Book Interview: Carl Fisher discusses the war on addiction and 'The Urge'

Carl Fisher: a look at the 'war on drugs' occurs through a predictably American lens

• The Urge 
• Carl Fisher 
• Penguin, €26.99 

Carl Fisher remembers the precise moment alcohol took over his life. He was 29 years old.

In the space of a few weeks, he went from being a seemingly stable, happy-go-lucky physician in a psychiatry residency programme at Columbia University, to a psychiatric patient in the depths of despair at Bellevue Hospital in New York. In the latter environment Fisher found himself in a dual diagnosis ward alongside other individuals with substance abuse problems and disturbing mental disorders.

“When I wound up in the hospital at Bellevue I immediately had a sense that something was desperately wrong,” the 41-year-old American author explains, via a Zoom call from Lisbon. “I then opened up to my treatment team, and said: I'm an alcoholic, I give up, I can't fight it anymore.” Fisher got sober, and eventually returned to the residency program at Columbia. Today he is Assistant Professor of Clinical Psychiatry at the prestigious Ivy-League university in upper Manhattan.

He recalls his rocky road to recovery in The Urge: Our History of Addiction. Using his own complex battle with addiction as a starting point, Fishers' book (which took a decade of researching and writing) argues that understanding addiction in the present requires a detailed study of addiction in the past.

Beginning his investigations during an opioid overdose epidemic in the United States, Fisher learned that human societies have been wracked by drug epidemics with dismaying regularity for more than half a millennium. He also came to understand how centuries of cultural policy, stigma, and racism cannot be separated from how we currently understand and treat— or in most cases fail to treat— addiction in western societies.

Most narratives around addiction largely involve wielding it as a weapon to wage war—not just “on drugs”, but also on people who use drugs, Fisher says: “A common mistake people tend to make when talking about legalizing drugs is they get stuck in these simplified binaries, like prohibition versus legalization.

“But societies that have done a really good job relaxing the legalities of drugs have paired it with a really powerful and broad sweep of social services, including housing, employment, and other ways of building structure, meaning, purpose, and a sense of community in people's lives,” Fisher adds.

Fisher currently divides his time between New York, and Lisbon, where he lives part of the year with his partner and son. Portugal’s decriminalising programme is a model the rest of the world should look to, Fisher explains. “In Portugal decriminalization policies were paired with social policies to make a really good reduction rate on an epidemic.” 

This stands in stark contrast to the United States. It has recently made the move towards decriminalizing cannabis but that decision has not been followed up with additional social support from government: “When you deregulate a drug, but you don't put in supportive structures with the people who have problems with that drug, then we can see a big wave of harmful abuse,” he says.

The history of addiction we read in Fisher's book is selective. Largely it's an American story.

This reflects his wish to understand addiction issues within the context of his own heritage and culture but his focus on the United States is important for other reasons. Fisher notes how the “disease idea of addiction”—that is, addiction as a chronic identity—solidified in the early years of the United States, around the time of the Revolutionary War. 

That idea then disseminated worldwide by movements that mostly have their origins in the United States. He cites Alcoholics Anonymous (AA) and the decades long so-called “war on drugs” as two examples. Both are American creations, and both have very fixed ideas about what makes an addict choose the behavior they do.

Framing addiction in this oversimplified manner (as, say, a moral issue that separates good from bad, or the weak from the strong) tends to miss a crucial point about addiction more broadly, he argues, namely: that addiction exists, to some degree, in all of us. 

“Thinking about addiction as something that's intrinsic to the human condition, and that involves an element of choice, is really useful because it shows how addiction is a behavior we choose as a coping mechanism to handle our suffering, and to seek distraction to avoid anxiety and pain.” 

Fisher's book identifies four broad approaches that western culture has used to responded to addictions throughout different periods of history. A prohibitionist approach has sought to control addiction through punishment and other law enforcement strategies. 

A therapeutic approach has argued that addiction is best handled as a disorder to be treated by the medical field. A reductionist approach has sought to explain addiction in scientific terms, often seeking biology-based cures. 

While a mutual-help approach has sought community healing, grassroots fellowship, and spiritual development to help addicts recover. “There is a lot to learn from the spiritual side of addiction, because it gives the sense that there is something beyond medicine,” says Fisher. 

“My primary home for recovery is Buddhism, and all Buddhist practitioners take certain presets: one of which is to vow to abstain from intoxicants.” Using theology and philosophy as a guide to curb his own problematic relationship with alcohol brought Fisher to the conclusion that medical science alone, while important, was insufficient for understanding addiction. 

“I got a lot out of medicine— psychotherapy, group therapy, and other treatments for addiction. They helped save my life in certain ways but sometimes the debates in medicine and science can become extremely polarized, where people tend to talk past each other, don't find common ground, and get caught up in very abstract explanations.” 

Fisher says this is especially true in the brain-centered field of neuroscience. For many years psychiatry has labored under the idea that mental disorders were categorical, fixed entities.

Today, however, there is a rising recognition in the scientific and medical community that all mental disorders seem to exist on a continuum, even though there is no clear transition in the existing scientific data that tells us where to draw the line between mild and severe issues pertaining to addiction.

He then points to a trend in the global scientific community which typically tends to classify addiction as a brain disease. It has many downsides, he believes. In the U.S., for instance, it has pushed federal research on alcohol and drugs toward reductionist biological research, and away from social, epidemiological, clinical, and policy investigations.

Neuroscience is undoubtedly one important way to understand addiction in a broader framework.

But Fisher remains cautious and skeptical about reductionism. “Specifically, this is the idea of seeing neuroscience at the single best framework to understand addiction,” he says. “It's a dangerous and I've seen it in patients. They buy too much into this notion of brain damage, whether it's because of trauma, prior addiction, or actual physical injury. 

Most “brain disease models of addiction are reasonable but border on uninteresting.” Fisher believes this one-track view of addiction lacks nuance and can lead to dangerous consequences for patients. “We know from some psychological research that the brain-based explanation for mental disorders, in general, increases fatalism, and increases pessimism,” Fisher says: “So we have to be very cautious about the way we interpret neuroscience, even as we continue to turn to it for a lot of good lessons too.” 

Fisher concludes his book with an ambivalent definition of addiction. “It is profoundly ordinary: a way of being with the pleasures and pains of life, and just one manifestation of the central human task of working with suffering,” he writes. 

If addiction is simply part and partial of being human, it is not a problem that must be indefinitely solved, the author claims. In other words: we should not seek to eradicate addiction. Rather, we must find ways of working with it.

After all, waging outright war on addiction is, in essence, an attempt to wage war on human nature, Fisher stresses: “These questions about addiction don’t have easy answers, because they are essentially questions about what it means to be human,” he says. 

“Addiction is not a curable disease, or something that we can just stop. So many times throughout the history of addiction we have done more harm than good by trying to stop addiction.”