Episode 18 | How Should We Talk About Addiction? January 23, 2022

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GUEST: Dr. Carl Erik Fisher, Author, The Urge: Our History of Addiction

At 29, as a newly minted physician in the psychiatry residency program at Columbia University, Dr. Carl Erik Fisher had much to look forward to – that is until his alcohol addiction landed him in New York City’s Bellevue hospital and nearly cost him everything. In this episode, we talk with Carl about that experience and how it inspired his new book, The Urge: Our History of Addiction. In it, he shares his personal experience with addiction and recovery, and offers a comprehensive look at how society has defined, treated, and tried to control addictive behavior for centuries. Is there a better way to think and talk about addiction? And, can that help us to create more compassionate and effective treatments and strategies?

GUEST BIO:

Dr. Carl Erik Fisher is the author of The Urge: Our History of Addiction, which explores how, over the centuries, society has historically, philosophically, scientifically, and socially grappled with the nature of addiction, its complexity, and how to treat it. In the book, he draws on his experiences as an addiction physician, bioethicist, and assistant professor of clinical psychiatry at Columbia, as well as an alcoholic in recovery, as he examines treatments and strategies that have helped, as well as hurt, those struggling with addiction. He has also written for various publications, including Nautilus, Slate, Scientific American MIND, and other outlets. His clinical work focuses on applications of meditation and mindfulness. He also hosts the podcast Flourishing After Addiction, an interview series focused on addiction and recovery. Born and raised in New Jersey, he  lives between Brooklyn, New York, and Lisbon, Portugal, with his partner and son.

LINKS:

The Urge: Our History of Addiction

Twitter, Instagram: @DrCarlErik

Dr. Carl Erik Fisher on Facebook

Flourishing After Addiction podcast

Full Transcript

BRAD PHILLIPS, HOST, THE SPEAK GOOD PODCAST:

I wrote the first-ever feature story for the Nightline website on ABCNews.com.

Now, that might sound like I’m bragging a little bit. But this was in the 1990s, before news organizations had gone all-in on digital. And precisely because my bosses knew that very few people would ever click on that website – at least at the beginning – they didn’t want to assign that task to someone more senior than I was. Their time was best spent on work that would be seen by millions of people on television instead of a few hundred early internet users.

Because it was my first published feature, I remember it well. But I also remember the interview I conducted for that story for a different reason.

I interviewed a man who had downed something like a dozen rum and cokes before boarding a Northwest Airlines flight from Fargo, North Dakota to Minneapolis-St. Paul. By the time he boarded, he was, unsurprisingly, drunk. But what made that story noteworthy was that that man – Lyle Prouse – was not a passenger. He was the pilot.

When the plane landed in Minnesota – mercifully without any harm to the 58 passengers in his care, law enforcement arrested him. He was ordered to 28 days of in-patient treatment, a month in a halfway house, and 16 months in prison. His story made national headlines and even made Prouse the butt of nightly jokes by Jay Leno on The Tonight Show.

After serving his time, Northwest Airlines gave Prouse another shot. At great reputational risk, the airline’s management re-hired him, because they wanted people to know that alcoholics could be treated and, in some cases, earn their profession back.

Nightline ran a two-part broadcast about his story and his redemption. My web article was to accompany those broadcasts – and because I didn’t want it to be redundant, I conducted my own fresh, in-person interview with Mr. Prouse.

He didn’t know how green I was – and even if he did, it probably wouldn’t have mattered. He treated me with way more respect than I had earned by that point – and I found him to be candid, funny, vulnerable, and tough in the best possible way. He answered all of my questions forthrightly and patiently.

But close to the end of our conversation, I asked him something that elicited an animated reply. I can’t remember my question – it’s been a long time – but I do remember his answer, in which he leaned forward and exclaimed, “Alcoholism is a disease! The AMA said that years ago!”

The question of the cause or causes of addiction has been debated for millennia. Philosophers, scientists, political leaders, and others have attributed addiction to everything from a moral failing and a spiritual emptiness to genetics and biology, or some combination of all of the above, or something different altogether.

The question of alcoholism as a disease is at least as old as our nation. If you’ve heard the name Benjamin Rush, you may know him as the mutual friend who helped to broker a detente in the long-strained relationship between one-time friends John Adams and Thomas Jefferson. They ended up exchanging a remarkable number of letters back and forth to each other late in their lives that is cherished by historians. Or you might know Benjamine Rush as the physician whose controversial treatment for yellow fever – which consisted of bleeding patients multiple times – quite possibly cost dozens of lives. But his less-known legacy – and an important one – was offering the “clearest statement to that point that habitual drunkenness was a disease unto itself.”

The American Medical Association picked up on that them in 1876, passing a resolution that called drunkenness both a disease and a vice.

More than a century later, in 1997, Alan Leshner, the director of the National Institute on Drug Abuse, wrote an editorial called, “Addiction is a Brain Disease, and it Matters.”

And yet, my guest today says that the binary disease label – it either is a disease or it isn’t – can be harmful. Here’s what Carl Erik Fisher, author of the new book called The Urge: Our History of Addiction, which will be released on Jan. 25, wrote:

“Calling addiction primarily a brain disease goes too far … While classifying addiction as a brain disease has helped to get research funded, some scholars have documented a long and worrying drift of U.S. federal research on alcohol and drugs toward reductionist biological research and away from social, epidemiological, clinical, and policy investigations.”

And that matters, he writes, in part because:

“A reductionist framing may not actually reduce the stigma attached to addiction … Several studies have found that a binary disease-model view of alcoholism, as opposed to a continuum model, makes it harder for people to recognize their own harmful drinking. In another study, the most potent predictor of relapse was belief in the disease model of addiction.”

Carl Erik Fisher is not only the author of The Urge, a sweeping look at the history of addiction, but an addiction physician and bioethicist who is an assistant professor of clinical psychiatry at Columbia University and who also treats patients through a private psychiatry practice.

But, in addition to those professional accomplishments, he also brings first-person experience to addiction. He’s the son of alcoholics and is, himself, a recovering addict who went from being a 29-year-old newly minted physician in a psychiatry residency program at Columbia University to a psychiatric patient at Bellevue, New York City’s most notorious public hospital.

We’ll discuss his personal experience with addiction, the unique view he brings to this topic as a professor, psychiatrist, and patient, and why some drugs users are labeled “good users” and receive treatment – while others are called “bad users” and go to jail.

(MUSIC PLAYS)

Carl, I think the place to begin is just making sure that I get the language right. And I noted that in your book that was the place where you started as well. In your opening note, you wrote that the language of mental health matters. Much of the old language around addiction is now considered stigmatizing by many advocates, not just junkie or drunk, but also addict and alcoholic. So, I would hope most of our listeners would know that junkie or drunk are pejorative terms and never to use them, but addict and alcoholic surprised me a little bit. And I’m wondering how you think we should be referring to those terms during our conversation, but also in general.

CARL ERIK FISHER:

Thanks for asking Brad, and thanks for having me on, too. It’s a pleasure to be here with you. First off, and I don’t mean to be glib, the easy answer is ask the person you’re with. If it’s on the individual level, then people have different ways of identifying as someone in recovery, or in my case, I consider myself an alcoholic. I won’t be offended by that. However, when we’re talking about policy and public communication and journalism, then the right answer is to use person first language. And that means to say a person with alcoholism or a person with addiction rather than an addict. And the reason why is because we don’t define people solely or primarily by their problems. Just like it’s not, it is not really widely accepted to say an autistic anymore. We say a person with autism. The same thing applies with addict and alcoholic. And, I think it’s important because the noun form, the addict or alcoholic label as some advocates have pointed out, points to fatalism and suggests that somebody is essentially that way. They’re permanently that way, that all people with addiction are alike in a certain sense, and that’s just not true.

PHILLIPS:

One of the things that really struck me about your book, and I made an assumption here, that the lens through which you’re looking at this to topic is rather unique. Many people have suffered from, and I’m very concerned about the language I’m using now …

FISHER:

(LAUGHS)

PHILLIPS:

… but a lot of people have dealt with substance abuse issues, have been what might be labeled alcoholics and/or addicts, and you certainly were very open in your book about how you have lived through that. You’re also a clinician who treats patients who are dealing with substance abuse issues, but this book really, I think, was an achievement because it shows that you are also a historian, who has gone back to the ancients and looked at how they were thinking about both causes and treatments millennia ago, all the way to the current day. And so, both through personal experience, clinical experience and through the lens you have as a historian, I think that makes you a rather unique figure in this. What do you think those three lenses have allowed you to see that maybe people who only can see this issue through one or two might miss?

FISHER:

First off Brad, I want say don’t feel nervous about your language …

PHILLIPS:

(LAUGHS)

FISHER:

… because I can tell that you are genuinely interested and curious about this, and if you happen to use the wrong word, I won’t hold it against you there. The language is tricky and we’re in a funny historical moment where people are talking about mental illness differently. And, this part of the conversation, I don’t intend to be the final arbiter or the king of language about addiction. But. I appreciate your interest in it.

PHILLIPS:

Yes. Thank you for your forgiveness in advance.

FISHER:

Now, you asked about those three lenses, about physician, scholar, and alcoholic in recovery. And, I guess what I could say is that I needed history. I had the sense in my own early recovery that I needed to go beyond medicine and science to really make sense of what had plagued me and my family for generations. In the process of investigating that I realized that I needed the personal, too, for me. I needed that to keep it connected to what actually mattered because it helped me stay connected to the emotional content of why I was looking at the history, what I was hoping to learn. And, it also helped me to disclose my own biases and my own privilege and my own blind spots because addiction, which I found in the process of the historical investigations, addiction is deeply personal. What I call addiction is different from the way, say, Benjamin Rush, one of our founding fathers, considered addiction around the time of the American Revolution. It’s different than the way people conceptualize self-control problems in the time of Plato and Aristotle and all the rest. And I didn’t want to make the assumption that my problems and my view of addiction neatly mapped on to all these points in the history. That would be a humoristic mistake. So, the personal really helped me to stay connected to what mattered most while also staying humble.

PHILLIPS:

One of the interesting pieces of feedback you got along the way was don’t look too deeply into the history. I think it was one of your mentors said that there could be a double-edged sword and advised you not to do this kind of sweeping historical analysis. Obviously, you did anyway, but did you have to put up safeguards to make sure that it was looking at history in a way that was productive and helpful for you?

FISHER:

Mm-hmm … yeah, one of my treatment professionals early on actually said don’t look too much at the history or the theory or the science or the policy, that’s intellectualization and it might lead you astray. It might just feed your own denial and allow you to talk yourself out of being addicted, or convince you that you can drink again safely or use again safely. And I think there’s something to that, to be fair. I think, as you imply in your question, I needed to be cautious about doing these types of investigations and, yeah, simply put, it was just a about getting feedback. I had a Zen teacher by that point who could help me call bullsh*t on myself. I had a therapist who could help me call bullsh*t on myself. I had fellowship in recovery. I had other doctors in recovery and other people in recovery who could help me call bullsh*t (LAUGHS), and so it was a practice of being honest about what I was actually looking for, whether it was feeding my own ego or feeding my own sense that I know what I’m talking about versus being open and inquisitive about what is really a millennial-old mystery.

PHILLIPS:

Our company’s name is Throughline, so I’m very interested in the thesis, the main theme that’s somebody is trying to articulate in whatever presentation or narrative work that they’ve put together. And I’m curious if I’ve gotten it right after reading your book. I think my big takeaway out of the 300 pages or so that you have put together is, and, by the way, there’s a single word that really was a signal to me (the word was reductionist). I didn’t do a word count, but I’m guessing you used it at least a dozen times, maybe more throughout the book. And, my sense is that if there’s a big takeaway, it’s that throughout history, there’s been a rush to identify a single cause and a single treatment for various types of addiction. And if anything, my big takeaway from your book is proceed with caution. When you see people who are so quick to come to a single truth, that the causes and treatments are myriad, and one size doesn’t fit all. Going into the book, was that what you intended to be – perhaps the central theme?

FISHER:

Not at all. One of the big surprises of the book was seeing how drug epidemics came up over and over again for centuries and centuries. The U.S. just released these awful figures that a 100,000 people have died of overdoses in the past year. That’s probably only getting worse. So, this is a historic and awful event, and it’s also nothing new. We’ve had drug epidemics throughout human history since at least the 1500s. And one thing I found is that societies across the globe have tended to reach for different responses to addiction. So, a reductionist response might be looking to science to solve the problem at some fundamental level. And then a prohibitionist response, in contrast, might be to crack down and try to just eradicate drugs or eradicate drug users. And you’re exactly right. One of the key messages of the book is that there’s no single response that is going to be adequate for dealing with addiction, not at a personal level and not at a policy level. We need flexibility and humility and a multilevel response to really respect the diversity of ways that people experience addiction and the diversity of ways that individuals can recover and get better.

PHILLIPS:

Yes. Addiction is often viewed as a personal failure, as a character defect of some sort, and obviously history offers a lot of contradictory examples that disprove that. One of them that you mentioned in the book was the American colonists encouraging drinking among native peoples to pacify their resistance, to tie them to the colonial economy. And then, of course, once they soften them in that way, they were able to promote this very expensive alcohol and swapped whiskey for crushing debt and mortgages on native land. This is one example of many that you offered the book. Can you talk about how the history of addiction is connected to being used as a tool to subjugate people to achieve a group’s larger goals?

FISHER:

Sure. Oppression, colonialism, misogyny, white supremacy, racism. These are all woven into the experience of addiction, as far back as we can look. Addiction itself is often portrayed as a form of oppression or bondage. And so, it’s no surprise that we find things like slavery or colonialism throughout its history. And addiction is used as a weapon in the sense that policies are used to encourage addiction outright, or at least to neglect addiction in say, for example, the way we have dealt with Native Americans and alcohol, or, the way we ignore the root causes of addiction problems in the urban poor today. Also, the label of addiction is used as a weapon. So even taking a step back, just the way we understand addiction can be a way of oppressing people, to label certain types of drugs as good drugs or bad drugs, and then to have totally inequitable and irrational policies that serve more to serve the interests of people in power. The key example is crack sentencing disparities, which have only just started to be unwound, but back during the crack epidemic in the 1980s, uh, there is this massive sentencing disparity between powder cocaine, which is primarily used by whites and crack cocaine, which is primarily used by the urban poor, black and brown folks. Those don’t serve to do anything rational about addiction, they don’t actually help anyone. It’s really more of a tool of control than anything else.

PHILLIPS:

You wrote, very movingly I think, about that idea of the right kind of drugs versus the wrong kind of drugs. I put both of those terms in quotes. And the right types of drug users versus the wrong types of drug users. When the NYPD entered your own apartment and, and removed you to … let me read your own language of how you describe that moment, and it gets to the disparities in punishment between whites and African Americans. Quote, “If not for an accident of my birth, my story could have been entirely different. The NYPD chose to take me, a white guy living in an upscale Manhattan neighborhood, to a hospital rather than booking me. If I’d been a person of color in a different neighborhood, I could have been sentenced to years in prison or even shot and killed.” So, I was surprised in reading your book because I aware of the disparities in cocaine and crack, but there were other examples you gave, such as what were known as the opium dens and Chinese immigrants, I guess this was early in the 20th century, that that type of disparity in how entire groups were viewed and then treated if they were caught as being on the wrong side of the wrong users line, were. Can you talk about that difference in racial disparities, kind of across history?

FISHER:

Sure. And thanks for bringing up that example, because it was an example for me of how racism redounds to hurt everyone. It’s a classic example of how we can’t just have inequity in one portion of our addiction treatment and not feel the consequences. So, I was lucky that I wasn’t shot, but the systematic oppression that has pervaded our addiction treatment system still has hurt me and hurts everyone because it impairs the way that we respond to addiction and makes it so even today our addiction treatment system is really a problem. And that goes back centuries. It goes back centuries because as long as we’ve had a notion of addiction treatment, we’ve had a notion of a two-tiered system. So, in the late 19th, early 20th century, there was a huge outcry about the wrong kinds of users, primarily Chinese immigrants who were doing immense work to try to build our country’s railroads and to develop our American west and throughout the country. On the other hand, there was still a gray market, or even a white market of regulated opioids that was available to middle-class and upper-class Americans. So, we tried to set up at that time a two-tiered system, where whites could go to get treatment and where the Chinese were subjected to prohibition and prohibitionism and punishment. But what that set up, actually, was a massive failure across the board. And then in the 1910s, 1920s, the whole thing collapsed into outright stigma and prohibition, and nobody could get treatment. And everybody was subject to these harsh law and order crackdowns, to the point where the American Medical Association came out and said that addiction is just bad action. It’s just Immoral behavior, and we won’t have any part in it. We doctors won’t do anything to help people with addiction, which was a massive, massive failure that lasted for decades and decades. And even today, we’re still trying to force the doors of medicine open, and we still live with that sort of legacy of a two-tiered treatment system.

PHILLIPS:

One of the other things that really struck me about the use of language is what is an opium den? If I understand correctly from your book, it was a gathering space. And yes, in those gathering spaces where Chinese immigrants would meet, they would occasionally use opium, but the term itself made it very easy to demonize a group of people. Much like in the 1980s, the term crack baby was the same thing and a crack baby, talking about person first or not language, really, almost in some ways, made the baby guilty for having been born to the wrong family. Can you talk about rhetoric and how rhetoric itself has been used to demonize its entire groups?

FISHER:

Right. Opium dens are a great example because they weren’t that bad. I grew up with the notion from say, Charles Dickens, that an opium den was a seedy and dangerous place where criminals lived and white people, and especially white women, would be seduced into the use of the wrong kinds of drugs. But, in actuality, back in China, and also in parts of the American West, there were very nice opium dens. They were more like a social club. And the problem was that in the broader context of xenophobia and racism around the late 19th and early 20th century, journalists selectively went out and they targeted the kind of dangerous and bad looking dens. It all fed into the overall narrative. And we see, like you said, we see that over and over again. We see that with tea houses and cannabis in say the 1930s, when cannabis was rebranded marijuana and turned into a bad drug. We see that with so-called shooting galleries, when people are trying to find a safe space to use heroin or other opioids through the 1950s, 1970s, and so forth. And certainly, with crack and the notion of crack house to the point where in Philadelphia today, advocates are trying to set up an overdose prevention site to try to help people, a safe place where people can use drugs under supervision and hopefully get connected to treatment. And one of the things that’s blocking it is a crack house statute because it’s supposedly a kind of crack house, which is exactly the opposite intent of that kind of legislation. So, these things really do carry through and carry a lot of weight and have a really powerful, negative prohibitionist legacy.

PHILLIPS:

I hope one of the outcomes of your book is that at least for the people who read it or hear about it, that when they hear those types of terms paraded in the popular media, that it immediately triggers them to stop and think about who’s using that term, who came up with it, and what’s their motivation. Because cracking down on a social club is probably not going to get a whole lot of political favor. Cracking down on a very scary sounding opium den will. Since you invoke the media and since I’m a former journalist, one of the things that struck me in your book is I think a lot of well-intentioned journalists and news programs, you cited many of them by name, Bill Moyers, Dan Rather, The New York Times, TIME magazine, who I think probably were trying to tell the story well and fairly, and with compassion, but made some pretty big mistakes in how they conceived the stories and presented them to their audiences. I know this is a very broad question, but in general terms, in contemporary times, what do you see as the biggest problems when the media writes stories about these types of issues?

FISHER:

Hmm. The biggest problem we have today is that we should stop calling addiction a disease. That’s one of the main pieces of messaging where I see us going wrong today. And like you said, I have a lot of respect for many of those journalists you name Bill Moyers, Dan Rather, I think they were doing the best job they could. And, in a way, looking at the journalism in the history is just a way of assessing the biases of a particular time, not to say that somebody screwed up or they did it wrong. So, throughout history, we see journalism as a reflection of the prevailing values and the prevailing judgments. And the thing we see today is that lots of people want to paint addiction as a disease because it’s been used as a policy plank to try to force open doors of hospitals like I mentioned, because the medical profession has so long neglected the treatment of addiction or consigned it to a separate and underserved sort of segment of medical care. But I think the time is passed. The disease label is misleading and probably harmful. We even have psychological research on the idea that looking into a binary model of diseased versus not diseased increases the risk for relapse, that describing people as diseased when they have a mental disorder increases fatalism; it increases social distance. So, when people hear that somebody is described as having a mental disorder as a disease, they don’t want them in their communities. They don’t want to work with them. And, you know, all of these things obscure the nuances and the possibilities for recovery, the possibilities for people to get better and to work in their own recovery for improvement.

PHILLIPS:

And that was one of the things that surprised me in your book, because the last I knew it was considered the right thing to do to call addiction a disease. It was seen as compassionate. It was seen as trying to take it away from blaming somebody for being defective in their character. What you just said about that binary, could you also just talk about if people see themselves as fundamentally diseased, then am I right in saying that it almost offers them an excuse of sorts to say, well, it’s out of my control. There’s nothing I can do, because it’s just the way I fundamentally am.

FISHER:

People mean disease in different ways. And I think it can be immensely personal. And even today, there are people who get tremendous strength and support and comfort from the notion of disease. And I certainly don’t mean to take that away from them. There are many varieties of recovery. There are many ways that people get better after a severe substance use problem. And if somebody, an individual is going to call themselves a person with disease, I don’t mean to police that. But, let’s go to a historical example because I think this will be helpful. Back in the 19440s, ‘50s, ‘60s, there was a woman named Marty Mann, and she’s not really known in the history of AA. The AA, many of your listeners will probably know started by Bill Wilson and Dr. Bob, these two alcoholics who started a mutual health fellowship. They were pretty much focused on the internal workings of the fellowship, but Marty Mann was a public relations genius, who saw the problems that I was just describing. She saw that American medicine had totally neglected the treatment of people with alcohol problems and addiction, and she wanted to force open the doors of hospitals and she wanted to provide more compassionate care, and ultimately to do something similar to what I’m trying to do now, which is to provide some notion of hope and support so that if people are wondering, do I have a problem, it takes kind of like the sting out of the issue. So, yeah, I feel a lot of community with her, you know, I think she was a wonderful figure at that time, in the ‘50s and ‘60s, disease was a really useful notion for her. It was a way of saying this is not a moral failing, hospitals should treat people, for example, in severe alcohol withdrawal that might kill them. She successfully lobbied for hospitals to actually treat people and save lives. And who am I to say? That might have been the right move back then, but, by now I think it’s out of date. And the problem with the disease language is that it really narrows our view and causes us to miss some of those other factors that you brought up before. Like the broader social factors, poverty, oppression, lack of health justice and health equity, lack of access to fundamental resources, all of these other things that also play into addiction. The disease language narrows that to a medical frame that we, as physicians, we just can’t do it. It’s not up to us. We can’t do it all.

PHILLIPS:

You mentioned PR a moment ago. And, I was struck by the fact that you mentioned kind of the founding father of public relations, Edward Bernays in your book. I was also struck by kind of the formula recipe of sorts. You laid out for how, what you label addiction supply industries use in order to make their products more palatable in the general public and thus make them make sure that they’re legal and available. This is what you wrote in the book: ”Addiction supply industries have powerfully shaped ideas about addiction for at least 100 years, in the process also shaping national and international policies, directly interceding in cultural norms, and generally trying to influence our core ideas about health and disease.” This is the key part, “the argument that the problem is located, not in the substance, but in the person is one of their most time-honored arguments.” And we see this come up time and time again with tobacco, with opioids, even I thought about with guns. It’s not the problem with the gun. It’s the person who uses the gun. Who are the addiction supply industries? And can you talk a little bit more about how they use this PR formula to market their products and make sure that they remain legally available?

FISHER:

So, addiction supply industries sell products that have a special hold over us, and those include alcohol and other drugs. And it also includes, nowadays we think about sugar and processed foods. And the point is that certain products have a hold over us in a way that’s say broccoli doesn’t. Tobacco has a sort of an inelasticity to it is the jargon term that the economists use. If you raise prices on Pepsi, then people generally go over to Coke. There might be some like Pepsi diehards out there, but, you know, most people switch around. But, products like alcohol, tobacco, and also cocaine and heroin and fentanyl are inelastic, meaning that some people just make it work. Some people just make it happen. Those products by their very nature suck people in and impel people to keep on using them. So, addiction supply industries have long sought ways of disguising the harms of their products, and they put externalities out onto the general public. And the best example we have today are alcohol industries. I think almost any alcohol policy expert would say that alcohol is undertaxed. We basically are footing the bill and giving the alcohol industries a free lunch for a lot of the harms that are caused by the substance, by, not even addiction, but also things like liver failure and other medical problems. So, addiction supply industries have done this, like you said, for centuries and centuries. Some of the earliest examples I saw was not tobacco in the 1960s. So , that was really bad, but tobacco in the 17th century, when parliament was debating tobacco in say 1600, 1610, because English colonies were engaged in producing tobacco and it was central to their lifeline.

It was closely interwoven with slavery. There were a lot of people who saw the problems and they saw the harms there, but the British empire was making so much money off of tobacco revenues that they actually eased the trade and enabled this. And we see the exact same thing going on, for example, with the opioid epidemic, when, because of, a series of complicated deregulatory issues in the 1980s, the regulatory apparatus was basically just captured by Purdue Pharma and other opioid manufacturers. And then, uh, they managed to evade a lot of control. And there are a lot of people who made a lot of money off those changes, too. So, the point of the book is that addiction supply industries are constant, ever since we’ve had commerce and ever since we’ve had commerce, particularly in these types of substances that have a special hold over human beings. The answer is not to try to stamp them out, because we can’t stamp them, but to be mindful and to enact common sense regulations when it’s necessary.

PHILLIPS:

Speaking of that, I thought of you earlier this week. I think it was in Australia where there was a new law passed, requiring a minimum price per unit. I don’t know what the unit was, if it was an ounce or something else, but it seemed to be very much in line with the types of common-sense regulations you were arguing for in the book

FISHER:

Mm-hmm . Yeah, exactly, exactly. I think we overestimate what an individual should do. in part, because that’s what addiction supply industries are trying to convince us. They put the focus back on the person over and over again, like you mentioned.

PHILLIPS:

That’s right.

FISHER:

That was a big argument in Prohibition saying that the root of the problem drinkers’ problem is in the person, it’s not in the bottle. But there’s only so much that we can resist in terms of social pressure and social psychology and groups. Like when I went to college, I’m not saying this is the cause of my addiction or a major, you know it would have changed the course of my life, necessarily. But when I went to a big state school where there was a lot of partying, everybody seemed to be drinking, and it was binge drinking all the time, every day around the clock. And the messaging from the university, which I think was, well-intentioned is, oh, some people don’t drink and, you know, come on. If you see everybody else around you drinking, there’s only so much you can do to resist that force. The point is that an individual fighting against the broader social and political forces is like taking a pea shooter to a tank. It’s preposterous. I think at the individual level, which can also be a route for some compassion and some peace, if you can recognize that, you know, like it’s not all up to me, it’s not all my job to somehow discipline myself out of my problems.

PHILLIPS:

I mentioned earlier that one of the thesis I took from your book was that there’s no single answer to these very difficult questions, but I do wonder if you’re able to sum up, based on all of your research, again, across millennia and different countries and different cultures, based on all of that, what have you concluded as being the primary or the most common causes of addiction?

FISHER:

Hmm. Addiction is in all of us. That’s one of the key points that I’ve settled on. One of the misperceptions I labored under, and that really hurt me, was the notion of an us-them phenomenon that addiction was something that happened over here to certain people. In my case, it was my family, both my parents were alcoholics and I defined myself in opposition to them. And I thought, because I’m succeeding, because I’m graduating with honors from Columbia medical school, I’m not like them. And that really hurt me. It’s really hurt societies over time. And it really hurt me individually. And I think it hurts a lot of people in my clinical practice. And just from the people I talk to in addiction, who are struggling with addiction or wondering if they have a problem with addiction. What I mean by addiction is something that’s in us all is not that everybody is sick and suffering. It’s that addiction is pointing toward a core human mystery of self-control. It’s not fundamentally different from the same types of problems that the ancients were describing in terms of self-control and philosophy centuries ago. We’re all on the spectrum somewhere. Some of us, like me, are farther out on the spectrum. I think it’s a good idea for me not to drink. I think if my life it’s extreme enough that I wound up in the Bellevue psychiatric ward, that it’s not a hard call for me to say that I should be extra careful about these sorts of things. But, I don’t think I’m fundamentally different from the rest of the population. I think I just have my set of vulnerabilities a little more clearly on display. And the more I work with people who say, have problem with eating or with sex, or even with power or status or a need for external validation, or just for something outside of the self to tell them that they are okay, the more I realize we’re in the same boat together. It’s a matter of degree and not kind.

PHILLIPS:

That idea of the spectrum really resonates with me. I remember this was now probably 15, maybe even more years ago, Arianna Huffington was married at the time to, I think, a California politician named Michael Huffington who left his marriage, came out as gay, and this was before this was a common occurrence or something that happened with some regularity. And so, there was a lot of curiosity about it. And the big question Arianna Huffington was asked at the time is how could you possibly not know? And what she said in response to that was that she believed that sexuality was on a continuum that there weren’t these stark binaries, but rather there was this spectrum of sexuality with some people having very little attractions to the same sex. And some people maybe being a four where yes, they might marry somebody of the opposite sex, but there’s still some attraction to the same sex. And that made a lot of sense to me. It was the first time that notion had ever been introduced to me. And it sounds like when it comes to addiction, there’s some I’m kind of analogy to be formed there.

FISHER:

No, I couldn’t agree more, that there is something about a spectrum concept in addiction and in mental health, in general. And it’s something that we’re still puzzling over today in mental health. So, I don’t promise to have some sort of easy pat answer here. Addiction is a bit like light. It’s a particle and a wave at the same time. That’s not my notion. I got it from George Vaillant, who was writing on this in the 1980s. Simultaneously addiction is something special. I saw it on my family. I saw it on myself. You can distinguish people with a serious addiction problem by the nature and the severity of the problems and by the sort of crushing and life- threatening problems to get themselves into sometimes. At the same time, it seems directly contiguous with all the rest of human suffering and the same problems that we see even on a neuro-biological level in people with addiction are the same types of self-control problems – something like intertemporal discounting, which is a jargon term for the way that we value current rewards versus future rewards. So, this is off kilter in people with addiction. People with addiction tend to overvalue immediate rewards in favor of future rewards, but that’s not something unique to addiction, that’s something that’s on a spectrum with the rest of human psychology. So, I think we have to hold those two things in tension at the same time and revert to some sort of easy pat answer about what addiction is or what it isn’t. Because the fact of the matter is we’re still puzzling over it.

PHILLIPS:

I’d like to end on a personal note with you if we can. I am curious because despite the fact that you were given advice along the way, don’t look too deeply into the history of addiction, you obviously did, and you consulted, as I mentioned, as you mentioned, Aristotle, Plato, Socrates, Alexander the Great. You looked at media sources across centuries. I’m curious as you delved into this project, what new you learned about yourself? What kind of insights you maybe gleaned from unexpected places that have helped you in your own understanding of yourself and in your ongoing recovery?

FISHER:

Ultimately, I wrote the book because it was the book I needed when I was stolid and stable in my recovery, and I felt like I wasn’t in risk of relapse or dying, I still had big questions about myself. I had big questions about my identity and what addiction meant to me. And I had the sense that while science and medicine, my own field and the field that had treated me when I went to a specialized rehab for doctors and got all this specialized care, it wasn’t enough. It wasn’t enough to really get my arms around what was happening to me. And I had this sense that fields like history and philosophy and even theology could help me with that and help me understand how other people, not just in my own time, but in other times made sense of their problems. So, I wrote it really, and that’s part of why I included my personal story, I wrote it for myself. I wrote it because I needed it for myself because it felt urgent for me. Not that I was in danger of dying that day, but because it’s something that was desperately necessary for myself and my family. And it helped me to appreciate the complexity of addiction. It helped me to appreciate that this is something that is enormously flexible and extremely variable. Even in med school and in that rehab, I was taught addiction is a disease and it’s only one way. And I don’t think that’s true. Nowadays, only in the past, like three or four years, there’s been a big movement in the research literature about the varieties of recovery. And we’re learning more and more every year that people with severe substance use problems recover along many different axes. Some people get better without even stopping their use entirely. For other people, that’s very dangerous. People get different sorts of supports from different places. And so, I think the message ultimately is that there are so many ways that people can get relief for their suffering and find some way of recovery. And, I think there’s a lot of energy here. We’re only, only, only in the early stages. The Biden administration has shown some interest in this. And I think professionals like me who are on the ground are starting to get a little more wise to this, but we need much more appreciation and engagement with that diversity of recovery pathways.

PHILLIPS:

One final question. Are you a different or better clinician as a result of having firsthand experience?

FISHER:

Yes, absolutely, Is my easy answer. And it’s been tempered by the fact that I needed inquiry and humility around it. It is dangerous sometimes when people have personal experience and then they apply their experience onto everybody that walks through their door. And I think that’s always the biggest danger, a big trap, and can be really, really harmful. So, for me, what I try to return to daily is the notion that my personal experience exposes the mystery. It exposes the need for humility and the need for ongoing constant work. If anything, it prompts me to think of how different we all are and how my own recovery journey is different than other people’s recovery journeys. That’s what I see in the history when I look back over so many different ways that people and communities have recovered over time. That’s what I see at the social level when I see how, you know, different policies can be helpful, and then when we narrow down to just a, a single track, one size fits all policy, it can be really harmful. So, I’m grateful for the fact that I have personal experience and I’m grateful for the opportunity based on my privilege also that I get to be open about it, that I get to be public about it. But it doesn’t mean to be arrogant about it. If anything, it’s a call for more humility.

PHILLIPS:

Carl Erik Fisher, the author of The Urge: Our History of Addiction, thank you very much for your time, insight, and experience. It’s a terrific work.

FISHER:

Thanks so much, Brad, it’s been a real pleasure talking with you, and I really appreciate the chance to come on and talk.

• addiction
• Carl Erik Fisher
• The Urge