“The Urge”: Psychiatrist On Addiction, Past and Present

Addiction is a terrifying breakdown of reason. People struggling with addiction 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. Carl Erik Fisher, The Urge

Addiction psychiatrist Carl Erik Fisher knows firsthand the topic of his new book, The Urge: Our History of Addiction. Not only did he come from a family with a history of addiction he once had a dependence on alcohol and Adderall. Unlike many with less privileged backgrounds, he points out, he was able to get the right kind of help.

Fisher doesn’t subscribe to the binary controversy over whether addiction is either 1) a choice or 2) a compulsion because he’s seen many struggle in an in-between state.  From a book excerpt in The Guardian:

By claiming that addictive behaviours are simply a kind of choice, people have justified punitive measures for centuries, from putting drunkards in the stocks to imprisoning people for drug possession. If their drug use is a free choice like any other, the argument goes, people should accept responsibility for their behaviour, including punishment. The opposite view, which these days is commonly presented as a compassionate counter-argument by neuroscientists and advocates, is that addictive behaviours are involuntary and uncontrollable compulsions, and thus people with addiction deserve compassion and treatment, rather than punishment.

Among other faults he finds with addiction care is the disease model and the related medical model of treatment. Jeevika Verma, NPR, interviewed Fisher, who stated the following:

…(T)he 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 had 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…

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.

How does the author of The Urge treat his own patients? “The bottom line…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.”

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