#12 "I was still left with this big question: what exactly had gone wrong in me?"

9 Questions with Dr. Carl Fisher, author of The Urge, on the disease model, addiction supply industries, the difference between faith and hope, and the history and future of recovery

Mar 21, 2022

I first read about Dr. Carl Erik Fisher, the author of the recently published The Urge: Our History of Addiction (public library), in The New York Times, in an Op-Ed about why calling addiction a disease is misleading, and then I reached out to him so I could make him my friend, which I have succeeded at.

We’ve had a few really fascinating conversations since our first chat back in January; he is a genuinely caring, brilliant human who also happens to be an addiction doctor (psychiatrist) and an Assistant Professor of Clinical Psychiatry at Columbia. He has an insatiable curiosity for the subject matter, lived experience (he’s in recovery), and a humanist lens; he’s here for the people and that’s evident in everything he does; he gives a shit in that kind of way that makes you want to give even more of a shit. I reviewed The Urge in my February book roundup (I highly recommend you grab a copy.)

Below is a written Q&A he completed for this newsletter. On Wednesday, instead of the Roundup, I’ll be sending out one of our conversations that we recorded (which will be for paid subscribers only—I’m trying out a once monthly podcast for this newsletter and this will be the first).

The thing I love the most about this entire exchange is what I doubt he’d call pragmatism, but I do. He’s a gentle soul that has an enormous amount of empathy; he’s her for everyone and I think he tries hard to stand in everyone’s shoes. It’s rare and it makes my heart explode with joy that people like him exist. He also challenges a lot of assumptions that exist even in more progressive spaces; the last answer on the difference between hope and faith is such an important distinction, especially now.

One last thing: This is a long read which I hope you take the time for; it gets better as it goes and I can’t imagine anyone reading his 7 answers and not being a little bit changed.

Free and paid subscribers of Recovering get the same exact content. Paid is for those who’d like to offer financial support, and be patrons of this newsletter and my work.

9 Questions and Answers with Dr. Carl Erik Fisher, Author of The Urge

HW: Dr. Carl. First things first: Can you talk a bit about yourself and your story? Give us the quick version of who you are and how you came to addiction medicine.

DCEF: I’m an addiction physician, a bioethicist, and a person in recovery. Here’s the short story: I struggled with alcohol during most of the earlier part of my life, through medical school at Columbia University, holding it together enough to graduate with enough the prizes and awards and pats on the head to tell myself that I was OK. Then, I started using Adderall and cocaine to compensate and to keep pushing forward in a individualized project of self-control and self-discipline. It all came to a head early in my residency training, when I had a manic episode triggered by a binge on alcohol and stimulants, which got me tased by the NYPD and landed me in one of the psychiatric wards at Bellevue Hospital (where I had interviewed for a residency training program just a year prior). It was at that point that I finally faced up to my addiction, and I was able to enter a specialized treatment program for doctors with substance use problems. I had and still have immense privilege: as a white man, a doctor, someone who was treated pretty compassionately by the police, someone who (albeit with some stress) could actually afford treatment.

Even so, and despite some really good things about that program, it also brought me face-to-face with all the problems of our current medical treatment programs for addiction, and, more broadly, the incompleteness of many “models” and “theories” about addiction. Despite reading everything I could find in the usual medical literature, I was still left with this big question: what exactly had gone wrong in me? I love medicine and science, but I had a feeling that coming to terms with addiction required a broader and more integrative approach, so I began to explore beyond my own field, to sociology, arts and literature, and especially history. Basically, I wrote the book I wanted to read but didn’t yet exist, because I needed it to help make sense of myself and my experiences.

HW: This book is a monster, necessarily, because addiction is a monster—it touches all the ologies and it’s hard to write a comprehensive book on addiction without looking at the socio-economic, cultural, psychological, theological, biological, etc. touchpoints. (We can’t talk about addiction unless we are talking about everything). When I step back from your book, I think I see a history of addiction and a history of treatment; as in I see how over centuries addiction has manifested, and the reaction to addiction manifested, and how that has changed over time, but not dramatically. I see a history of people who didn’t know better, and some really brilliant and compassionate approaches to treat addiction, as well as the horrors we’re well aware of (like the war on drugs, mass incarceration, punitive treatments). This wasn’t really a hopeful book; I walked away heartbroken over how this obvious and persistent thing—addiction—is continuously misunderstood and mishandled and how much unnecessary suffering follows that. Two questions: (1) Was that your intention of writing this book—to show our failed history of “diagnosis” and “treatment” or to show some kind of linear progression of addiction and recovery through the ages; like an anthology? Or was it something else? You spent ten years on it I think I want to know what you were hoping to provide without guessing. (2) Given what you uncovered in your research, what should we be doing NOW to create a pivot in this history of what feels like summary failure—like if you could write a proud history of this time, what would it be, and how can someone reading this be a part of that pivot?

DCEF: Ha, so first, I feel compelled to say the book is a brisk read at only a little over 300 pages (not counting endnotes), so let’s clarify: the problem of addiction is the monster, but the actual book is pretty fun and quick, considering what it could have been.

That aside, I agree, addiction is one of the most complicated human problems we face, spanning all those fields you mention. My initial intention was to arrive at the definitive answer, the one neat theory or explanation that would tie it all together. I’m grateful that during the process of writing the book I got a little more humble about the objective, and by the end, I realized that a wiser, more honest, and more reasonable goal was simply to try to represent the immense complexity and multifaceted nature of addiction, without trying to arrive at something falsely negative or conclusory. If anything, my hope is that the book is an antidote to quick-fix, oversimplified thinking, and that it can help promote compassion and even provide a sense of strength and peace.

“When I saw how people for literal millennia have struggled with essentially the same problem, it helped me work with some of that unhelpful shame—to realize I’m not sick in some extraordinary way.”

I say peace because, as you say, the cycles of history often felt tragic, but in the end, I get a lot of strength and encouragement from the history. The scope and enormity of the problem is soothing to me. There are so many shameful messages today about how people with substance use problems are sick or bad, or should be doing better somehow. I really bought into a lot of those toxic messages and internalized them as self-criticism (and incidentally I want to mention that there is something perhaps uniquely American about that kind of hyper-individualistic narrative). But when I saw how people for literal millennia have struggled with essentially the same problem, it helped me work with some of that unhelpful shame—to realize I’m not sick in some extraordinary way. It’s humbling in a liberating way. That’s an important part of the intention of the book: to call for a more nuanced and honest appreciation of addiction. I think if people could just slow down and look with more care at the phenomenon, that would go a long way, and in fact is quite a difficult thing to do and one deserving of pride.

“About the ‘official’ messaging from the main federal research institutes: I actually think if you look closely at the writings of people like Nora Volkow and George Koob from recent years, they are not so committed to the disease term. They seem more likely to use different words in their public communications. So I am hopeful that they have recognizing that the term has become so overused and ideologically freighted that the “disease” label just isn’t that useful anymore.”

HW: I found out about you through your NYT piece and I think the thing that struck me the most was that you are, I believe, one of the first physicians to come out directly opposed to the disease model of addiction. I mean we obviously have Dr. Jellinick who was instrumental in creating the original concept of addiction as a disease; there’s Dr. Gabor Mate who trends toward more of a self medication model but who hasn’t to my knowledge come out directly and said “it’s not a disease”; and then there’s obviously many outside of medicine who have opinions about what it is (Bruce Alexander, Maia Szalavitz, Marc Lewis come to mind); but you are a psychiatrist, a professor of psychiatry at Columbia, a medical professional: and you are arguing against the classification of addiction as a disease. Can you talk about that—about why there aren’t more doctors going on record to refute the disease model, or whether you are some kind of rogue trailblazer in that way? And why do you think people like Nora Volkow and NIDA are so committed to the disease model? Finally, if it’s not a disease, what IS it? And what does that mean for medicine?

DCEF: I actually don’t consider myself against the “disease model,” it’s more that I think the notion of “disease” is misleading because there’s so much historical, social, and conceptual baggage attached to the term that it does more harm than good. (For that reason I tend to say “disease label” or “term”, because the one term can contain within it so many different ideas.) Sometimes, for example, “disease” has been used to mean that people with addiction should be treated with care and compassion by the medical profession. I’m fully on board with that idea, and I think it’s a helpful one—and there were people arguing along these lines hundreds of years ago, by the way. But at other times, “disease” is taken to mean totally different ideas—for example, that biology is the best way to understand addiction, or that people with addiction are neatly divided from the “normal” population—those ideas are harmful, fatalistic, and dehumanizing, and we have some research that those overly reductionistic ideas actually cause real-world harm at the level of stigma and pessimism.

About the “official” messaging from the main federal research institutes: I actually think if you look closely at the writings of people like Nora Volkow and George Koob from recent years, they are not so committed to the disease term. They seem more likely to use different words in their public communications. So I am hopeful that they have recognizing that the term has become so overused and ideologically freighted that the “disease” label just isn’t that useful anymore.

Free and paid subscribers of Recovering get the same exact content. Paid is for those who’d like to offer financial support, and be patrons of this newsletter and my work.

Ultimately, I think to get sucked into a debate “for” or “against” disease is already sort of missing the point, and I worry sometimes that I have already gone too far down that road! But when looking at history, I felt I had to include some discussion of the many ways that the term has been used—most important, “disease” is a signpost toward the more specific and really rich questions about addiction (like: what exactly does medicine have to add, how can it best help, what does neuroscience actually show us?).

HW: Speaking of Nora Volkow: in February 2020 she published a review in the American Journal of Psychiatry, “Personalizing the Treatment of SUDs”, which I thought was groundbreaking: she argued for a holistic approach to recovery; she also argued that the limitations of recovery and advances in treatment were held back by the limitations of medicine (“The existing pharmacopoeia for substance use disorders is severely limited”); I was optimistic reading it until I concluded what she meant was that addiction necessarily needs pills to treat it and we’re slowed in our process of effective treatment because we don’t have enough drugs; that we’ll find utopia when a drug for each drug addiction exists. I walked away feeling really disgusted by that; there’s a place for medicine, obviously naltrexone and suboxone and methadone are but a fraction of the evidence of effective science; but when the head of NIDA believes addiction can’t end without what’s produced in a lab, it feels reflective of why we don’t really as a culture understand addiction at all. It makes me think of this line from your book: “What is necessarily a complex web of intersecting forces is too often reduced to one simplistic story: trauma, brain disease, an evil and unstoppable drug, a bad pill-mill doctor, a hereditary taint, or a weak will or poor morals.” You even referred to a name this impulse to reduce things into a simple solution “Monocausotaxophilia: the love of single causes that explain everything.” I guess I’m asking: do you have any hope that we’ll ever get to holistic, personalized, meaningful recovery, when everyone has an agenda, a quick fix, and our government authority on addiction thinks we just need more fucking pills?

DCEF: (So, by the way, note that in this article she says “addiction is a chronic disorder of the brain,” not “disease.”) (HW: touché)

Anyway, I agree that the focus on medications feels really narrow here, but I want to push back a little and say I think the article has at least one really beneficial core message. The way I read her main thrust is as follows: “clinical research to date have been hampered by focusing on total abstinence as the primary measure of success. We should expand our definition of successful treatment outcomes, especially by including reductions in use, or even improvements in other kinds of life functioning.” This I think is a big shift and a necessary message for much of our clinical research, which is her primary audience in this academic journal, after all.

But zooming out beyond that, I agree I wish there were more appreciation of all the different forms “treatment” might take, especially non-medication therapies in all their forms. Even more importantly, treatment is only one part of the puzzle—medicine alone is insufficient to respond to the challenge of addiction. In this one article, Volkow leaves unaddressed the question of whether medical treatment is the best way to address addiction.

Big picture, the problem that this brings to mind for me is that medical research on addiction has highly prioritized reductionistic explanations of addiction, including medication treatments. It is a problem that NIDA is basically the national institute of basic research on addiction by this point. It used to study and fund more epidemiology, sociology, and other disciplines, for example. We need the basic research, but we need the other levels of exploration too. This is not a problem unique to addiction. The former head of the National Institute of Mental Health (NIMH), Tom Insel, has a new book out where he admits that focusing on the basic science of mental illness led to neglect of how to actually deliver care effectively. (I haven’t yet read the book so I can’t necessarily recommend it, but I do like this story he tells…) He describes how he was giving a talk one day and the father of a boy with schizophrenia yelled from the back of the room, “Our house is on fire and you’re telling me about the chemistry of the paint! What are you doing to put out the fire?” I think we cannot count on the professional scientists to worry about putting out the fire—they are too engrossed with the chemistry of the paint, that’s why they became scientists after all. So it’s up to others to yell from the back of the room.

HW: You mention that defining addiction as a disease does not help individuals in the long run: you talk about your mother, but also you point to studies done on the topic: Page 177: “In another study, the most potent predictor of relapse was belief in the disease model of addiction.” You also mention that calling addiction a disease, while it might not help the individual struggling with addiction, helps the family members and loved ones of the addicted person. I don’t know why this made me so mad, but it did—to me it was a really clear indication that most of what governs addiction treatment and conceptualization of addiction is the comfort and maintenance of polite society, not the person who is actually sick (the same way early mental health institutions were built to keep strange and inconvenient relatives of wealthy families out of site). Can you talk about this?

DCEF: Let’s be clear: there are many people who feel that notions about “disease” have been personally helpful to them. In most cases, I take them at their word. I’ve seen how the “disease” term and certain of its associated ideas gives them comfort and clarity about a complicated problem. “Disease” might help some people to accept they have a problem and get help—I’ve seen this in my practice and my personal life, and I don’t want to police the language of those people. Now, that being said, in the book I also describe studies on stigma and the effect of essentialist ideas about mental illness (like the disease notion), and those studies suggest that the net effect of those ideas is harmful: that those ideas can cause pessimism, heighten the risk of relapse, increase stigma, etc. But, again, even if the average effect is negative, that doesn’t mean that there aren’t positive effects for some people. So I wouldn’t be so quick to say that the disease label does not help individuals. I just think we should hold the notion loosely, and think carefully about what we mean by “disease.”

There’s an important related issue here that I also want to highlight: “disease” has been weaponized as a tool of social control. We have to be extra-careful about how it is used to convince a supposedly wayward family member to get in line, and especially how it is used in the criminal legal system. But if we didn’t have the disease label, there’d be another label to justify those power moves. The key is to look deeper at what the labels actually mean and how they are being used.

Now, that’s all at the personal level. At the level of advocacy, public communication about science and medicine, and so forth, I think it’s probably better to drop “disease” for the reasons I noted above.

“For me, the mystery at the heart of addiction is the why: why do people keep on using despite the urge and intention to stop? The deepest thinkers in philosophy, theology, and spirituality have long wrestled with this question, not from the standpoint of addiction as an extreme condition or special kind of sickness, but rather addiction as an everyday, universal problem of self-control.”

HW: If you had to pick one theory of addiction that you feel most closely explains why it exists what would it be and why?

DCEF: This is a quick one, though I’m not sure it counts as a “theory”: addiction exists in all of us. In other words, unless you are completely free from suffering, you have some addiction in you.

To talk about a theory of addiction we have to talk about what we mean by addiction. For me, the mystery at the heart of addiction is the why: why do people keep on using despite the urge and intention to stop? The deepest thinkers in philosophy, theology, and spirituality have long wrestled with this question, not from the standpoint of addiction as an extreme condition or special kind of sickness, but rather addiction as an everyday, universal problem of self-control. That’s why I go back to people like the Buddha, Aristotle, and Augustine of Hippo in the book. They are not interested in the issue of addiction as a problem of sickness or disorder, but as an everyday human problem. That’s how I like to think of it.

“Pharmaceutical companies and other addiction supply industries have repeatedly tried to equate physical dependence with addiction as a way to protect their products from scrutiny.”

HW: One of the most surprising things I read in your book (p90) was: “Addiction does not proceed inevitably from use.” I’ve been taught, or read over and again, that you can addict anyone; continued exposure creates tolerance and eventually dependency. Can you talk about this?

Physical dependence and tolerance are not the same as addiction. The science of addiction has been profoundly misled by this confusion for decades. In fact, pharmaceutical companies and other addiction supply industries have repeatedly tried to equate physical dependence with addiction as a way to protect their products from scrutiny. A key example comes from the burgeoning trade in stimulants in the 1920s and onward. At that time, and in large part because of moral panics about opioids, both the criminal legal system and scientific research into addiction was focused on opioids as the “sine qua non” of addiction. Meaning, they took opioids as the model for all addiction. The stimulant manufacturers liked this and deliberately used those types of ideas to argue: because amphetamine didn’t cause the same kind of physical dependence and tolerance as opioids, they weren’t truly addictive. This provided cover for the pharmaceutical industries to package and market, for example, amphetamine in pill form for depression, dieting and weight control, and even alcoholism.

The distinction between so-called “physical” and “psychological” addiction is overplayed and misleading. Physical effects have a powerful influence; heroin is stronger than chocolate, after all. But calling something a “physical” addiction or attributing the power of addiction solely to the force of tolerance and withdrawal is missing the bigger picture. After all, gambling addiction is one of the oldest and most powerful examples we have—I have an account of someone with gambling addiction in the book that comes from a Sanskrit hymn from 1000 B.C.—and by some measures, gambling addiction has the highest suicide rate of any addiction.

“The alcohol industry has long assumed a major role in shaping the way people think about addiction itself.”

HW: You give a brief overview of the end of prohibition, rise of AA and the general acceptance of alcoholism as a disease. I wrote about this in my book: about how the shift from prohibition-era thinking (“there is something wrong with the substance”) to post-prohibition era thinking (“there is something wrong with the people who can’t drink right”) was fueled by the alcohol industry: I believe I said something to the effect that AA, or the NCA, aligned with the drinks industry. Page 169: “For decades after repeal [of the 18th Amendment], every major conference on alcoholism received some amount of industry funding.” I don’t think we talk about this enough: how much it benefits the drinks industry that individuals are turned into sick defectives who cannot use alcohol correctly. Can you expand?

DCEF: Yes, the alcohol industry has long assumed a major role in shaping the way people think about addiction itself. One thing I want to emphasize is that these types of arguments also play off a powerful strand in American thought that puts such an overwhelming focus on personal liberty and responsibility. This individualistic focus can be so toxic. Of course, those arguments have been used in so many different contexts; one that always sticks in my mind as one of the most perverse is an anti-littering Keep America Beautiful” campaign funded by can companies to divert attention from the fact that they were manufacturing enormous quantities of cheap, disposable, and profitable packaging, putting the blame instead on individuals for being litterbugs. (See my older article about willpower.)

I’m really interested in the American-ness of ideas like this about addiction. Many ideas about addiction, such as 12-step programs, the disease label, and dominant models of treatment programs, are American exports—things we’ve created and spread around the globe. Some of that is a simple consequence of American post-WW2 hegemony in biomedical science. But some of it is philosophical and even theological. Those types of hyperindividualistic ideas about responsibility, autonomy, self-control, and self-determination can be traced back to an Enlightenment tradition that was profoundly influential on the thinkers that first described addiction as a disease, like Benjamin Rush in the 1780s and onward. Then we have a particularly American strain of Christianity that puts special focus on willpower and demonstrating “faith by works.” In cases like this, I’m hopeful that looking at the history can be part of a process of undoing: that by looking carefully at the roots of these deeply held ideas, we can start to unravel the ones that don’t serve us.

“We can do tremendous good just by working on stopping harm to ourselves and to others—it’s a beautiful and noble thing, and it should be celebrated. “

HW: Final question: Not long ago, in the HHS rolled out a harm reduction based grant program that was immediately coined the “crack pipe distribution plan” https://www.foxnews.com/politics/crack-pipes-distrubtion-funded-hhs as it contained a small provision for clean fix equipment to reduce Hepatitis C and AIDs (a proven tactic to save lives); the most controversial, racist detail was pulled out and used to drum up the same way blatant, racist and racially driven fear mongering in the 80s fueled things such as the crack/powder laws (https://www.aclu.org/other/cracks-system-20-years-unjust-federal-crack-cocaine-law). Give me reasons to hope that things are changing.

DCEF: I consider hope to be a spiritual question. I have heard spiritual teachers from the tradition in which I’m a student (Buddhism) describe a useful kind of discernment and even skepticism about hope. Is hope an attachment to an imaginary future (which, of course, is ever-changing and beyond our control)? Or is hope something more like a wise aspiration for doing good and preventing harm? Personally I am more into the idea of faith than hope. I have faith that humans can change, that we can recover, and we can work for meaningful change in our communities. This has to do with your question about a proud history.

I think it’s useful to consider the intensely personal dimensions of “what we should be doing now.” For Holly Whitaker, “what to do now” probably means writing, speaking, connecting with people, raising consciousness about these issues. For someone doing street outreach, “what to do now” means suiting up and get out there every day and working for harm reduction on a more concrete level. For someone who has just entered recovery, “what to do now” probably means to take compassionate, exquisite care of yourself, and I think usually that’s more than enough for today. I know I struggled with that early in my own recovery. We can do tremendous good just by working on stopping harm to ourselves and to others—it’s a beautiful and noble thing, and it should be celebrated. None of these things are enough to stop greed, hatred, and division in the world, but all these things are so profound and deserve to be celebrated. One of my favorite quotes from the founding teacher of my lineage, Shunryu Suzuki Roshi, is this: “to shine one corner of the world–that is enough. Not the whole world. Just make it clear where you are.”

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