'The Urge' says calling addiction a disease is misleading

Just after graduating from medical school, Carl Erik Fisher was on top of the world. He was winning awards and working day and night. But a lot of that frantic activity was really covering up his problems with addiction.

Fisher – who says he comes from a family with a history of addiction – descended into an alcohol and Adderall binge during residency. A manic episode led to his admission to the Bellevue Hospital Psychiatry ward in New York, where just years ago, he'd interviewed for residency.

"Because I was a doctor, because I'm white, because when the NYPD came to get me out of my apartment I was living in an upscale neighborhood —I got a lot of treatment and I got a lot of compassion," he says. "Sadly, many people with addiction can't even access services, let alone the kind of quality of services I was able to get."

Today, Fisher is in recovery and an assistant professor of clinical psychiatry at Columbia University. His new book The Urge: Our History of Addiction – part memoir, part history – looks at the importance of careful language when talking about addiction, and how treatment has historically ignored its complex socio-cultural influences.

Interview Highlights

On why it matters whether addiction is considered a disease

I think addiction is not a disease. To call it a disease is misleading. Now, I say that with the understanding that for some people, the word "disease" is really powerful and liberating. It [can] provide an organizing framework for making sense of their struggles and a feeling of safety. And I would never want to police an individual's understanding of the word. But on balance, when we look at it as a socio-cultural phenomenon, I think the notion of disease can be misleading because it takes focus away from the forces of racism and other forms of oppression that are so often bound up in addiction. Initially, the word disease was introduced to try to force open the doors of hospitals and otherwise get medical treatment for people with addiction. That's because the medical profession has largely abandoned its duty to take care of people with addiction. So those advocacy efforts were absolutely necessary. But people still struggle with getting access to care. People still struggle with stigma. People still struggle to get insurance benefits for problems with addiction. There is a useful version of the word "disease" when talking about addiction that says therapy and medications can save lives. But the term is messy, and it also locates all of the causes in biology and overlooks some of the other determinants of people's health.

On how racism has historically influenced addiction treatment

For centuries, people have tried to divide folks according to good drugs and bad drugs, to say that certain drugs are dangerous, they're infectious, or that they lead inexorably to vices and social problems. Often that kind of stark exaggeration of the harms of one drug and the supposed benefits of other drugs rebounds to hurt everybody. A great example from the turn of the 20th century: there were all of these powerful efforts to criminalize certain drugs because they were associated with certain racist and xenophobic panics, like the panics associated with Chinese opium use or with Black cocaine use. Even just the urban poor was a major development around that time and an association with heroin drove a lot of those attitudes. At the same time, a sort of entitlement allowed the continued use of certain drugs. At first, things like morphine and more tightly regulated opioids and then later stimulants, which were only shortly thereafter invented. And white people and privileged people were harmed by those sorts of entitlements, too. So, drugs are such a powerful example of how racism rebounds to hurt all of us that whenever we create those sorts of separations and to try to assign the good and bad categories to different forms of drugs, we invariably wind up causing widespread harm.

On how the medical model should change to get more people into recovery

One simple pivot we could do is to shift our focus away from controlling people's use to meeting people where they are and helping them with what matters most in their life. For too long, medicine has been dominated by an abstinence-only model. Now, I myself am in an abstinence model. I don't think I should drink or use again. And for many people, that's necessary and lifesaving. But addiction is also profoundly diverse, and we have emerging evidence that there are some folks who can really improve their functioning even when they have a substance problem without totally cutting out use. Or they could be in a sort of partial abstinence when they stop using heroin. I don't think that it's wise to be cavalier about drug use, especially if somebody has had a problem before. But there are a lot of people who don't want treatment because their current treatment system is really domineering. For example, it's a crisis that people are discharged from treatment because of continued use. One definition of addiction is continued use despite negative consequences. So, I think it's imperative that as medical professionals, we work harder to work with people where they are while also recognizing the profound dangers of addiction.

On the approach he uses with his own patients

The bottom line in working with my own patients is — they're in charge. The main insight that looking at the history and looking at the science behind addiction recovery has given me is a respect for the many different pathways there are for recovery. That's something I felt myself — I had a lot of shame around thinking I wasn't recovering in the right way or thinking that I could be doing a better job. And I think a lot of people carry that shame. That if they're not doing recovery in the traditional sense, then maybe it's not as good. And you know, I think that can be a real distraction and unnecessary because there are lots of opportunities to grow and improve and to work toward resolving the kinds of severe substance problems that we're working with.

This story was edited for radio by Jeevika Verma and Reena Advani and was adapted for the web by Jeevika Verma and Barbara Campbell.

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