Lambert here: I wish an intellectual history that traced the use of “recovery” in law, economics, and addiction.
By Peter Andrey Smith is a freelance reporter. His stories have been featured in Science, STAT, The New York Times, and WNYC Radiolab. Originally published at Undark.
At age 29, Carl Erik Fisher, a newly minted physician, arrives at Bellevue, the public hospital in Manhattan best known for serving the most challenging cases of mental illness. Only Fisher comes as a patient, and he’s locked in a dual diagnosis ward after a manic episode involving alcohol and Adderall. If you passed him in the hall, you might have pegged him as a “Nurse Jackie” type: the doctor with a drug problem.
Fisher’s meticulous and meticulously researched new book, “The Urge: Our History of Addiction,” is deeply informed by his experience as both a self-described alcoholic and a specialist in addiction medicine. For years after his release from rehab, he was forced to pee in a cup in front of a urine monitor. As Fisher reflects on the surreal, and galling, situation, he begins to wonder about how he — or anyone else — gets better. “I knew that the addiction treatment system was broken, having experienced it firsthand, but the why was mystifying: Why was there a totally separate system for addiction treatment? Why do we treat addiction differently from any other mental disorder?”
“The Urge” ultimately unfolds as far more than an addiction memoir. Arriving at a time when the so-called opioid epidemic has become a defining crisis of our time, it presents both the personal history of someone reckoning with mind-altering substances and an argument for a reframing of the idea of addiction. “It is,” Fisher writes, “the story of an ancient malady that has ruined the lives of untold millions, including not only those of its sufferers but also the lives touching theirs, and yet it is also the story of a messy, complicated, and deeply controversial idea, one that has eluded definition for hundreds of years.”
Among the misconceptions, Fisher writes, is the strangely persistent belief that addiction can somehow be eradicated or fixed. “The primary goal should be not victory or cure,” Fisher writes, “but alleviating harm and helping people to live with and beyond their suffering — in other words, recovery.”
The book’s main text clocks in at just over 300 pages, and it condenses anecdotes and detail into engaging, tightly woven vignettes. In the first chapter, Fisher introduces one of his patients, a woman who resolves not to drink but then gets sick drinking vanilla extract from the corner store. Then, he introduces one of the earliest known references to addiction in the “Rig Veda,” a Sanskrit hymn about a gambler who struggles to quit playing, before moving on to Augustine (the early Christian philosopher), the author’s own magical first sip of beer, and the etymology of addiction.
Fisher places readers into evocative scenes, weaving historical snapshots with his own memories. You almost want to roll down the window and find some fresh air as he describes the experience of inhaling secondhand smoke in his parents’ car as they head to the Jersey shore. That scene follows a pithy account of punishing European tobacco users in the 1600s — an early example of an anti-drug scare that had xenophobic undertones and practically no connection to the actual medical harm. Scaring people straight didn’t stop addiction then — or now, for that matter. Indeed, Fisher notes, under the 17th-century Ottoman ruler Murad IV, the punishment of death didn’t stop soldiers from smuggling pipes in their sleeves to sneak a puff.
Fisher, now a practicing clinical psychiatrist and a professor at Columbia University, relies on a range of previous scholarship. He’s not interviewing researchers or sifting through archives to uncover some lost history. But, in retelling some of the more familiar stories involving drugs, including Thomas De Quincey (Romantic writer, and a requisite feature in practically any book on opium), Benjamin Rush (a founding father and among the first to characterize addiction as a disease), Alcoholics Anonymous, Narco (the sprawling prison hospital and treatment center in Kentucky), and Synanon (a cult-like group that laid the exploitative framework for drug rehabs), Fisher turns to sources both obvious and obscure.
The writing is brisk without being breezy, and Fisher draws fresh insights, particularly when it comes to alcohol. For instance, he describes Samson Occom, a Mohegan preacher, as “far ahead of his time,” for linking alcohol with the oppression of Native Americans in the 18th century. Pairing abstinence and mutual aid, many Native American leaders at that time emphasized community healing — principles that predate AA and today’s peer-mediated support groups. The look back also helps Fisher understand his own family’s addictions. Later, when he’s coerced into rehab and forced into a feedback session, he comes to appreciate the concept underlying these groups: a shared fellowship and support from people who understood addiction because they too experienced it firsthand.
At times, “The Urge” can seem almost too concerned with nuance. Fisher explains that he’s avoided stigmatizing language, such as “addict” and “junkie.” He dismantles commonly used terms like “non-medical,” which place “recreational” drug use outside of medically sanctioned contexts. (Fisher argues that the definition is historically misguided since “the instrumental use of intoxication long predates modern medicine.”)
Taken as a whole, these critical points reinforce his central argument, which builds off the growing consensus that addiction does not stem from a moral failing, and that it is more than simply, or primarily, a brain disease. Fisher redefines addiction as more than a substance acting on the brain. Narrowly defining addiction as a disease, or a discrete biological phenomenon, he writes, fails to encompass its multidimensional aspects (e.g. spiritual and psychosocial). The therapeutic response, he continues, fails to appreciate recovery as “a process of ongoing positive change,” not just the absence of pathology. More importantly, he argues, “Drug use is not synonymous with addiction, and criminalization is not a rational way to reduce drug harms. In fact, it is often a central driver of those harms.”
The argument is persuasive. Despite a catastrophically failed war on drugs, the U.S. has primarily operated in punitive mode. It does not need to be this way: Drug use does not have to be so deadly. While some may see treatment as a step in the right direction, Fisher argues that the therapeutic approach takes the focus away from the oppressive forces of racial injustice and mass incarceration, which shaped the system treating people with addiction. (It’s not entirely clear how such a reframing and redefinition of addiction would play out, but Fisher says he would prioritize policies and approaches that recognize drug use and addiction as facts of life, focusing on practices that reduce harm.)
A sprawling history of a concept, spanning decades of prohibitionist thinking and the latest in recovery research, could easily fall apart were it not informed by Fisher’s experience. I won’t say too much about what happens inside his fifth-floor walkup in New York after he checks himself out of the hospital the first time — against medical advice. It is shocking, but sadly not surprising. Later, Fisher recognizes that his punishment at the time was not the norm: As a clinician, he sees how people caught in the criminal legal system are denied lifesaving medication, and realizes he could have ended up incarcerated, or shot dead, had he not been “a white guy living in an upscale Manhattan neighborhood.”
Ultimately, the takeaway isn’t so much prescriptive policy advice (though there’s some of that), or practical tools to narrow the gap between people who want help and — in the lingo of harm reductionists — responses that meet them wherever they’re at.
And maybe that’s the best part about “The Urge.” Fisher doesn’t pretend to have the solution to addiction, a way of being that, in his telling, has always existed as an ordinary response to human suffering and “a desire to break free.” He’s rigorous without sounding preachy. He doesn’t drink, yet acknowledges that abstinence is not for everyone.
In one telling section, Fisher says he poured over the scientific literature on addiction — despite admonitions from authorities. “The counselors in rehab had warned me that it could be dangerous to look too closely at the science of addiction — they said my disease could twist that information into a basis for denial — but I still felt drawn to learn more,” he writes. “I wanted to see how the research could help me understand who I was and who I might become.”
If his account seems to urge readers towards anything, it’s the one thing most sorely lacking in the discourse around drugs: curiosity.
I’m not sure that one can assert this: “he describes Samson Occom, a Mohegan preacher, as “far ahead of his time,” for linking alcohol with the oppression of Native Americans in the 18th century. Pairing abstinence and mutual aid, many Native American leaders at that time emphasized community healing — principles that predate AA and today’s peer-mediated support groups.”
And then assert that addiction is a brain disease. I suspect that Native American peoples would point out that Native Americans aren’t suffering from brain disease at all.
If anything, and ironically, what this book is about and what the author of the review is describing is something socially constructed. The concept of addiction is socially constructed, just as Americans’s attitudes about alcohol are socially constructed.
As people have pointed out, in Mediterranean Europe, public drunkenness is frowned upon (social low approval), which results in lower rates of alcoholism. This appears to be the especially the case in Spain and Italy (and Greece and Cyprus).
Binge drinking, which is socially acceptable and endemic in the US of A, is part of the reason for the enormous problems with alcohol.
And many of the “recovery” movements are dominated by religious ideas or puritanism or both. Think of the religiously sponsored disaster of Prohibition (and the two useless amendments stuck in the U.S. Constitution). So “recovery” (which smacks of “redemption,” another flexible U.S. concept) isn’t even truly their main business.
There is more going on here than diagnoses, punishment, and “recovery”.
Would that people got the help they need–but that would require recognizing that Bernie Sanders and his class approach to problems are the compromise position on how to redress these griefs and grievances.
USA drug policy is seriously warped– that’s a given– and shaped by scolds and moralists fixated on the “could happens” of their dark and limited imaginations, and guided by their determination to control or use others for their own selfish ends.
In no way denying addiction as a health or mental health condition, I see mandated treatments reinforcing addiction more often than not, with many so-called treatments being little more than money-chasing scams.
Our current models that address drug misuse and addictions need to be broken-up and, where needed, treatments applied at an individual level and not in some cookie-cutter, one-size-fits-all manor– something almost only available for the “well-to-do” right now.
And we seriously need more, legitimate opportunities in capitalism for current practioners and employees of street-level pharmacology, opportunities attractive enough to provide real alternatives to illicit trade.
These are just my observations from a decade of professional experience in these fields (not drug-dealer, although I’m sure that could be quite exciting). I see too many vested interests in our current systems to expect that a turn towards humane and rational treatments of substance-use disorders could happen at more than a glacial pace.
One more thing to add before I shut up on this issue: many of the programs that we used (back when I was loading prisoners onto trains) seemed to make as much sense as shouting to a person who’s trapped on a ledge, “Don’t think about FALLING!”
most people are “using” drugs the way most people “use” alcohol.
in my experience, those who tip over into abuse have one or more problems in their lives and they are using the drug(s) to cope with those. emotional, social, financial, whathaveyou.
and i saw more drug scenes than you can watch on Breaking Bad in my living room every day before the age of 9. i was essentially the waitress for those people purchasing drugs from my parents on their way to concerts and parties on the weekends. my life was spent serving coffee, cleaning up beer bottles and cigarettes, and running the entire rest of the household because the parents were too busy with their home-based business, and too strung out when they weren’t.
generally a “good” drug dealer doesn’t deal to outright addicts or keeps them under strict control. that is, until the dealer succumbs to their own product.
throughout my life, my mother was an addict of various things. her main problems were a father who had molested her and beaten and abused the family, and then carrying out her life as though that was what one had to expect normally from men. so she was “coping” with drugs and alcohol from being abused by men. and then was also coping from the shame and stigma of not only continuing to be beaten and abused, but also now a drug addict. otherwise, she was a kind and intelligent person with a high moral code (at least about non-male abuse issues) who taught herself music and music theory, electronic repair, and quite a few other things during her shortened lifespan.
i believe the social aspect of being “labelled” a drug addict is what causes some of the largest damage, as normal people withdraw from those so labelled until they “straighten up”, and that leaves whom to socialize with? other addicts that normalize such behaviors. and this is simply repeating what social science appears to understand about labelling people—they adapt to those roles and take them on. it is the old logic of “if i’m being punished for the crime already, i might as well take on that behavior and enjoy what i’m being punished for. that’s all people see me as anyway, and i can’t convince them otherwise”.
Thank you for this insightful comment. My heart goes out to you — I’m grateful that you can share your experiences with us.
So much of the compulsive behavior that manifests as addiction can be traced to coping with traumatic experiences like those your mother endured as a child. The flip-side is that one can have a childhood picking up beer bottles and cigarette butts in a dope house and become an empathetic adult who can take or leave the objects of others’ compulsions.
The Kaiser-Permanente/CDC ACE studies from the mid-90’s (recently updated) identified the interplay of Adverse Childhood Experiences (ACE) with adult outcomes — especially addictions. Shaming and criminalization often amplify these compulsive behaviors (but not always; we’re unique individuals with unique experiences).
Nicotine, Dexadrine (Obetrol “diet pills” later reformulated as Adderall), and alcohol fueled the great artistic flowering of the 1960’s. They also shortened the lives of many of those artists and led to a lot of negative behavior by people who mistook getting high for having talent. We should be focused on “supply” because we will never be able to address “demand.”
The impact and resulting consequences on spouses, and families (on going decades) for latter stage addiction(s) is grievously dark (especially should a close reliant
member be disabled).
Abusive vulgarity, violent overtures, duplicity and deception are commonplace, often to redirect narratives and form alliances.
There is no silver bullet for cause but yes, many points in one’s childhood development formulate a precariat that drives social anxieties along with the spirit’s industry marketing solutions.
Much empathy for those enduring.
I am curious if the book doesn’t explore the idea of addiction as self-medication. That is, not a disease but an attempted treatment for other diseases. Even moreso since the author has bipolar disorder (manic episode).
Thank you, Lambert, for posting this impressively well-written review of what sounds like an interesting read.
I first heard about Naltrexone in this critique of AA’s abstinence model:
Not sure why it isn’t a commonplace.
I’m not sure what Lambert is driving at with his opening sentence but I agree that the word recovery is strikingly confusing.
“The primary goal should be not victory or cure but alleviating harm and helping people to live with and beyond their suffering — in other words, recovery.”
If the sentence had ended right after the first and, I’d have agreed. But the rest of the sentence seems to define the criteria of victory/cure and to name it recovery. These criteria of recovery seem uncontroversial in our current practice that I and it seems both authors in this piece agree is broken.
In a recent article on NC the idea of harm reduction as the goal of institutional intervention in addiction was discussed, and the radical part of that proposal appeared to be the leaving it there and insisting that we don’t define criteria for an end state of recovery. I can go along with that since our modern methods of management establish measurable goals, i.e. metrics, and then to pursue them to perversity. If we add recovery metrics to the harm reduction as goals then we’ll likely end up using them to justify not reducing harm.
Read that same long form and this was one of my impressions. Read this post to see if there was more to the Doctor’s view. Not seeing it.
This looks well worth a read.
I have more than a passing acquaintance with alcoholism and addiction having grownup with an alcoholic father.
I have lost people I cared about to a variety of addictions, seen others come out the other side and recover and did volunteer work in the jail system for 17 years where I met and dealt with many hundreds of addicts and alcoholics.
Most of those I met started using because they had no better way to cope with a brutal and seemingly hopeless reality.
Which was a realistic appreciation of their situation in most cases.
The “War on Drugs” and the way addicts are treated in the USA is all about the money and the joy of abusing the helpless.
Punishment never works, 12 step and other treatment programs do,sometimes.
Create a more equitable and less abusive society and all forms of addiction.would decline, which is not going to happen here in the USA/
The benefits of keeping the rabble in line and the amount of $ involved are simply too sweet..
A huge problem is that insurance companies, thorough their managed care units, parcel the number of treatment sessions with the aim of quickly transitioning from treatment to AA and similar type groups.
meat of nut: “prioritize policies and approaches that recognize drug use and addiction as facts of life, focusing on practices that reduce harm.”
way back when i was a pariah and a folk devil(ages 16-25, especially after 18, when i helped that girl)…i overcompensated for the bewildering circumstances i found myself in by drinking like a fish.
there was nothing i could do to fix the problem…except evacuate…but i hadn’t the resources, so when i went on the road, i was the homeless crazy guy in a van by the river, with predictable response by leo’s wherever i went.
the numerous interactions with leo’s(and the folk devil mythology they operated under) led to forced AA…which i found intolerable and overly religious.
wallowing in failure, without ever acknowledging the circumstances, etc….as well as the ubiquitous nonsense like how weed = booze = heroin….but chainsmoking is fine(what do they do now, now that tobacco is the new devil’s weed?)…and shitty coffee at 7 pm by the gallon is cool as well.
i finally got a handle on the problem by removing myself entirely from the region…dropping off the grid in a big way(my name not used for anything, etc)..and endeavoring to avoid Imperial Entanglements as much as possible.
that, and recognising that the alcohol wasn’t the root, but a symptom of something else.
it was how i learned to deal with extreme and intractable stress…remove the hyperstress, and everything’s cool.
i also applied the psychology put forward by Neitszche: Appolonian/Dionysian…that both are within us all, and both require expression(echoes of Jung, here, too)
so i limit my drunken excess to(ideally, twice a week, and only in controlled circumstances= wilderness bar, or back on the Mountain)
i admit that the last year(or4) haven’t made this easy,lol…since wife’s cancer…then pandemic, dad, then stepdad’s deaths…and my mom’s descent into a more overt narcissistic psychosis…i do drink more than i should, or want to…
but it’s the hyperstress.
not the alcohol.
the alcohol is the palliative for the overwhelming stressors…a bad one, to be sure…but it’s what i got.
i want nothing more to get back into a routine…a groove where i’m a yeoman farmer philosopher guy who rarely goes to town(and never goes to the city)…until then, it’s the held breath and the grit teeth(bruxist tenacity).
the one size fits all methodology…and the total dismissal of personal circumstances…as well as the almost religious orthodoxy regarding what addiction is and why it happens…are counterproductive and ultimately harmful in themselves.
for instance, what would the picture be like if we enjoyed universal, comprehensive healthcare…including mental health?
what if we used a humanist approach…recognising the humanity of those so afflicted, instead of making numerous assumptions and sticking to them no matter what?
for all the hooplah about “evidence based medicine”..it doesn’t appear to have been applied much in his field…they’re still telling kids in public schools that pot is a gateway drug…and DARE makes regular appearances at the elementary school to encourage flipping on yer folks.
the one good thing i took from AA was HALT…avoid getting Hungry, Angry, Lonely or Tired. of course, it’s only the first 2 that i have any control over,lol.
I derive better results from the words inscribed at Delphi…things like “all things in moderation”, and “know thyself”.
extemporaneous rant, off.
Thank you, Amfortas, for sharing that.
Hey Amfortas, sending you some love and light. My dear husband passed away last July after five years fighting stage IV cancer. Cannabis and alcohol were necessary medicines for me during that time of “hyperstress.” I wish I’d had better ways to deal but we use what we can get. When I came home from hospice after he’d left his body I put away all the intoxicants b/c I knew if I started I might not be able to stop and I wouldn’t last long. I found a tea that I used every night that both helped with cravings and gave my head some space. It’s Yogi brand and called “relaxed mind.” Since then I can use a bit of herb but alcohol has lost its appeal completely. I also found an ssri that helps a lot.
You have waaaaay more commitments than I do now, but please do remember to be gentle with yourself. Your body and spirit are fighting a battle equal to your wife’s.
May you both stay strong and love each other every minute of every day. Don’t forget to talk about the hard stuff, once we leave this life it’s too late. Blessings to you both, dear Brother and Sister.
Thanks for this post, Lambert. I now have a new methodology: curiosity. But I’ll never turn my back on humor. If it isn’t funny, it isn’t real (in my alleged mind). Not that I’m a serious addict… but certainly a moderate one. My biggest barrier to getting obliterated on a daily basis is that I just don’t like being that physically sick – I do enjoy good health and fresh air and etc. So that’s one thing I’d add to a protocol for happiness: enjoy (and protect) yourself and this miraculous planet. And the people you love. And don’t forget to tell them you love them. In addition to good clean legal recreational drugs we need the things that balance us out. I agree with some of the comments above. Especially the one about profiteering on misery. That’s the thing we need to eradicate. I just googled ayahuasca – it’s close to being as legal as booze. And they now have (even here in Utah!) Ayahuasca Retreats. For $500/weekend you can attend. I gotta admit I’m curious ;-)
i ate a sugar cube laced with DMT(the thing that makes Ayajuasca/Yage work)…made by my college chemistry lab guy buddy…and it was the most profound 4 hours of my life(i know i’ve mentioned it, here, before).
i can definitely see the therapeutic potential in such things(and i have a lot of experience with the sorts of mushrooms that grow in cow patties)…but i question the qualifications of the “Guides” at those “retreats”.
i mean, i’m a natural guide..and routinely fell into that role during my late adolescence all the way through my Wild Years…never lost a “patient”.
but i don’t think that’s something you can really teach…at least not in the way that teaching is, today, regarding Therapists.
such guiding is inherently ad hoc…and to not screw it up badly, you must have some hard core principles…so that they’re an automatic bedrock.
without that, you…the guide…are just as adrift as the “patient”(see: the words are all wrong for this)
with all that said, i find that i am against monetising shamanism in this way…it can’t be quantified reliably enough to intersect with the Borg.
The problem, or at least one big problem among others, is guys with guns have carved out for themselves a vested financial interest in that punitive system, via the policy of asset forfeiture and the existence of for-profit prisons and are not going to simply agree to give it up after the folly of this policy is revealed, or widely accepted even by most of the American people.
It’s been common knowlege for 60 years that cigarettes cause lung cancer and are addictive. Same with Meth as instantly addictive. Same with heroin.
Anyone who starts of these drugs is as much a victim as one who jumps off a building and ends up a cripple. Now, as to people addicted thanks to doctors prescribing Oxy etc, they are victims.
When do the Sacklers get the federal death penalty?
It is not “common knowledge for 60 years” re cigarettes causing cancer:
Make it 50 years. There was a big shift in collective opinion in the 1960s.
But Calvin, we are the exception to the rule.
It certainly is the criminalization of drugs that causes far more harm than what we describe as ‘addiction’, IMHO.
I once wrote an article on Mexico entitled ‘Mexico: A gated economy powered by NAFTA’ (https://lab.org.uk/mexico-a-gated-economy-powered-by-nafta/) in which I pointed out that the Mexican industry that had done by far the best from NAFTA was the drug trade.
Multiple unchecked lorries crossing the frontier, accelerated passage of workers/tourists (=mules), massive growth in business areas each side of the border for storage and transport, etc. etc.
Criminalization of drugs makes them massively profitable and puts their control well outside official regulation, since imprisoning a whole bunch of addicts constitutes no control at all and a massive cost to society.