Why are Americans in such pain? When researchers asked people in 30 countries: “During the past four weeks, how often have you had bodily aches and pains?” Americans seemed to top the charts. As Dr. Anna Lembke reports in her new book, Dopamine Nation, more than a third of Americans said they felt pain often or very often compared to 19% of people in China, 18% of people in Japan, 13% of people in Switzerland, and 11% of people in South Africa. Depression, too, is up significantly with the highest increases in new cases seen in North America. Lembke, the medical director of Stanford Addiction Medicine, asks: “Why, in a time of unprecedented wealth, freedom, technological progress, and medical advancement do we appear to be unhappier and in more pain than ever?”

The answer, it seems, is that we have more access to pleasure than ever before. Though Dr. Lembke treats patients with the sorts of addiction and levels of addiction that might seem foreign to the typical reader, she suggests that our on-demand culture makes us all susceptible to these problems. She introduces a story of her own addiction—to erotic novels. The problem began innocently enough with her reading the Twilight novels, a popular series about vampire romance.

When I finished Twilight, I ripped through every vampire romance I could get my hands on, and then moved on to werewolves, fairies, witches, necromancers, time travelers, soothsayers, mind readers, fire wielders, fortune-tellers, gem workers… . At some point, tame love stories no longer satisfied, so I searched out increasingly graphic and erotic renditions of the classic boy-meets-girl fantasy. 

Soon Lembke’s habits were interfering with sleep and paying attention to her husband and children. “I just wanted my fix, and these books, written according to a formula, were designed to hook me….” She writes. “I started rushing through the first part of the book until I got to the climax and didn’t bother to read the rest after it was done.”

The example may sound silly, but the conditions that allowed Lembke to indulge in her habit are the same ones that allow for addictions to video games, pornography, sex, and gambling. Access to the internet allows us to indulge in immediate gratification and privacy in doing so. The worst combination for many of Lembke’s patients seems to be spending time in hotel rooms—alone and with unlimited access to the Internet. 

Alcoholics could always call ahead to ask the front desk to remove the mini-bar or at least keep it locked. But now people are removing televisions, too. And even that form of “self-binding” can be unlikely to help in an era where everyone is carrying a phone, a tablet, or a laptop. Many of the problems that the modern era creates for our ability to control our appetites will seem familiar to anyone paying attention. But what Lembke offers is a better scientific understanding of the ways that our constant pleasure-seeking may actually be causing us physical pain. 

She describes the experience of neuroadaptation: 

With repeated exposure to the same or similar pleasure stimulus, the initial deviation to the side of pleasure gets weaker and shorter and the after-response to the side of pain gets stronger and longer…. With repetition, our gremlins get bigger, faster, and more numerous and we need more of our drug of choice to get the same effect. 

Even more dangerous, she notes, is that “our hedonic (pleasure) set point changes as our capacity to experience pleasure goes down and our vulnerability to pain goes up.” Those two things are more closely related than we think. She points to the effect of long-term opioid therapy for chronic pain as one example. She saw patients coming in who reported their pain had gotten worse over time as they were taking these drugs. “Exposure to opioids had caused their brain to reset its pleasure-pain balance to the side of pain,” she explains. “Now their original pain was worse, and they had new pain in parts of their body that used to be pain free.”

The fact that one-in-four Americans is on some kind of psychiatric drug is a sign to Lembke that something is seriously amiss and that these drugs may, in fact, be making our pain worse. She describes patients who come to her self-medicating with Adderall or Ambien or marijuana for that matter, and the first thing she does is recommend a period of abstinence for a month—a dopamine fast—so that they can reset the pain-pleasure balance in their minds. 

The results, she reports, are often successful. While there are patients with serious and diagnosable psychiatric disorders, she suspects that a good many of those who are self-medicating and even those who get a prescription from a doctor may be making the problems worse in the long term. One patient, a teenager named Delilah, is brought in by her parents because of her cannabis use. She tells Lembke she feels tremendous anxiety without it—from the moment she gets up in the morning. But the pot itself may have been causing the anxiety. 

After she stops, she reports: “The word anxiety doesn’t even come into my head. It used to rule my day. Clear-headed, I don’t have to worry about my parents smelling it and getting mad. I’m not anxious at school anymore…” the teen tells her. “I put so much time and mental effort into organizing my next high, rushing off to do it. It’s such a relief not to have to do that anymore.” 

To which a reader may say, “Well, duh.” But Lembke treats adults who are taking prescribed medications for similar problems, and she sees the same results. 

How have we lost sight of the importance of feeling the full range of human emotions, of understanding that boredom and sadness and anger are all part of life? For one thing, we have stopped training our children to handle them. Parents rush to fix every problem, to solve every complaint, to always entertain are training kids to jump from one pleasurable experience to another. And by the time they are adults they are only used to mountains, not valleys. 

Lembke advises her readers to “immerse yourself fully in the life you’ve been given. To stop running from whatever you’re trying to escape, and instead to stop, and turn and face whatever it is.” That, too, can lead to better things, she says: “The world may reveal itself to you as something magical and awe-inspiring that does not require escape. Instead, the world may become something worth paying attention to.”

Wise advice for both young and old.