Carl Fisher talks about the war on drug addiction and “The Urge”

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

In a matter of weeks, he went from a seemingly stable and carefree doctor in a psychiatric residency program 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 others with troubling substance abuse and mental health issues.

“When I found myself in Bellevue Hospital, I immediately had the feeling that something was desperately wrong,” said the 41-year-old American author, via a Zoom call from Lisbon. “I then opened up to my treatment team and said, I’m an alcoholic, I’m giving up, I can’t fight anymore.” Fisher got sober and eventually returned to the residency program at Columbia. Today, he is an assistant professor of clinical psychiatry at the prestigious Ivy-League University in upper Manhattan.

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

Beginning his investigations during an epidemic of opioid overdose in the United States, Fisher learned that human societies had been ravaged by drug epidemics with appalling regularity for more than half a millennium. He also came to understand how centuries of cultural politics, stigma and racism cannot be separated from how we currently understand and deal with – or in most cases do not deal with – addiction in Western societies. .

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

“But corporations that have done a really good job of relaxing the legality of the drug have linked it with a really powerful and wide range of social services, including housing, employment, and other ways to build structure. , a meaning, a purpose and a sense of community in people’s lives,” adds Fisher.

Fisher currently divides his time between New York and Lisbon, where he lives part of the year with his partner and son. Portugal’s decriminalization program is a model the rest of the world should look to, says Fisher. “In Portugal, decriminalization policies have been combined with social policies to achieve a very good rate of reduction of an epidemic.”

This contrasts sharply with the United States. He recently took the decision to decriminalize cannabis, but this decision was not followed by additional social support from the government: then we can see a big wave of harmful abuse,” he says.

The history of addiction that we read about in Fisher’s book is selective. It is largely an American story.

This reflects his desire to understand addiction issues in 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 wartime United States. of independence.

This idea was then spread around the world 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 strong ideas about what drives an addict to choose the behavior they adopt.

Framing addiction in this oversimplified way (as, say, a moral question that separates right from wrong, or weak from strong) tends to miss a crucial point about addiction more broadly, he argues. , namely: that dependence exists, to some extent. , in each of us.

“Thinking of addiction as something intrinsic to the human condition, and involving an element of choice, is really helpful because it shows how addiction is a behavior we choose as a coping mechanism to manage our suffering and seek distraction to avoid anxiety and pain.

Fisher’s book identifies four major approaches Western culture has used to respond to addictions across different periods of history. A prohibitionist approach sought to control addiction through punishment and other law enforcement strategies.

A therapeutic approach argued that addiction is best treated 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 self-help approach sought community healing, grassroots fellowship and spiritual development to help addicts recover. “There’s a lot to learn on the spiritual side of addiction, because it makes it feel like there’s something beyond medicine,” Fisher says.

“My main house of recovery is Buddhism, and all Buddhist practitioners adopt certain presets: one of them is to swear to abstain from intoxicants.” Using theology and philosophy as a guide to curbing his own problematic relationship with alcohol led Fisher to the conclusion that medical science alone, while important, was insufficient to understand addiction.

“I learned a lot from medicine: psychotherapy, group therapy and other addiction treatments. They helped save my life in a way, but sometimes debates in medicine and science can get extremely polarized, where people tend to talk to each other, can’t find common ground and disagree. be drawn into very abstract explanations.

Fisher says this is especially true in the brain-centric field of neuroscience. For many years, psychiatry worked on the idea that mental disorders were categorical and fixed entities.

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

He then points to a trend in the global scientific community that generally tends to classify addiction as a disease of the brain. It has many drawbacks, he believes. In the United States, for example, it has pushed federal alcohol and drug research toward reductionist biological research, and away from social, epidemiological, clinical, and policy investigations.

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

But Fisher remains cautious and skeptical of reductionism. “Specifically, it’s the idea of ​​seeing neuroscience in the best framework for understanding addiction,” he says. “It’s dangerous and I’ve seen it in patients. They buy into this notion of brain damage too much, whether it’s from trauma, past addiction, or actual physical injury.

Most “brain disease addiction models are reasonable but borderline uninteresting”. Fisher thinks this one-sided view of addiction lacks nuance and can lead to dangerous consequences for patients. “We know from some psychological research that the brain-based explanation of mental disorders, in general, increases fatalism and increases pessimism,” says Fisher: “So we have to be very careful about how we interpret neuroscience, although we continue to look to it for many good lessons as well.

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

If addiction is simply part and parcel of being human, it’s not a problem that needs to be solved indefinitely, argues the author. In other words: we must not seek to eradicate addiction. Rather, we need to find ways to work with it.

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

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

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