I spoke with Carl Erik Fisher over Zoom about his book The Urge: Our History of Addiction. Fisher is an addiction physician and bioethicist. He is an assistant professor of clinical psychiatry at Columbia University’s Division of Law, Ethics, and Psychiatry, and maintains a private psychiatry practice focused on addiction. Fisher’s writing has appeared in The New York Times, Nautilus, Slate, and Scientific American MIND. He hosts the podcast Flourishing After Addiction, an interview series exploring addiction and recovery.
In The Urge, you describe how societal views of addiction and treatment have been cyclical. How do you think studying this history can help us break some cycles?
One of the powerful messages I got out of the cycles of history is that when views on addiction became strongly polarized towards one extreme or another, it caused big problems. It caused problems for people who were trying to deliver treatments, and certainly for people who were suffering with addiction and trying to work towards recovery.
That was definitely true when things were very moralized in the earlier part of the 20th century, when addiction was largely treated like vice. But it also became a problem when addiction treatment was too focused on 12 steps as the only way; it also became a problem when addiction treatment was too focused on therapeutic communities; it also became a problem when it was too focused on methadone to the exclusion of all else. The division of ideas about addiction into those camps was really damaging—and the legacy of those divisions continues today.
I think one of the opportunities we’re faced with is to make a more synthetic set of connections across previously divided camps. This is not my idea; there are multiple thinkers that have pushed for many paths of recovery. But I think that’s one of the big lessons about breaking out of cycles—to stop engaging in the us vs. them mentality that creates the cycles in the first place.
Yeah, I was going to ask how you think we move away from the black-and-white approach that seems to have dominated for so long, but you kind of answered my question.
Yeah, because ideas about addiction itself and ideas about treatment are so strongly linked. Even a third level to that is how we should respond to problems of addiction. In all those different lenses, we can see reflected ideas about the others. I think it’s really important to think humbly about what the underlying characterization is.
You talk in the book about how so many of us with addictions have felt at times that we have free will, and at others that we’re losing control. You also show how we as a society have gone back and forth in viewing it as one or the other. How do you think society’s viewing it as either of those tends to impact policy or treatment?
There are very wise and thoughtful advocates who at times have leaned into what I would call caricatures about the nature of addiction—describing it as completely abolishing free will. And maybe that is helpful in some circles; maybe it helps summon compassion or resources. But I also think all-or-nothing portrayals of addiction—as some sort of free choice on one hand, versus a complete and total hijacking that takes away every shred of someone’s free will—are a double-edged sword. I think it’s better to tell the truth, and to be as clear as possible about these very complicated gray areas.
My experience in addiction—and I think the experience of many of my patients and people I’ve met along the way—has been a push and pull. Sometimes you feel in full control and sometimes it feels totally automatic; you wake up the next morning and are like, “I can’t even describe how I got from point a to point b.” It’s one of the deep mysteries about addiction. In my own work, it’s been a priority to avoid caricatures and work towards more nuance.
Yeah, that’s one thing I really appreciated about your book, and I also liked how you described that there are no “good” or “bad” drugs. Can you explain why that’s the case?
As long as we’ve had drugs, we’ve had powerful social, political, and moralistic forces that have divided them into “good” or “bad.” Which is important, because almost every single human society on the face of the planet has used some sort of mind-altering substance at some point. Usually, the stories about “good” and “bad” drugs are more about people, class, race, and colonialism than they are about the drugs themselves.
Even in recent history, opioids were considered safe and not a real addiction; it was a pseudo-addiction, and it was really crack cocaine that was the bad thing. Then you rewind the clock a little to the crack epidemic, and I have cases in my book about researchers saying, “If my daughter were to use heroin or crack, I would rather she use heroin.” Compare that to today, when people are thoughtful about and aware of the opioid overdose crisis. We’ve gone through these cycles where meth gets demonized, and methamphetamines in the form of prescription drugs are given a free pass as if they’re not mind-altering in any way.
The bottom line is that those divisive stories always come back to hurt all of us. The stories about “bad” drugs are used as a weapon for oppression and domination. The “good” drugs come back to hurt the people who have entitlement to them—people like me who grew up white, middle-class, and privileged. It was my own entitlement—my easy access to Adderall—that really put me over the edge in terms of my addiction crisis, where I truly was no longer able to function.
You wrote in the book about how you wanted to study addiction after experiencing it, but also studying the neuroscience and medicine behind it. What about those experiences made you want to learn the history?
A lot of things. The first is just that the history seemed interesting and it was an untold story. Some of it was a gut sense that maybe it would be helpful. But it was also disillusionment with the existing narratives. There were all these overly simplified, all-or-nothing portrayals: all addiction is trauma, or all addiction is a lack of connection, or all addiction is this or that. Each of those stories are helpful, but don’t tell the full picture. For me at least, they didn’t provide enough depth and careful consideration for what I was experiencing and what I had seen in my family. Going to the history was a way of taking a really broad view over what the phenomenon was. The history is the framework; it’s a way to make sense of it all.
I didn’t do this for fun, because it wasn’t that fun at various points. I didn’t do it because it would be helpful to my academic career, because in most cases writing a book for a general audience is not that helpful for an academic career. I did this because these were questions that were really alive for me. I didn’t know who I was, and I didn’t know how to make sense of the problems that had beset myself and my family.
I started writing the book in early recovery, when I had the sense that I was safe for today; I didn’t feel like I was going to relapse that day or week or month. But I recognized that there was more work to be done. For me, the process of making sense of my identity, my addiction, and my recovery was life or death.
The history was extremely helpful in that way, probably because of the stories about different people across times and places. Even though they had different names for and ways of recovering from it, I had the sense that there was this fellowship; folks I met through historical research had struggled with the same problem. I needed that to make sense of it all and to be comfortable in that identity within myself. To the extent that it’s helpful for anyone trying to make sense of their own or a family member’s addiction—that’s why I wrote the book in the first place.
I told myself I was going to get sober a month in advance, and starting then until now at close to seven years, I’ve read widely about addiction and recovery. And because I agree with you that it’s very nuanced, I’ve read everything I could, listened to everything I could. I tell people I feel like that’s kept me sober—or at least it’s one of the things that has.
Which is interesting, because I was told I should be careful about intellectualization, and that part of the process was to take the cotton out of my ears and put it in my mouth. There’s a kind and wise motivation behind that advice sometimes, but it can also go too far; it can be a tool for coercion and control, where people might say, ‘These totally legitimate questions you have are not worth anything and you should just shut the heck up.’
There are a lot of people I see in my practice and personal life who have really complicated and legitimate questions about the mystery of addiction. ‘What does this mean about me?’ ‘Is it a thing I catch like a virus or bacterium, and if not, how do I make sense of it?’ Questions about mental health are some of the most complicated questions we have in all of psychology. The ways that we describe, make sense of, and recover from addiction are necessarily not going to work for everyone—and there’s a lot of value there.