.
I’m going to tell The New York Times that I am just unplugging from the internet, and I don’t think it’s going to go very well. Exactly. But what can I tell you? My kids are now between ages 18 and 23. They have struggled to various degrees with their time online, but what I’m really grateful for is that they have that base-line notion that too much time on the internet is not a good thing. This past winter holiday, we decided to go to Yosemite Valley together as a family. We had done tons of vacations with the kids, always device-free, which by the way, is like being a blind person now when you’re traveling. It’s literally like you cannot see. But we’ve done it. And I said, “Are you guys still game for device-free?” Because it had been a couple of years since we’d gone on vacation together. And they were excited. And from the moment we got into the car and started driving, I felt a distinct difference in the quality of the presence of all of us, even in the car, and it lasted through the whole three days. We played board games, we had meals together and the key thing there was: Nobody was looking toward the end of the meal to go check their device, because there was no device to check. We lingered. We extended these conversations. We moseyed along after dinner under the stars. It was so different. And I became even more convinced that we need internet-free communal spaces. We need places where we come together — not all of the time, but some of the time — and nobody is connected to the internet, and they can’t get connected. Because when the ability to choose is removed, it changes the state of craving.
I’m imagining this beautiful utopia where we have communal spaces where there’s no internet. But the way that our society is moving is: We now have wearable devices like glasses. There are discussions about implants in our heads. And there’s the rise of artificial intelligence. The New York Times just published a profile of a woman who fell in love with her A.I. boyfriend. It seems as if a lot of these technologies are actually going in the direction of pushing us toward even more engagement. Yeah, I think that’s right. We are now turning to these devices and to the internet to meet our physical, emotional, sexual, educational needs. Every need we have, we don’t really need other people anymore. And I think that’s a very scary prospect, because it means that we will get more and more isolated. And originally the concern was, Oh, they’re getting their needs met through other people in chat rooms or what have you, for good and bad. But as you point out, now with A.I. and large language models, it’s not even real people. It’s like this amalgam of collected language creating a simulated person. I don’t know. It’s really scary.
Even as we’ve seen the rise of temptations, we’ve also seen the rise of other things to counterbalance them. I was an early adopter of Ozempic, which is part of that class of drugs known as GLP-1s. I had done everything to lose weight, including surgery, but this was the first thing that really worked for me. I know we don’t know exactly how these drugs work, but one thing that we are seeing is that it seems to curb other addictive behaviors. I’m wondering what you make of that. So, the data here is really preliminary, and we need a lot more research, but there is clearly a signal that the GLP-1 agonists can help with alcohol addiction. We have patients in our clinic who have failed all other treatments for whom we have prescribed things like Ozempic and Mounjaro and seen the benefit. And these are people who literally have tried everything and struggled for years and years and now report sustained remission from alcohol in a way that’s just so hopeful and wonderful. I think there are some studies showing its benefit in patients with behavioral addictions like gambling disorder and sex addiction. I want to emphasize that they don’t seem to work for everybody. So it’s not like some kind of miracle cure. And that’s true across the board with our medication treatments for all kinds of addictions.
In your book, you seem to be skeptical of medical interventions. And one undercurrent of the conversation around GLP-1s is how long people should stay on them. Do you encourage people to create new habits to try to get off the medication, or is there no problem as far as you can see it with staying on them long term? I know that my work is often interpreted that I’m skeptical of medical interventions. I guess I would nuance that a little bit and just say, I have seen that our medical system overemphasizes prescribing pills and performing procedures, because it’s more lucrative, and it’s faster, and because we have a system that’s not well set up to deal with chronic relapsing-and-remitting disorders like addiction and other mental health concerns. But I very much use all kinds of medical interventions. I prescribe psychotropics and other types of medications on every clinic day. So what I’m seeking is more balance here and the recognition that psychotropics are overprescribed and that many patients experience debilitating polypharmacy where they’re on 13, 14, 15 different psychotropics to the point where it becomes completely unclear what’s working, what’s not — plus you have drug interventions, which can be really dangerous. But getting back to GLP-1s: I don’t really have a judgment one way or another about whether people should stay on them long term. It does appear that when people stop the GLP-1 agonists, they have, with food addiction, a resurgence in their appetite, and they’re at risk to gain the weight back. I’ve seen reports of individuals now kind of pulsing the GLP-1 agonists — using them for a period of time, and then going off of them, and then going back on for brief periods in a kind of pulsing way if the weight starts to creep up again or the relationship with the food starts to get verklempt again.
A lot is being written about the sober-curious trend. This is the other side of the spectrum — it’s not a medical shift; it’s cultural. Do you see these shifts as producing long-term results, or are they just fads? Cultural shifts can have a huge impact. I think we are seeing that with alcohol. More people, especially in the last two to three years, seem to be interested in drinking less alcohol. Outside of the temperance movement and prohibition, this is definitely a new trend. I think, like most things, it tends to be a pendulum swing. We typically go too far in one direction and then too far in another. But, given my profession and all the terrible harms I’ve seen associated with alcohol and drug use and other addictive substances and behaviors, I’m glad that there’s more awareness and that people are interested in finding out about how to have fun together without using substances. I do have a fear, though, that progress in the arena of drugs and alcohol might be happening because people are turning to digital drugs. I hope that’s not the case, but I do have some concern.
That’s interesting, the idea that we’re retreating from real-world dopamine fixes to digital-world dopamine fixes. Exactly.
Are we just playing Whac-a-Mole with our addictions? It’s a fair question. And I think on some level we really are, which then begs the question “What is it about human nature?” Or, I would argue, “What is it about modern life that makes us so vulnerable to these addiction problems?” I have some theories. Totally speculative.
Hit me. I think we’re essentially struggling with endemic narcissism, where our culture is demanding that we focus on ourselves so much that what it’s creating is this deep need to escape ourselves. And I think that is what is driving much of our pursuit of intoxicants as a way to just not have to think about ourselves for a blessed, you know, hour or two. And it’s not, like, the whole explanation, because obviously the whole point of “Dopamine Nation” is that we also live in this world of abundance with constant access, and access alone is a risk factor. But although I think access is important, and supply is more important than we have given it credit for, we do have to focus on the demand part of this equation. What is it about our lives now that make us so desperate to essentially be intoxicated in one form or another? And I do think it is this obsessive self-focus.
This is weird for a therapist to say, because so much of our culture is now inundated with this therapy-speak, in which we’re all trying to analyze ourselves and think about ourselves and actualize ourselves. It’s true. I think we can, like most things, take it too far and end up doing harm with all the time that we spend thinking about ourselves. Now, having said that, good therapy gets us to a place where we can mindfully observe ourselves without being self-absorbed.
This leads us to how we break the cycle of addiction. It’s something that I think about a lot, simply because my sister died of her addiction, and it was one of the catalysts for making me stop drinking. And it’s the two different paths: I took sobriety and she, with a lifetime of struggle, of trying to be sober, it ended up defeating her. What have you learned about why some people can do it and others can’t? It’s a really sad thing when people die of their mental disorder, addiction or otherwise. There are lots of risk factors for addiction. There are genetic risk factors. People don’t come into the world with equal risk. Having said that, given all of the different drugs, including drugs that didn’t exist before and the increased access, I think even without a genetic risk, we’re now all more at risk than we were before. There are social determinants of health that make a big difference in terms of people’s ability to get into recovery. There’s a whole element too of just unpredictability. I used to think that I could predict when a patient came in whether or not they would be able to get into recovery. And I’ve long given up that idea. There is still a lot we don’t know.
What made you become an addiction specialist? Is there something in your life that led you to that? My father’s alcoholism was a major factor in my childhood. He was a surgeon. He would go long periods without drinking. And then he would have long periods where he was drinking large amounts every day. I remember coming home from elementary school with my best friend, Laura, and finding him not on the hammock, but under the hammock, passed out, and just looking at her and saying, “Let’s go to your house.” So that was sort of a specter in my childhood. What I first did with that in medical school and residency was to not want to have anything to do with addicted patients. So I didn’t have the tools, didn’t know what to do. And then very early in my career, I was specializing in treating mood disorders, and I had a young woman in my clinic I was treating for depression. Her parents were paying for the care, and I saw her weekly, and we had in-depth discussions about her childhood. I talked about every conversation she’d ever had with her mother. I was prescribing an antidepressant. And I noted that she would often nod off in the sessions and I thought: Huh, that’s funny. I wonder why she’s so sleepy? Maybe she’s a slow metabolizer. I was trying to draw on what I had learned in medical school. And then one day her brother calls me out of the blue, and he says she’s been in a rollover car accident. I said: “Oh, my goodness. That’s terrible. What happened?” And he said, “Well, she’s been using again.” And I literally did not understand the structure of that sentence. I said, “Using what?” And he said: “Heroin. Isn’t that what you’ve been treating her for?”
Oh, wow. Yeah, and that was the moment that I realized I’m a bad psychiatrist. I was really doing harm to patients out of my ignorance, and that was a huge turning point in my career. I realized, oh, my goodness, I need to figure out something about addiction, or I’m going to be a menace. And the irony is that as soon as I started asking patients about drugs and alcohol, they were eager to talk about it. And the majority of my patients had problems with drugs and alcohol. And when I started treating that problem alongside their other psychiatric disorders, they got better in ways I had never seen prior to that. And the work was fun. It was so enjoyable. People got into recovery. Their recovery impacted their spouses and their children and their parents and their workers. It’s, like, the most rewarding work.
So we’ve been just having this very wide-ranging conversation about all sorts of different types of addiction and all the struggles that we have. And I don’t want to land this on you, but: What are we supposed to do? What I argue for is trying to avoid using intoxicants in high volume too often. So, it’s not that I imagine that we’re never going to use intoxicants. We wouldn’t be human. And it’s a deep part of our culture, and it can be neutral or even beneficial. But we have to really be careful about overconsuming intoxicants or consuming them too often. And I do think given this world of abundance, that we have to now intentionally seek out things that are hard. Because our lives have become so easy, so convenient, so sedentary, the default is a state of consumption that’s ultimately not good for our bodies or our minds.
That’s something that I did. But the other side of this is that while I’m happier and healthier, I also sometimes wonder if I’m becoming an amoeba. That all this abstinence is just making me into someone who is always saying no to dopamine and to pleasure. Do you hear that concern often? Well, I’ve never heard the amoeba analogy [laughs]. There’s the risk here that it all starts to sound too schoolmarmy, right? That lady doesn’t want us to do anything! I think what I’m advocating for is something like a reframe when we decide not to indulge in these pleasures. The culture has us telling ourselves that we are denying ourselves. And I think a potent reframe here is, no, I’m actually going toward something that’s good for me, and that in the long run makes my life better. That’s what I see clinically. That’s what I’ve experienced in my own life. And I think people are searching, you know? I think people are unhappier than they’d like to be, and can’t figure out why.
This interview has been edited and condensed. Listen to and follow “The Interview” on Apple Podcasts, Spotify, YouTube, iHeartRadio, Amazon Music or the New York Times Audio app.
Director of photography (video): Aaron Katter