Tune in as Elizabeth sits down with Dr. Fisher to discuss the human capacity for recovery, the institutionalized stigma surrounding substance use disorders, the “double-edged sword” of labeling addiction as a disease, and how recovery took him from Bellevue Hospital’s psychiatric ward to an assistant professorship in the department of psychiatry at Columbia University.
Carl Erik Fisher, welcome to Heart of the Matter. It’s great to have you.
Thanks so much for having me. It’s good to be here.
Congratulations on the book. It’s really an incredible read. It’s called The Urge: Our History of Addiction. And in the introduction you write, “This book is a history of addiction. It is the story of an ancient melody that has ruined the lives of untold millions, including not only those of its sufferers, but also the lives touching theirs.” It’s a real examination of the fact that addiction isn’t anything new.
Yeah. That was one of the most soothing parts of the project actually. I looked to the history for myself. It was ultimately a selfish project of trying to figure out what happened to me in my own recovery, trying to get my arms around what does it mean to have addiction. And to see the enormity of it and how far back it’s stretched into history up to and past the ancient Greeks and Romans, and to even like 1000 BC in ancient Sanskrit hymns, it was comforting. It was comforting to see. I know, even as I’m saying this, it sounds kind of funny to say it’s comforting because it’s also, just like you said in there, awful melody. And it’s nothing new and woven into the human condition and there’s a real fellowship in community there.
You are a doctor who specializes in addiction. You are a doctor who suffered from addiction and is in recovery. And I think because you wear both those hats, you write very vividly about the torment you see in patients, especially I wanted to read something from the book. You write about a patient named Susan who comes in to see you and she’s relapsed and you write this is awful for her. She dwells on the past month of failed resolutions and unsuccessful attempts to cut down as she goes around and around butting up against the limits of language and reason and trying to make sense of it all.
A note of frustration, even desperation, enters her voice. “I know what I need to do. I want to do it, but I don’t do what I want to do. And then I’m drinking again, and I just don’t know why or how.” I really felt like that captured. I mean, even for me, I would get up in the morning and like record videos to myself saying, “Don’t drink tonight. Don’t drink tonight.” And I would delete them by 4:00 PM and drink by 6:00 PM. I mean, it was a horrible vicious cycle.
I really – I was drawn to that vignette because her story I think really captures one of the core mysteries at the heart of addiction. And there’s so many different definitions of addiction. That in a way is one of the things that sent me down the path of looking at the history. But really, one of the most interesting mysteries is why do people keep on doing this thing that so often we, I should say, even though we say I fully intend to stop and I know this is not working for me, I know this is not working for my family. I had that experience myself waking up in the morning saying I’m not going to drink, dumping out all the alcohol, and then I would watch myself walking to the corner store all the while saying to myself, just like my patient, “I’m not going to do it, let’s not do this, let’s not do this.” There’s stories like that throughout all of history. I mean, there’s a classic example of Bill Wilson in one of his later biographies talking about exactly that moment that I only came across-
Bill Wilson, the founder of AA?
The founder of AA. But even going back to that Sanskrit hymn I mentioned, a gambler from 1000 BC who all the while he keeps on gambling is saying to himself, “Oh no, maybe yes.” It’s that sort of like powerlessness and internal struggle, I think, that is the thing that really butts up against the deeper philosophical and even spiritual questions of why can’t we do what we intend? Why can’t we go toward the good?
So what’s the answer. You’re a doctor studying this, what’s the answer? Why can’t we, when we know what we’re doing is so destructive?
I think just opening up to the mystery is a really beautiful step. Let me say it this way. I really wanted the answer when I started out because I was about a year into recovery. I was relatively stable. I was in my medical training, and I did what I always did, which is go to the medical literature and the scientific literature. And I thought, okay, sure, there’s going to be some disagreement, but I’ll find the theory of addiction that makes sense and I’ll find the person that I can trust, or maybe I’ll have to put together a few things myself, but surely there’s someone out here who’s got the answer.
And there’s a lot of really great science and medicine about addiction, but I didn’t find one definitive theory. I found like 30 different theories of addiction. And when I looked deeper, the thinkers and the scholars and the researchers I really respected kept on drawing beyond medicine, because I think there’s so much richness and wisdom there in literature and arts and ancient philosophy. That’s the thing that led me back to say, for example, Aristotle or Augustine of Hippo, one of the early Christian theologians, because they saw this as one of the core, core mysteries of self control in the human condition.
Why is it so hard? I mean, that’s the real deep understanding of sin as I understand it. It’s not about something that’s bad or shameful, it’s about this question of how can we be so out of control, how can we move toward the bad, even knowing the good? So for me, it’s not about finding an answer, coming up with a solution to kind of discipline myself into good behavior, it’s more about relaxing into the mystery and making peace with it. That’s a part of acceptance the way I look at it.
You go on to write about this mystery, as you call it, in your book. “Addiction is a terrifying breakdown of reason. People struggling with addictions say they want to stop. But even with the obliterated nasal passages, scarred livers, overdoses, court cases, lost jobs and lost families, they are confused, incredulous, and above all, afraid. They are afraid because they cannot seem to change despite the fact that they so often watch themselves clear eyed do the very things they don’t want to do.”
There are a lot of people I hear speak in the rooms of recovery who say I was born an alcoholic, I was born an addict. Do you think people are born an addict? I’ve never felt like I was. I mean, I think that trauma can play a huge role into why people turn to substances. I think one of the biggest… I’m asked all the time, by women especially, because I wrote a book about myself, a woman who medicated anxiety with alcohol. Women ask me a lot, how do I know if I’m drinking problematically? And I always ask them, well, why are you drinking? Ask yourself the question why you’re drinking. Are you drinking to enhance your life, or are you drinking to numb something? I was drinking to numb something. That’s a big red flag. What do you about the origin of it? Are you born an addict or is it something that happens to you along the way?
I don’t think that hardly anyone is fated. I don’t think our behavior is determined in that way. I know throughout history, we’ve consistently as a society overestimated that kind of fate and underestimated the capacity for recovery and underestimated the capacity for change. In a way there’s a sort of seductive narrative that people with addiction are broken in some way. That comes up in say like the mid 19th century when people first started learning about genetics and then it quickly turned into a story about mothers and how mothers who drank basically pickled their babies in their wombs. And then the children were faded to be a sort of underclass.
So these sorts of fatalistic narratives, they’re put to use as a sort of like us, them story. It turns into like a sneaky way of excluding certain people or shaming certain people. My understanding is, from the contemporary research, there’s tremendous capacity for change. We probably underestimate the way that people get into recovery. It’s going to be a very long process sometimes, but it is such a huge proportion of people that actually do really well. So I’m just very, very cautious of the ways those sorts of fatalistic narratives are used because they can swing way too far over on a very hopeless and dehumanizing side.
Right. And while we do know that there is a strong genetic link, like your own family. Your own family, both your parents, were alcoholics. We know that people in families where alcoholism runs through generations often have a greater chance of becoming. But it’s not destination in other words. You’re not sentenced to a life of addiction just because your parents or uncle or aunt or grandparents suffered from addiction, nor is everybody who’s suffered from trauma sentenced to the only way to deal with this trauma is to turn to drugs or alcohol. In other words, it’s not a given. There’s plenty of ways to veer off the path, right?
No, I couldn’t agree more. I think everyone has pain. Pain is inescapable. There’s some element of suffering. And then that manifests in different ways. So I think addiction is more than a substance problem. I think there’s a little too much skepticism about the so-called behavioral addictions like gambling like we were just talking about, but I don’t think anybody is fated to develop along certain lines. We just have different ways that we manifest our pain. That’s one of those interesting tensions about addiction that I struggled with throughout the whole book is there’s a paradox there that I feel like I belong to a community and a fellowship.
Just connecting with other people with addiction has by far been the most tremendous part of my recovery. It wasn’t about going to the right rehab or getting the right kind of medical support, although that stuff was really important too. It was about this sort of fellowship. So there’s something special about acknowledging and accepting the status of addiction. And at the same time, I think addiction exists in everyone. It’s almost like addiction is the place where the sorts of universally human vulnerabilities we were just talking about about self-control and about willpower are just clearly on display, but just on display in a really life threatening and profound way.
You intersperse throughout the book in your study of the history of addiction little snippets of your own story. You drank, you used Adderall and had a pretty scary episode where the SWAT team came into your apartment and tased you, and then sent you to Bellevue Hospital where you were locked up in the psychiatric ward. But before that, you write in the book about going on rounds and showing an intern how to measure the size of an alcoholic patient’s liver. And you write, “I knew my own alcohol intake had shot way into the unhealthy range. Some mornings I imagined I could feel my own swollen aching liver. My eye twitched if I went too long between drinks. Even on nights when I didn’t want to drink, I joylessly downed a few shots of whiskey to put my body to sleep.” I mean, it got pretty bad for you to be tased and then sent to Bellevue. How did you get out of that? How did you get into that?
I mean, I love that we can laugh. Both of us are smiling and chuckling, because that’s what I love about recovery communities is that we can look back on it with some humor.
I know. We can tell at our horror stories and go, “Yep. Me too.” Although I wasn’t tased.
Fair enough. Yeah. But I think, from what I know of your story, there’s an element of that sort of strategizing and the shame and the hiding and all of the effort that goes into the concealment and denial, hiding a part of the self from the rest of the self. I don’t know that I got myself out of it. That’s not really how it went for me. It’s almost as a contrary that I repeatedly had people hold out their hand to me in very compassionate ways. I’m extremely privileged in that respect. I couldn’t have wished for a better say psychiatric training program. So while I was at the psychiatric residency at Columbia, very thoughtful, skillful, and compassionate. None of the sort of like tough love intervention, our way or the highway, just really careful and thoughtful attempts to engage me.
And I kept on hiding and concealing and concealing. So part of my story was just that I took it exactly to the breaking point where I tried to do it myself, me, me, me, me, me as far as I could absolutely go to the point that I lost my mind and that I was manic and I thought I was in a spiritual war. The only thing that I can say that I did to get me into that hospital, because that’s really where I was safe in the near term, was there was a moment when I was manic. I only glance on this in the book. I don’t spend a lot of time on it. But I had this sense that I was out of my mind. I thought, what’s more likely, that I’m in a spiritual war and I’ve been selected as some sort of creature of light, or maybe I’m in a stimulant psychosis, which is what I was studying at the time.
So you’re diagnosing yourself as you’re going through your manic episode.
Well, almost like different parts of myself are working to diagnose myself. And there was a part of me that was able to seize on to reality for long enough to say I need help. I need something outside of myself. So many people had been reaching out to me and trying to help me that I have to trust that if I just scream out that I will get something, I will get the help I need, that I’ll be safe. And that’s literally what I did. I just yelled in my apartment. So people took me in, took me to Bellevue and I was lucky. It could have gone otherwise.
You were alone in your apartment. It wasn’t neighboring-
Alone in my apartment, a big guy, I’m 6’3. I wasn’t in my right mind. It helped that I was white. It helped that I was in the West Village, fancy neighborhood in New York. Could have gone totally differently if some of those details were different. Could have gone differently just if we rewound the tape and played it back again. But that’s the only thing I can say I did myself to get myself out of that was have one brief moment of recognition where I said, “I can’t do this myself.”
Right. You get into a hospital, and you write in the book, “For the first time I truly let my guard down and recounted my whole drinking history, how I grew up with two alcoholic parents and swore to myself I’d never be like them. How even as I finished medical school at Columbia, I had the creeping sense that my drinking was out of control, how the blackouts got more and more frequent but I didn’t reach out for help and I didn’t accept the help that friends, colleagues and supervisors all had offered and then implored me to take. I tell them everything, even the one time that I woke up on the floor of the hallway in my building shirtless, my skin sticking to the tacky linoleum, locked out of my own apartment. It was only by getting up to the roof and climbing down the fire escape that I made it to work that day at all. I was late again and so ashamed and scared by what it said about me. It was obvious that something was wrong, but I never told anyone about it because to do so would acknowledge what I had long suspected.”
That’s something I really related to. I didn’t tell anybody either. In fact, even as I was telling everybody else I’m fine, mind your own business, I was recording videos to myself pleading with myself not to drink again. A lot of people who struggle with addiction live with one foot in each world. I’m okay to the outside world while inside you’re just contorted with shame and torturing yourself over your inability to make the right decision, which begs the question, are you in any shape to make the right decision? If you’re suffering from a disease of addiction, can you even make the right decision?
Yeah. I know I couldn’t. I couldn’t make the right decision. It was that mind divided against itself that was really getting in my way. I had an idea of myself. This is another way that the history was helpful to me is seeing the way that identity and ideas about who I’m supposed to be or ideas about what’s the right or wrong way to be as a person sort of infected my thinking and made me put on a show. Going back, one set of examples is the English romantics like Samuel Taylor Coleridge and Thomas De Quincey. This is almost exactly 100 years ago, and people were talking in the same way about that double game, about presenting a strong face and also that sort of like romantic celebration, even to the end.
This might be a place where our stories differ, but even to the end, I had this sort of like romantic notion, heroic notion of showing how cool I was or how accomplished I was that I could go out and party and be the fun guy, and then return to serious academic work and being a doctor. And so it wasn’t just a matter of stopping drinking. I think I also had to acknowledge that the very stories I was telling about myself were totally off and that this importance… I ascribed so much importance to being able to drink in that way.
It really meant something to me. I thought it really meant something to me that I could do this and then that. And when I entered recovery, that was one of the biggest barriers to me is just to totally reformulate who I thought I was. I thought it meant something so threatening about me to say like I could never drink again. It was just such a terrifying notion that I would be like them, getting back to the sort of like dangerous us/them distinction. I thought it meant something awful about me and really it was just a tremendous gift.
Do you accept that you can never drink again? Did you have a hard time accepting that if you do?
Well, it was a really tough time, because as I describe in the beginning of the book, that two days after I’m in the Bellevue psychiatric ward and I disclosed to everyone, I say, “I’m an alcoholic. My parents are alcoholics. I’ve been hiding it for myself, such a problem.” Two days later, I pick up the phone and I call my best friend and I say, “Do you really think I can ever drink again? Maybe I do this for a few years and then I start again.” So already two days in, I’m still on a locked psychiatric ward, I’m already strategizing about five years out.
And I see that phenomenon all the time. People worry about the wedding toast for their son or daughter that isn’t even born yet, or something like that. So I’m really cautious about that part of myself. I know my capacity for self-deception and overconfidence is really, really strong, and I really like the guidance to keep it in the present moment. Today I am absolutely convinced I can’t drink and that’s good. I don’t think I’ll drink again. But for now it’s in the day. I don’t have any question in my mind about it. I’m still working with addiction for sure, but my addiction today is more about sugar and anger and other things like that.
How did you finally get sober? I mean, what did it for you, because I think that the average attempts to sobriety before somebody finally finds it can be up to five times. There’s this myth out there, I think, among people who have never struggled with substance use disorder that, well, it’s all a matter of willpower. That’s myth number one. And then myth number two is, you just need to decide you want to stop, and then you can stop. Boom, case closed, done. That rarely happens. The unicorn in the rooms of recovery in the meetings that I go to is the person who got sober the first try. Those are rare. Much more common is the person who took two, five. I’ve known people who’ve gone to rehab 18 times. I mean, it can take a long time. How did you do it?
Yeah. One of the things I was playing with in the book is exactly that question, when can I be said to have stopped? When can I be said to have gotten sober? Because you could date it. The conventional way is when you had your last drink. And so you could date it to when I went to Bellevue Hospital and I had to stop because I was in a lock psychiatric ward. And then after that, I went to the specialized rehab for doctors. I still had a lot of denial but I wasn’t going to leave involuntarily and then put my medical license on the line. So that’s one time that I stopped.
The time that I really stopped is when I realized that I could drink again and “get away with it,” and I still chose not to. It was such a banal turning point, honestly, because while I was in the program, part of being in the physician health program is I signed up for this program where I got urine tests that could also test for alcohol. And I’m still allowed to go on vacation. So I went to a friend’s wedding. I knew there was enough time that I could have a beer just to prove to myself that I was okay, that I wasn’t like what those fools at rehab were telling me, that I was different, that I was special in some way. There was a part of me that really, really wanted to do that.
I had to really think about what it was worth and in the end, the thing that scared me the most, this is very similar to what we were just talking about, but the thing that scared me the most was the strength of that part that had such a strong idea about who I was. Just the fact that there was something in me that said you can be special, you can be different, you can go prove that you know better, that kind of self deception was enough for me to say, “Okay, maybe I’m not that special. Maybe I should trust. Maybe I should take a leap of faith and trust that for all of the messiness in terms of trying to understand addiction over centuries and centuries and centuries, there’s also an element of taking a leap of faith and just trusting that I can find some refuge in that concept.”
You’re a doctor who got sober. Most people aren’t doctors who don’t have to go in and get tested by their employers for drug or alcohol use, which is probably a very effective check on those early days when you can be tempted in sobriety. What is it like being a doctor in recovery, going to a specialized facility? Is there more stigma as a doctor in recovery, I’m curious?
I think there is more stigma in a way if we want to talk about self stigma, because I don’t think that I’m all that unique in having that strong sense of trying to be special, trying to prove my worth through my effort or my achievements. That can be a real barrier, that sort of specialness in a lot of high achievers, including but not exclusively physicians and the other medical professionals. I mean, we had a lot of nurse anesthetists there too. In a way we saw how access to the substances was such a powerful trigger. But I think that there’s an expectation that is more and more crumbling during COVID that medical professionals are supposed to be superheroes.
We had all the banging on the pots in the early days of the pandemic and all of this talk about frontline heroes. I have an in-law who is a COVID nurse. She does incredible work, and she is in fact a hero. That sort of story about individualism and heroism I think can really stand in the way, that can be stigma in itself because it’s a way of putting a should on ourselves. Like it should be able to go through and take all this pain, take all this trauma, take all of this moral injury of a crumbling healthcare system.
Part of the reason I was drawn to the history is there’s a way that that sort of myth of individualism and heroism and independence and self-determination and self-discipline is woven into the American psyche in a way that’s very beautiful but that can also be really dangerous in some ways when the expectation is we’re supposed to be able to just keep on going no matter what and succeed and control ourselves no matter what the circumstances.
You’re not only a doctor in recovery, but you’re a doctor specializing in addiction. What are we doing right and what are we doing wrong as a society when it comes to how we treat people who suffer from addiction?
Yeah. It’s a really important question because there’s so much that we could be doing better in terms of medical treatment. Medical treatment is one of the really important pillars to the way we respond to addiction. I mentioned earlier, medicine’s not the whole story. I have tremendous respect for medicine and I think we have to look beyond medicine to fully respond to the challenges of addiction. So there are a lot of things that we could be doing to expand treatment. We’re still woefully, woefully short on providers, and not just super specialized providers like me.
Terribly short, yeah. And it’s expensive and people’s insurance, it doesn’t cover it. It is like one thing after another, how do you find a good rehab? Do you need to even go to a rehab? How do you afford the rehab? What happens if you relapse? Do you go back to rehab? By that point, the insurance company says, “No way, we’re not covering it.” It’s like a barrier after a barrier after a barrier.
That’s a great example of how it’s not just workforce though. Workforce is a jargon for just the number of providers that we have. But even if we could wave a magic wand and all of a sudden have a lot of addiction doctors and nurses and therapists and all the rest, we would still have this weirdly separated system, which is in itself a historical legacy of ways that my profession, the medical profession, essentially abandoned the treatment of addiction in the earlier part of the 20th century, 1910s, 1920s. I think there’s so many great forces within medicine that are working to integrate addiction care with the rest of medical care, but we still have a long way to go to remediate that betrayal.
And so we also need to mainstream care, meaning that why should it be that we have to go to some like retreat place to go get treatment? Like rehab saved my life, but it’s not for everyone. Why can’t we go get treatment? We meaning people with addiction. Why can’t we get treatment at other general medical facilities? Why is it so broken up and sort of weirdly disconnected? When I was in training and I was starting to learn psychotherapy myself, I had to turn away a patient who was drinking at nowhere near the same level as I was.
I looked at this guy and I thought, “Oh, that’s cool. He’s got mild to moderate alcohol use disorder. I’m really excited to work with him. I can work with the supervisor and I can look at my own biases and get a sense of…” And my supervisor said, “No, we can’t take that guy. We can’t work with him. He’s too sick. He has to go to a separate clinic down the street.” I mention that story not because my supervisor was a bad person or that she had some terrible stigma. In fact, I knew her well and she was a really thoughtful, caring and compassionate humane psychiatrist. She was just exhibiting an institutionalized stigma, a structural stigma about the way we set up our addiction treatment system from the ground up.
You talk about that stigma. It’s pervasive. There seems to be lately a greater acceptance that we need to be compassionate about the way we approach addiction. And yet it’s a very shallow pool. Most companies, for example, if I came forward and said I’ve been diagnosed with breast cancer, they would give me the leave I needed to go get treatment for it. My insurance would cover that treatment for it. And then if two years later the cancer came back, the company wouldn’t say, “Oh, I’m sorry. We already paid for the one treatment. You can’t take leave again.” And the insurance company wouldn’t say, “I’m sorry. We already paid for one round of chemo. That’s it.”
But with addiction, we do. Companies do say, good companies will say, “Okay, great. You can take a leave hopefully and get treatment for this addiction and insurance company will hopefully pay for a tiny portion of that.” They should pay for more. But a lot of times, people, if they relapse, they’re out. So it just feels like even whatever well of compassion there is out there for people struggling with substance use disorder, it evaporates quickly in the reality that most people relapse.
So we were talking about medical treatment before, and I mentioned the medical treatment is essential and life saving and there are a lot of lives that we’re essentially leaving on the table. There’s so many simple things we could do to save lives. And what you’re talking about in terms of that well of compassion makes me think that what we also need is a change in consciousness around what we think about addiction. We could talk another hour about all of the different policy responses that would save lives, stuff specific to the opioid overdose crisis and other stuff specific to medical regulation and legal problems.
And if we had a magic wand and we could wave that magic wand about getting all of our policy wishlists, there would still be a need for grassroots change in consciousness around how we accept and respond to addiction and accept and respond to our pain. So I think that’s part of the reason I’m really excited about your podcast and other ones like this. I know you have Ryan Hampton on this podcast. And I asked him, what is the one thing that we really need? And I thought he would say some policy thing, because he’s a policy guy. Like we need to get this line item or pass this law. And he said, “The most impactful thing I think is get people to tell their stories.”
I think that’s really… It’s not the whole story. For some people, it’s not safe to do that. They have to be careful about how they come forward because of that stigma. But I really think that there’s a deeper… That’s why I wrote the book. I think there’s a deeper need for a really cautious, humble, careful investigation of this phenomenon of addiction for us to really meet it with the kind of compassion it deserves.
Yeah. It’s a bit of a conundrum. The only way you start to break the stigma is for people to come forward and tell their stories. And yet people don’t come forward and tell their stories because of the stigma. So it’s how do you break that apart? I was struck by something that you said, fewer than 5% of people in the United States with substance use problems actually believe they have a problem and want treatment. Is that true? I mean, why is that so tiny? Although as I say that, Carl, until the moment I finally accepted that I needed to stop, I needed help to stop, I was one of those people.
Right. You and I, we have this bodily somatic sense of the things that might be stopping someone from recognizing that fact, of being willing to enter and receive treatment or just ask for help in a more general way from a mutual help group. I think some of that reason I do want to say is because we need better treatment and our treatment system is so fragmented and people know that there are ineffective treatments out there and that there are treatment programs that are mired in too much of the sort of confrontational and ineffective methods and there are a lot of people who have not been served well by some versions of treatment that are out there.
And like you were just saying, I wrote that passage not in the section about the failures of the treatment system, I wrote that passage about denial – it was about the denial that I faced when I was given the opportunity to finally get help, maybe one of my best cracks at getting help, when my program director at my residency very compassionately sat me down and said, “Whatever the problem is, get help.” And still, it’s just still shocking to me looking back on it how powerfully that notion of denial was able to lie to myself and almost brought reality to convince me. In that moment, I honestly feel like I did not believe I had a problem even though the evidence was clear as day just laid right out in front of me.
I didn’t either. I didn’t either. And I think I also, as you describe Susan in your book, I think I was afraid to admit that there was a problem because it was like I was leaning against a door that was shut. I didn’t want to open that door and look behind it because I thought I would be overwhelmed by it. And I also couldn’t conceive of living without alcohol. I too romanticized it. It’s something I wrote about in my book about flaying the romance, about the importance of doing that, because I was really, I did romanticize it. I loved to drink beautiful glasses of Chardonnay. It was all romantic and fabulous and sophisticated.
You know what, there was nothing sophisticated or romantic about walking up and down Broadway on a Sunday morning so hungover and desperate for wine that I was buying Chateau Diana from Duane Reade, which doesn’t even qualify as white wine, to drink it. Like there’s nothing romantic about that. And yet for the longest time, it was just like I just need to feel better and then I’ll worry about it. I don’t know, it’s a funny lack of… Maybe it is just pure denial, I don’t know.
Yeah. I mean, denial kind of gets a bad rap because of Freud. Freud had some kooky ideas about denial, frankly. I think there’s a lot to love in Freud. He had some interesting insights. I describe this briefly in the book. Freud had a big issue with cocaine himself. He himself as a provider was in such denial about the harm he was causing. This is such a powerful theme that medical providers are blind to the potential harms because they divide up the world into good drugs and bad drugs. And for Freud, cocaine was a good drug, and so he could use it. And he actually used it to treat his friend’s opioid addiction with the result being that the guy started using cocaine and opioids together and then ultimately died from it. But Freud had these wacky ideas about denial.
And so I think a lot of modern medicine is a little hesitant about the notion of denial. But people with lived experience as well as some of the more modern psychological theories recognize that denial’s a real thing and it’s a really complex thing. It can manifest in a lot of different ways in the stories we tell ourselves and the barriers we put up to getting help and the kind of armor we put on to protect this use and this addiction that we think is doing something to help us.
You wrote an editorial recently in The New York Times around the publication of this book, and the headline on the editorial was “It’s Misleading to Call Addiction a Disease.” What did you mean by that? Not surprisingly, there were a lot of letters to the editor taking real issue with what you wrote, including one from one of the former directors of the NIH who called it misleading and polarizing for you to say this isn’t a disease. Why are saying this decades after the AMA classified addiction as a “disease”?
Yeah. It’s a topic that I know is close to a lot of people’s hearts and it’s something that I have tried to approach in a balanced way. That’s why I said that it’s misleading rather than everyone should get in line behind me and my preferred view and nobody should ever say disease. What I was hoping to do was raise a flag about the double edged sword of this notion of disease. I’ve seen it, and I describe in the book about the many ways that people have used this notion of disease in positive ways.
Around that time that the AMA decided to call addiction a disease, that was in part because of the efforts of a woman I profile in the book, Marty Mann – truly pivotal in the early history of Alcoholics Anonymous, but largely forgotten today and I think it’s a shame because she’s such a dynamo and so interesting and saved a lot of lives using the disease concept – forced open the doors of hospital, got insurance coverage. And in a lot of ways, de-stigmatized alcoholism and more broadly addiction through this notion of disease.
I’ve also seen, going back to, say the time of the American Revolution, where the disease notion has been used in harmful ways, where disease has been used to say, like what we were talking about before, that people are faded, like they’re doomed to drink, that there’s something broken about people with addiction and they should be shoved over here separate from the so called normal population. That it can be dehumanizing and fatalistic. And even the notion of disease can be used as a weapon as a justification for treating people with addiction in really horrific ways.
I just think after 200 years of sniping and debating and theorizing about the notion of disease, it’s more trouble than it’s worth. It’s got too many notions kind of glammed onto it that at the very least, what I’m hoping to do is to prompt people to look a little deeper and do what I do in my therapy room. Honestly, if somebody came to me and said, “Oh, I have a disease and therefore da-da-da-da.” I would stop and I would ask, “Oh, what do you mean by that? What does disease mean to you?” I wouldn’t shake my finger in their face and say stop doing it.
I just think that we need to look closely at those different ideas because in some people’s mouths, disease means… Addiction is something that the medical profession should take care of and that we should be compassionate toward, and I have no problem with that idea. But then in other people’s mouths, the notion disease means it’s fundamentally best understood as a totally determined scientific process and people have no choice or freewill, and people have made those claims in the past.
So you’re arguing that it’s what, that it’s a mixture of things that could cause people to suffer from addiction and not just the “disease model” but life factors, trauma. My gosh, you make even a compelling argument for your race and socioeconomic status having a huge… I mean, I personally find that most people I’ve met who are in recovery have suffered a lot of pain of some kind and have tried to self-medicate that pain. That doesn’t seem to follow the “disease model” that I was born an alcoholic and my grandfather and father were alcoholics and therefore I am an alcoholic and there’s nothing I can do about it. There does seem to be a fuzzy ground in there of life experience. It’s sort of like what Dr. Gabor Maté calls the pain. What happened to you was what he asked all his patients.
Don’t ask why the addiction, ask why the pain. I think it’s a good question. Yeah, I don’t even use the word disease model in that New York Times editorial. And it was surprising that so many people came back at me, including Alan Leshner, the former head of NIDA, the National Institute of Drug Abuse, saying he’s against the disease model. And that’s not what I said. I don’t like to use the word disease model because of precisely what you’re saying. That people mean different things by model. And sometimes people say disease model means that biology is relevant, but then there are also a lot of ways that it’s been used to say biology is primary.
And there was a word that was in the American Society of Addiction Medicine’s definition that addiction is a primary disorder of brain, da-da-da-da. And they took that word out, and I think appropriately, because there’s a big difference between saying biology is the best way to understand addiction versus what I believe, which is biology is one of many factors. And in 2022, we don’t have all the answers. So we have to be humble and look across multiple levels and try to make sense of it in a sort of flexible and pragmatic way.
I think it probably touched a nerve because the stigma is still such a huge issue for so many and so many don’t get help because of the stigma. And I think that a lot of people believe that accepting it is… I mean, my gosh, a third of all Americans think that opioid addiction is a moral failing. I mean, that’s a problem and that keeps people from getting help, I mean, it keeps society from doing what it needs to do to provide quality help that people can afford. I mean, it’s an issue. So I’m curious, how do you help your patients struggling with addiction?
The first question is like you were just saying, ask why the pain, and it’s different for different people. I think for too long in addiction treatment, not necessarily in addiction medicine but in a lot of forms of addiction treatment, there’s been a one-size-fits-all treatment system. We just know that that doesn’t work for everyone. It worked for me. I’m really glad it worked for me. A very traditional model rehab saved my life. And now I’m still in abstinence space recovery going to mutual help meetings, still pretty straightforward. But we also know that there are a lot of people who don’t want treatment or who are not willing to sign up for the full-on marathon of abstinence right away.
And so I think a really important question therapeutically and otherwise is, what do we do? How do we meet those people where they are, help them, help support their lives, prevent deaths and hang in there with them as we support them on a road to recovery. I mean, there’s no one way that I help people. I just think one of the key motivating questions that has been missed for too long, again, because of certain historical legacies, is what is this person really looking for and how can I help them today and how can we start to make moves toward recovery so that they can understand recovery and progress toward health?
We’ve heard a lot of people talk about something that falls short of an abstinence-based recovery. There’s that term California Sober, which is I don’t drink but I smoke pot. In fact, the singer Demi Lovato for several months after suffering a very serious drug overdose stayed with California Sober and then went back to rehab and announced again, “Okay, I was wrong, California Sober doesn’t work, for me.” I ask you as a doctor of addiction, is there a middle ground? I mean, are you just helping those people who are reluctant to stop altogether finally get to the end point, which would be abstinence, or is there… As we as a nation grapple with these record setting numbers of substance use disorder and overdoses, is the goal always complete abstinence? Is there a middle ground? There doesn’t seem to be, but is there? I don’t know, you’re the doctor.
There are different middle grounds because I think moderation is a fine goal for almost anybody who’s having trouble with cannabis. I think moderation is a fine goal for most people who are having trouble with tobacco. I don’t think a lot of people would argue with that, at least as a first step. And then the stakes of the game are totally different if somebody has an opioid use disorder with a street supply essentially poisoned with fentanyl right now and the risk of overdose so powerful. One key point is that different substances deserve different considerations.
What about alcohol?
Yeah. Alcohol is the ground over which a lot of these folks fight about definitions, what counts as recovery, what counts as sobriety. On one hand, we have evidence that people can improve their life function even without making major changes in their substance use. And a lot of that data comes from alcohol where people’s lives get better even though they don’t impact the actual number of drinks all that much. And at the same time, alcohol’s a toxin. It’s a poison. I mean, maybe you can drink 2, 3, 4. Not you, Elizabeth, but like maybe someone can drink 2, 3, 4 drinks a night and not have those blackouts or binges or those life destroying consequences. But then 20, 30, 40 years down the line, there’s severe physiological tolls that are taken from that.
For me, the real question in the consulting room when I’m working with a patient is usually not about what counts as this or that. It’s more about intention. I like to support people in recovery as long as they’re bringing an intention into the process, as long as they’re saying, “I’m working to make changes. It’s my intention to improve. It’s my intention to cut down.” Or even, “It’s just my intention to pay attention to this and really take care of this part of myself that is struggling with use.” And in that sense, it’s a bit like the definition of addiction which I encountered comes from 500 years ago was more about an action than it was a status. It was like more something you did, it wasn’t something that happened to you. I think there’s a way we can look at recovery in the same way where it’s more about the action and the intention rather than does this person count, does that person meet the criteria or not?
You end your book with this paragraph. “Addiction 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. If addiction is part of humanity then, it is not a problem to solve. We will not end addiction, but we must find ways of working with it, ways that are sometimes gentle and sometimes vigorous but never war like, because it is futile to wage a war on our own nature.” Carl, thank you so much. Congratulations. The book is The Urge. Carl Erik Fisher, a doctor of addiction, it’s been wonderful to have you. Thank you so much.
It’s been a real pleasure. Thanks for having me.
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