How a 1960 traffic stop transformed attitudes on drug addiction

Exploring Addiction with Dr. Carl Erik Fisher

Champagne Problems

Patrick and Sam dive in with addiction physician and author Dr. Carl Erik Fisher to explore addiction as a spectrum and the possibility that we all suffer from some degree of addiction. Don't worry, our hosts discuss how this perspective on addiction can actually be very empowering. Plus, Dr. Carl Erik Fisher highlights how culture and economics have influenced addiction throughout history.

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Physician and author Carl Erik Fisher on the history of addiction and the capacity for recovery

Points Interview: Carl Erik Fisher

Points

Today we’re excited to feature a Points Interview with Dr. Carl Erik Fisher, the author of The Urge: Our History of Addiction (Penguin Press, 2022). Carl is an addiction psychiatrist, bioethics scholar, and author.

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“…first: don’t conflate drug use with addiction or even with harm – heed the research by Lee Robins on Vietnam vets, for example, which showed that most of those who used heroin in that war stopped once they returned to a normal life.”

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Hosted by Jonathan Bastian Link to full article

Addiction is not a new phenomenon to Americans. Heroin, alcohol, meth, and opioids are among the substances complicit in destroying far too many lives in recent years, with drug overdose deaths now topping 100,000 annually in the U.S Historically and in the rest of the world, addiction is nothing new either. Some of our earliest South Asian texts describe men with gambling addictions. The Greek philosopher Aristotle describes those who were unable to act in their own best interest as having an “incontinence of will.”

Modern research ushered in new schools of thought — compulsive and addictive behaviors began to be labeled as mental and physical diseases, treatable with psychiatric medication and therapy. But do we need to hit the pause button and broaden out that definition? Dr. Carl Erik Fisher, assistant professor of clinical psychiatry at Columbia University, says labeling addiction as a disease might be misleading. Fisher, the author of “The Urge: Our History of Addiction,” says society, race, suffering, and abuse also play key roles in addictive behavior.  

Jonathan Bastian talks with Fisher about his own personal experience with alcohol and Adderall addiction while he was a driven young medical student. Fisher explains that his addiction and subsequent treatment was a lightbulb moment for him that opened his eyes to realizing  addiction is “not something scary” but something that “exists in all of us.”

The following interview has been edited for length and clarity.

KCRW: When did we begin to think of addiction as a disease? 

Carl Erik Fisher: I'm glad you asked about the term “disease,” specifically, because it's a real stumbling block. And different people mean a lot of different things by disease. I wrote a piece in The New York Times about being skeptical about the label disease. And a lot of people took that as a personal affront, like I was questioning the reality or the way they make sense of disease. And that wasn't my intent at all. 

The problem I see is that disease can mean, at a baseline, that something is amenable to medical treatment, that medicine has a role to play in helping folks, and that is absolutely the case for addiction. We can save so many lives by expanding or improving medical treatment. But there are many other levels of disease that have been, at various times throughout history, superimposed on that more basic and defensible position. So for example, addiction as a disease might be taken to mean that biology is the best — that through a reductionist lens, we're going to figure it out that brain science or some sort of chemical understanding is the way that we're going to crack this nut and finally cure addiction. And that's misleading. 

And then there are other notions like addiction as a disease is permanent, or that all people with addiction have the same kind of addiction. And that's also untrue. We have very good data establishing the heterogeneity and the diversity of addictive experiences. So when you ask, “When did we start thinking of addiction as a disease?” I was curious about this too. And what I found is that it wasn't one question, it was many questions with many threads that appeared in different ways, sometimes helpful, sometimes harmful, and that there was a lot of use even just in making sense of my own situation to unravel those threads a little bit.

With this multiplicity of definitions, how are you now making sense of the word “addiction” and the field in which you work? 

I like a really broad and capacious understanding of the word “addiction.” I like the way that we used it 500 years ago, back when it first entered the English language — that it was a strong devotion that had some element of an impairment in self control. That's not a neat definition. It's not something that you could put in a medical textbook, but I don't think that medicine is the only frame for understanding this. I think there's a lot of danger if we police the borderlands of addiction too tightly. In the end, I think it has a lot to do with self-definition, and one's own personal identity.

“I think there's a lot of danger if we police the borderlands of addiction too tightly … it has a lot to do with self-definition, and one's own personal identity.”

I've seen people who have really struggled with substances, and they say, “Addiction doesn't make sense to me. And I don't see that as my problem.” And I would never try to force that identity on them. I think that as a clinician, it's really important to support someone's self determination and not put my own belief system or my own labels on them. 

And then I've seen other people who have what might be considered a relatively mild problem. And they say, “I feel like I'm suffering with addiction.” And I fully support that, because in the end, I do think that it's universal enough that everybody has a right to say it. One of my Buddhist teachers once said, “If you're not a Buddha, you're an addict.” And my understanding of what that means is that as long as there's something in you that is impairing your self control, or you struggle with ambivalence, then you're not free of that part of ourselves that is not always in charge all the time.

What else do Buddhist teachings have to say about the nature of addiction?

In the West, in a particular kind of addiction advocacy, we have grown up with this idea of suffering as something to be conquered, or addiction as a disease, meaning a special case of human suffering. And there are good reasons for that, involving trying to force open the doors of hospitals and trying to get the word out about addiction and raise compassion. And I understand the reasons for that, and describe that a little bit in the book. But it is a way of understanding human psychology that's a bit opposed to some of these other more spiritual understandings, which I got a lot from. 

I'm not a Buddhist teacher. It's my personal religious practice, but I'm not qualified to teach on it. But I'll say [that in] my own understanding of it, a key form of human suffering [is] what's referred to as dukkha, which is sometimes translated as “suffering,” but it's probably better translated as “unsatisfactoriness.” And so the mind clings [for] a way to try to make that satisfactory, a sort of attachment to the way things could be rather than the way things are. 

There are plenty of other folks, like Johnson Brewer for example, who then use the addiction model or description as a way of making sense of anxiety. For example, worry can be addictive. Sometimes compulsively engaging in a worry loop or trying to predict the future or anticipate any problem is volitional. It has something to do with my own quest to manipulate reality, or to make things otherwise, or avoid danger. And so I think that these sorts of philosophical and psychological insights are sometimes really diametrically opposed to our Western understandings, which are all ultimately a legacy of Judeo-Christian philosophy. So it's worth interrogating [things] like, what is our operating system? What is our working model of how the mind works and what suffering is? 

There can be a huge spectrum here, but the way that some drugs are presented to us these days, like fentanyl or the opioid crisis, is that we simply don't have control. That in certain cases, there are things that are just too strong for us out there to handle. How you make sense of that or parse that question?

Fentanyl is a great example with a lot of historical antecedents as a killer drug, or almost a “magic” drug. One classic example from the more recent past is crack cocaine. When crack cocaine first appeared, it was described as a super drug, something that totally eradicated agency. The most addictive drug to man. One researcher at the time was quoted as saying, “If my daughter could try heroin or crack, I would rather they try heroin.” Which was remarkable. It's unthinkable nowadays in the context of the current opioid overdose crisis. 

But it just goes to show the ideas we had about that particular drug, crack cocaine — which is ultimately just a different formulation of powder cocaine — as if it had some sort of special agency in itself. And one thing that came up for me over and over throughout the book is this sort of “demon drug” idea, where we lose sight of human factors and even the individual factors, let alone the social, economic, political, and cultural factors, and put all the power in the drug. 

“We lose sight of human factors and even the individual factors, let alone the social, economic, political, and cultural factors, and put all the power in the drug.” 

And we have a particularly American strain of doing that, which is very strongly represented in the temperance movement, when advocates first tried to ban alcohol in the 19th century, and came up with this idea of “demon rum” — that there was something special in alcohol, alcohol was like a possessing force itself, and it came into you. And it did something to you that took over your agency and sort of zombified you. 

That's a really dangerous notion, because, especially in the case of the crack epidemic, it served as a cover for law enforcement. It served as a way of saying, “This is an individual problem and people are broken. And they're irretrievable once they've been subjected to this contagious force of crack cocaine,” and ignores all of the social and economic and political factors that also enabled the epidemic. 

What I found is that drug epidemics are nothing new. We've had them for 500 years. And every time a human society has an epidemic, they tend to want a villain. The natural question is, where's this from? Is it the bad drug company? Or is it the bad drug? Or is it something bad in the people who are using it? And ultimately, it's much more complicated than that. We have to be able to think on multiple levels or have no hope of any resolution here.

Do you think with fentanyl, as an example, that there really is no such thing as this kind of demon, all-powerful drug where any person who takes a little taste of it is addicted forever? That's that's all fictitious?

I know for sure that's not true for fentanyl, because fentanyl is an FDA-approved drug that people use for pain control. So there's plenty of people [who disprove that]. And in fact, the demonization of fentanyl, and opioids in general, is leaving a ton of pain patients in the lurch right now. The narrative that the opioids themselves are the problem and they are the thing that has all of the power has led to, in some cases, unnecessary restrictions on opioids that leaves people with legitimate pain and really suffering. 

At the same time, the opioid epidemic shows us that we need some regulation. It can't be laissez faire, it can't be a free-for-all, especially when we have these powerful, asymmetrical market forces, like drug manufacturers that are very well documented. That did awful, awful things during the marketing of opioids in the ‘90s, 2000s, and so forth. So thinking across these multiple levels, and being skeptical about this sort of “demon drug” idea, while also trying to hold in mind the social and economic forces is maybe a path to finding a middle ground where we can be comfortable with a little moderation, you could say.

“Every time a human society has an epidemic, they tend to want a villain … And ultimately, it’s much more complicated than that. We have to be able to think on multiple levels or have no hope of any resolution.”

How a struggling socialite convinced the world alcoholism is a disease

Book Bite - The Urge: Our History of Addiction

By Carl Erik Fisher Link to full article

Carl Erik Fisher is an addiction physician who studies and teaches ethics, psychiatry, and neuroscience at Columbia University. He is also in recovery from addiction.

Below, Carl shares 5 key insights from his new book, The Urge: Our History of Addiction. Listen to the audio version—read by Carl himself—in the Next Big Idea App.

1. Addiction is a human universal.

A little more than a year after I graduated from medical school, I went on a drinking and Adderall binge that got me admitted to the psychiatric ward at Bellevue Hospital. I was sent to a specialized rehab for doctors, and in time, returned to my training under supervised treatment.

Fast forward a few years, and I felt pretty stable in my recovery. I had joined the psychiatry and bioethics faculty at Columbia, and I was training as an addiction medicine specialist. But despite studying neuroscience and psychology, I was troubled by some huge, unresolved questions about my condition—mainly, what exactly had gone wrong in me?

I got little help from my home disciplines of medicine and science, which were riven by bitter divisions about theories of addiction. I had the sense that other fields could help, so I started looking to history, philosophy, and more. I found that addiction is an idea with a long and enriching history. The word’s origin encapsulates a key lesson: addiction is a human universal.

“Addiction” comes from theology. When the word first entered the English language, it didn’t mean a disease, but a “strong devotion.” It could be positive or negative; you could addict yourself to naughty practices like necromancy, or good pursuits like prayer. It wasn’t a status, but an action. Addiction was not something that happened to you—it was something you did.

Most importantly, the word reflected a nuanced point about will and agency, pointing toward a gray area between freedom and powerlessness present in all of us. This core mystery of self-control has been taken on by philosophers from Aristotle to the Buddha. From the beginning, and for most of history, this was the point of addiction—it was an idea about this mystery of the human condition.

“Addiction was not something that happened to you—it was something you did.”

2. Drug epidemics are nothing new.

We are in the midst of a tragic overdose crisis. This is a mass-casualty event that is killing over 100,000 Americans a year. As awful as this is, it’s not unique. Since the beginning of modern commerce over 500 years ago, drug epidemics have wracked the modern world with disturbing regularity.

For example, from the 1500s on, tobacco use exploded across Europe and Asia. Anti-tobacco writers called it a “plague intolerable.” Then, in the early days of American independence, there was a massive epidemic of alcohol, supercharged by cheap molasses from slave plantations being turned into rum by enormously profitable distilleries. The first American opioid epidemic occurred in the 1860s and 1870s, fueled by the unspeakable trauma of the Civil War, the pharmacological enthusiasm of American doctors striving to capture market share, and the development of new, powerful ways of delivering opioids, such as the purification of morphine and the development of the hypodermic syringe.

What we see across those examples is a clear pattern in which drug epidemics occur at the intersection of three main causes. First, a new drug or a new way of taking a drug is often an important component. Secondly, powerful industries are often behind the scenes pushing those drugs. And third, the ground is usually prepared by social wounding, oppression, and trauma—from the plagues, revolts, and wars driving tobacco use in the 17th century, to the despair of inequality, isolation, and alienation driving our 21st-century crisis.

3. Stop calling addiction a “disease.”

In both medical school and rehab, I was taught that addiction was an extreme mental illness: a “disease.” It was a damaged condition, discretely divided from the rest of the normal population. This is a misleading idea rooted in our history, and it does more harm than good.

“Biological explanations for mental disorders increase aversion and pessimism toward people with psychological problems.”

In 1784, following the Revolutionary War, one of the Founding Fathers, a physician named Benjamin Rush, took a rare vacation through the Pennsylvania backcountry. He was struck by the postwar poverty and social upheaval. Whiskey and rum were everywhere, and binge drinking was widespread. Americans drank alcohol, not coffee, to wake up before work—then for the “elevens” (at 11:00 a.m.), then again in mid-afternoon, before dinner, and more—not to mention at meals themselves, as water was thought to be unhealthy. Rush returned to Pennsylvania and began calling habitual drunkenness a disease. But Rush was only arguing that medicine could help in part, as he recognized that social and economic policies were also central to the problem.

The word “disease” became a plank of alcoholism activism in the 1940s and 1950s, when advocates were trying to force open the doors of hospitals. This was a period of harsh stigma against people with addiction—to the point that the medical profession had almost totally retreated from attempting treatment—so they used disease language to try getting a foothold.

Now, more than half a century later, the disease notion has gotten twisted. Disease language slips too easily into the notion that medical science is the best framework for understanding addiction. Biologically reductionistic descriptions of “brain disease” imply that people have no capacity for choice or self-control. This strategy is meant to invoke compassion, but it doesn’t work. The best studies have found that biological explanations for mental disorders increase aversion and pessimism toward people with psychological problems. This notion is dangerous not only because it implies fatalism, but also because it narrows our view of a multi-level problem—one that requires, for example, less of an individualized perspective, and more attention to community support, like the problems Benjamin Rush saw over 250 years ago.

“This notion . . . narrows our view of a multi-level problem—one that requires, for example, less of an individualized perspective, and more attention to community support.”

4. The good drug / bad drug myth.

In the 1980s, seemly overnight, crack cocaine exploded throughout the U.S. The media was saturated with stories of an unimaginably powerful new drug, and the moral panic was supercharged by racist stories about dangerous Black and Brown users infecting white America. Physicians and researchers followed suit, describing crack as a superdrug, “the most addictive drug known to man,” one that would cause “almost instantaneous addiction.” Soon, the star of that story became dopamine, a neurotransmitter that had been a relatively obscure molecule.

Dopamine was supposed to govern the “pleasure center in the brain,” responsible for all the good feelings produced by food, sex, and drugs. This explanation became immensely fashionable during the crack scare. Dopamine was called the “master molecule of addiction,” and fueled by the popularity of neuroimaging in the 1990s, the story was that drugs hijack the natural reward system of the brain through dopamine.

This is still a common story about addiction—but it’s false. Major figures in academia still get this wrong. Dopamine is not a pleasure molecule; it’s about desire and wanting, not liking. Also, not all drugs bombard the brain with dopamine—crack does powerfully and directly release dopamine, but other drugs (including cannabis and opioids) do not. But the idea of “dopamine hijacking” was a perfect reflection of predominant social concerns, and provided cover for law-and-order crackdowns in the war on drugs. The stage was being set for our current opioid epidemic, as Purdue Pharma launched OxyContin, and federal regulators and the medical profession overlooked the dangers of flooding the market with opioids.

Panic about supposedly bad drugs warps our understanding of addiction. During the temperance movements of the 19th century, anti-alcohol preachers spun stories about how alcohol produced “pleasurable and painful vibrations” in the nerves of the stomach. The good drug / bad drug myth also enables blindness to supposedly good drugs. After World War II, during a postwar opioid epidemic, scientists became so focused on opioid withdrawal that they missed the dangers of a rising amphetamine epidemic (obscured by marketing from powerful pharmaceutical companies). The tail wags the dog; misguided ideas about dangerous drugs drive ideas about addiction, causing us to miss the full picture of potential benefits and harms.

“Misguided ideas about dangerous drugs drive ideas about addiction, causing us to miss the full picture of potential benefits and harms.”

5. We will not end addiction.

Addiction is part of us—it’s not a curable disease. But this is not to say there isn’t anything we can do, because there is. One of the key things is bringing addiction care into the mainstream.

Once I returned to my psychiatry residency and started to see my own patients, I did an intake interview with a young guy with alcohol problems, drinking about four to five drinks a night. His problems weren’t nearly as bad as my own had been, but my supervisor still said we had to turn him away from our clinic. And my supervisor was a compassionate, caring clinician. The issue is structural stigma—policies and practices that exclude people from opportunities to heal.

There are innumerable ways we can help alleviate the harms of addiction without waging a violent war against it. We must expand harm reduction efforts like safe consumption facilities, overdose prevention sites, syringe service programs, and other crucial services that reduce drug harms and provide an opportunity to connect with people. We must support all the different varieties of recovery, and support recovery as a long-term process.

All of these efforts need to be undergirded by the recognition that addiction is part of us. Beyond technocratic and structural changes, we need to change the way we think about addiction. Even as we discover treatments that might reduce cravings and support recovery, we still have to recognize the other personal and social elements of addiction. In other words, addiction is profoundly ordinary—just one manifestation of the central human task of working with suffering.

Psychologists Off the Clock: The Shaping of Addiction & Mental Health with Carl Erik Fisher

by Yael Schonbrun Link to full article

According to the National Center for Drug Abuse Statistics, since 2000, the United States has experienced over 700,000 deaths due to drug overdose. Addiction and substance use disorders are at the root of this enormous loss, and about half of people who struggle with substance use disorder will experience some mental health disorder during their life. And vice versa—many individuals struggling with mental health disorders also struggle with various forms of addiction.

Carl Erik Fisher, author of The Urge: Our History of Addiction, has expertise in law, ethics, and policy related to psychiatry and neuroscience. His personal struggle with addiction in combination with his professional expertise converges to help us understand the forces that have shaped addiction throughout our history. On this episode of POTC, Carl and Yael discuss the social contingencies and historical contexts that lead to addiction, substance use disorder, and co-morbid mental health issues. Join us in this episode to learn more about commonly held beliefs about addiction, prescribers’ blind spots to certain medications, and much much more!

Listen and Learn:

• Yael and Debbie discuss the importance of contextualizing human behavior

• How society tends to neglect the historical context of addictive behaviors (and why it’s so important to overcome this neglect)

• The issues that come with treating addiction differently than other mental health disorders

• Practical advice for clinicians and patients working with co-morbid addiction and other mental health disorders

• Carl provides insights on how addiction has been weaponized to serve corporations and politicians

• An important, historical example of what happens when scientists and researchers rigidly adopt a particular view (read: biases) but find information that conflicts with that view

• The expert-approved definition of harm reduction

• Carl answers commonly held beliefs about addiction (e.g., is addiction a brain disease?)

• How Carl, a practicing psychiatrist with an in-depth knowledge of the history of addiction and mental health, approaches prescription by balancing values, change, and harm reduction

• Things consumers should know about prescribers’ blind spots to certain medications

• Carl’s personal story of addiction and recovery

• What to consider when balancing evidence- and RCT-based treatments with clients’ individuality and choices

• Practical advice for helping those who are in denial of their substance abuse problem

Resources: 

• Read Carl’s book, The Urge: Our History of Addiction!

• Check out Carl’s recent New York Times piece, Why It’s misleading to call addiction a disease

• Listen to Carl’s podcast, Flourishing After Addiction!

• Read RAND reports on drug policy research, prescription drug abuse, and substance abuse

• Grab your copy of all our favorite books at bookshop.org/shop/offtheclockpsych.

• Check out Debbie, Jill’s, Yael, and Diana, websites to access their offerings, sign up for their newsletters, buy their books, and more!

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