HEFFNER: I am Alexander Heffner, your host on The Open Mind.

I'm delighted to welcome our guest today, assistant Professor of Clinical Psychiatry at Columbia University, and author of The Urge: Our History of Addiction, Carl Eric Fisher.

Dr. Fisher, a pleasure to see you today.

FISHER: Likewise.

Thanks for having me.

HEFFNER: Dr. Fisher, what was the impetus in driving this research and this book project?

FISHER: Well, it was the book I wanted to read but couldn't find.

It's really what I needed for myself.

When I was a psychiatry resident getting training in psychiatry after medical school, I had a moment where I thought I was on top of the world and working toward an academic career, but I also was having significant problems with alcohol, and then later stimulants such as Adderall and cocaine, and I got into recovery, and we can talk about how that happened and what it was like to be a doctor in recovery.

There are certain things that I benefited from because of my privilege and otherwise.

But the upshot was about a year or two, despite learning about the science of addiction and studying the clinic, the clinical practice related to addiction, I still had this question in me of what exactly had happened to me.

I still didn't understand exactly how to make sense of addiction in my own life.

And, yeah, like I mentioned, the science is fantastic.

I still draw on the science and the best clinical thinking that we have today, but it wasn't answering the questions I had about the fundamental nature or how do I make sense of this identity, but I noticed that people who were focused on those topics kept on referring to history and the intellectual and the cultural history of addiction.

And that's what, that's what led me to the book.

HEFFNER: The void you're talking about was a chronology or anthology documenting the history of addiction, our understanding of the science of addiction, or the stories of addiction, or a combination of the two?

FISHER: It's a good question because it's a limitless topic.

I initially set off, and I'll admit this openly I wanted to write the definitive book on addiction.

I thought maybe if I pulled in enough other disciplines and I studied not only the science and the most recent studies that I could also incorporate history and philosophy and anthropology and culture, then maybe I could come to some sort of definitive answer.

And again, that's what I wanted for myself.

I was having difficulty making sense of myself as an addicted person like my parents were.

And so I had to change that view.

I really benefited from the process of investigating, looking for that ideal, because it helped me to let go of that kind of certainty.

It helped me to it helped me to let go of the notion that I would land on one clear, simple, easy answer.

But yeah, what I was looking for was something synthetic across time and place, and that that's what led to such a sweeping treatment.

That's why I start with the ancient Greeks and the ancient Romans, and even earlier, back to the South Asian Indian Rigveda to find examples of not only thinkers and clinicians over history, but also people who have struggled with addiction and found their own version of recovery throughout history.

HEFFNER: What are the common lines, the commonality from the way the ancient Greeks dealt with the problem to the way we're dealing with it today?

Is it more similar or dissimilar?

FISHER: They didn't have modern medicine there, so I would have to say off the top of my head, it's definitely dissimilar the systems and the structures and, you know, just the ways that people who are struggling get treated.

The first thing that was really helpful for me is even prior to that question, which is just seeing the commonalities between the individuals who are struggling.

Because there is a notion in academia that addiction is somehow a modern malady.

Maybe it's a product of industrialization or a product of these new drugs that we have.

And it was reassuring and in a way helped me with my own shame and feelings of uniqueness to see people like ancient Chinese scholars, or you know, people from even before the Common Era who had struggled in a way that was immediately identifiable to me.

And so that's the most important commonality to me.

The ways that societies and cultures have responded to addiction have changed dramatically throughout history.

They've gone through different cycles sometimes focusing on prohibition and policing, sometimes focused on more of a bottom up grassroots, mutual help response.

And, and there are other cycles that we can talk about.

There's some regularity, there's some rhyming there in a way.

But the most common element is just the immediate human reality of addiction itself.

HEFFNER: But necessarily the empathy with which people view those who are addicted or not.

If you look at the through line from the ancient civilizations to today, how has the idea of empathy evolved over that period?

FISHER: The empathy is intimately related with the question, what do we think the problem is?

And that's why I was interested in this core question, what is addiction?

What is going on?

And a view that I think has created a much more empathetic set of responses over time, and that has waxed and waned and, and, and frankly we're a little deficient in these days, is, is the idea that addiction is universal, that addiction is something in all of us.

That's the way it first entered the English language around the time of Shakespeare.

And that's the way it was most commonly described.

It, it goes all the way back to the oldest philosophical traditions that we can trace.

It was this central preoccupation of Aristotle, for example.

Aristotle was very curious about this, this breakdown in will about what is sometimes translated as weakness of the will, akrasia, but is also sometimes translated as incontinence, which I think is very evocative too.

It's this notion that many of us will struggle with self-control and sometimes find ourselves doing the thing that we know not to be good, and not just good in some sort of moralistic, top-down definition, but also good in the sense that my heart yearns for this.

That this is what I truly want with all my being.

And still, I find myself acting against those desires and watching myself walk to the corner store to relapse on alcohol or watch myself calling my dealer.

That's pronounced in addiction.

That's extremely important in severe cases of addiction.

But it's I think something common to the human experience.

And when we adopt that viewpoint that it's nothing special, it's a universal, in fact, that naturally leads to more connection and empathy and care.

HEFFNER: I think also the redefinition of addiction as a malady as something that is a medical problem and not something for which you ostracize someone as subhuman that, that has shifted the dial.

FISHER: It depends on how that definition is crafted in medicine and otherwise.

And the, the, the narratives that we shape about addiction, it can just as easily fit into some old stigmatized discourse, meaning there are ways that a sort of disease language around addiction, for example, has been very helpful, has been very destigmatizing, and has opened the doors to hospitals, for example, when they didn't even allow people with alcoholism as patients in, say, the 1940s, 1950s.

But it's a double-edged sword.

And sometimes a, an overly reductionistic and deterministic definition of addiction from the medical view or from the science viewer, otherwise actually cuts in the opposite direction.

And it can be very stigmatizing.

Sometimes the, the idea of addiction as a malady or an illness or a disorder is, is oversimplified to mean someone is faded to use or they have no control, or they're destined to develop in this way.

And those types of cartoonish portrayals are really harmful.

They're really harmful because they're just not true.

HEFFNER: In your own journey that you referenced, you said there was a unique lens as a practitioner of medicine or an aspiring practitioner of medicine.

How can you describe that and suffering through addiction and overcoming addiction as a medical practitioner yourself?

FISHER: Well, there are wonderful aspects of being a physician and recovering from addiction that I mentioned before.

I got incredibly compassionate treatment.

And in a way, if what happened to doctors was used as a model for the rest of the country, and for other folks that struggle with addiction, it would be a tremendous benefit.

I was met with coercion in the true philosophical sense of having a hard choice.

The hard choice I had was if I wanted to practice as a physician, then I had to go to treatment.

It, it wasn't coercion in the sense of harsh confrontation or tough love or all the rest.

And in some studies, 70% of people who are entering addiction treatment or looking for are subject to some sort of coercion.

They, a lot of people with addiction, this is, I think, obvious on a first pass, if you think of the, the most common examples, people don't want treatment.

A lot of people don't want treatment.

Some people do, and they should have treatment available to them.

But as I was developing as a physician, I also saw some of the structural stigma that is involved.

For example, you know, through no fault of the individuals and the supervisors and the people who were involved, but the clinic that I was training in excluded people with substance use disorders when I was continuing my psychiatric training at Columbia.

People who were much less severe than I was when I started off in that training program.

And that's just a function of the way we have this artificial boundary between addiction care and the so-called rest of care.

HEFFNER: To your point, we all have vices, and we can be addicted to Oreos or Chips Ahoy!, and therefore we buy fleetingly packages of such cookies.

My myself, case in point and look, if I were buying Oreos, every grocery order, every time I went to the market, there would be a societal blow.

And it could cause heart disease or obesity or any number of conditions that are not as acute in the moment as a someone who is addicted to a drug that is not Oreos.

How acute is the problem of addiction in the, in the sense of alcoholism, in the sense of hard drugs?

We have been told for the last decade or so that opioids are the forefront of the American addiction crisis, and that there, there is a significant population of opioid-addicted people in every city and every county, and every town in this country.

But I'm interested in your perspective on the landscape of how acute the problem here is in 2023.

FISHER: I'm so glad you mentioned alcohol, actually, because that's what gets missed.

And we are living through a historic overdose epidemic.

It's incredibly important, and we have not yet met the challenge.

There are many simple things that we could do to confront the opioid epidemic, which is not even an opioid epidemic anymore.

The favored term now is overdose epidemic, because stimulants such as methamphetamine are such a crucial feature of it now.

And the numbers are very bad.

It's over 100,000 deaths yearly for the overdose epidemic, but alcohol is more than that.

Well more.

More on the order of, say, 140,000 deaths a year from alcohol related causes.

And alcohol gets a pass because we consider it a good drug or a socially normal drug.

And it is still a drug, and it's a powerful drug that has a profound role in things like domestic violence and motor vehicle accidents as well.

So we're not in good shape.

The, the short answer to your question is that things have been quite bad.

I don't think I need to even say that things have been quite bad regarding the overdose epidemic.

It's been accelerating, accelerating, accelerating, and the alcohol problems have been accelerating as well.

There was already pre-pandemic a big increase in alcohol related-deaths from, say, like the two thousands, so the 2010s, and then during the pandemic a massive rise in alcohol-related deaths, alcohol-related liver disease, all the rest.

So I believe very strongly in medicine, we urgently need more medical care for the problems of addiction and for substance use disorders overall, because there can be mild to moderate cases too.

But we need a fully holistic response too, meaning it's not just up to the medical profession.

It needs to be a full court press across many different domains of how we respond to these crises HEFFNER: To take more precise ownership of the numbers.

You're saying 140,000 alcohol related-deaths in the most recently recorded year, roughly?

FISHER: Yeah, that's right.

Roughly.

HEFFNER: And so that accounts obviously for people's long trajectory with alcoholism as well as fatal instances.

So liver disease that devolved over time.

And if you were to characterize quantitatively the impact of non-alcohol addiction, what are those numbers?

As you said, opioid is not just opioid, you can get hooked on anything from opioid.

It then becomes gateway to anything else.

But if that's a separate category of let's say opioid or gateway drugs, what kind of numbers are we looking at in terms of deaths or hospitalizations in the past year or whatever the last year was recorded?

FISHER: I don't have hard numbers, say, for example, the entire world of other drugs.

But what I would say is the most dangerous drug that we face is tobacco, or more specifically nicotine.

That's the highest rate of drug-related deaths.

And people that struggle terribly with nicotine addiction, people go to nicotine anonymous, take any number of over the counter or prescribed pills.

I see you like the stats, and I like the stats too.

It paints an important picture.

I think the other crucial stat that tends to get overlooked is just the number of people who are struggling with substance use disorders overall.

The death rate is terrible.

It's been growing immediately and, you know, of course, when somebody's dead, they can't recover.

And so it's absolutely necessary to work on stopping deaths.

But all told the, the yearly prevalence of substance use disorders in the states is like 40 million.

So when you consider the rates of people in terms of the impact on their lives, just the hiding and the shame and the consequences and the way it affects families and other individuals, I think even the death rate stats are a little misleading.

They kind of make us think that it's a severe and sort of rarefied problem only affecting the most severely affected, but in fact, it's cutting across a huge swath of the population.

HEFFNER: I was asking about mortality.

You're bringing up substance abuse broadly and saying that there could be in the ballpark of 40 million cases of substance abuse in a given year in America.

FISHER: Yeah, I would say substance use problems.

Because again we shouldn't just associate substance use problems with addiction.

You know, one of the things that I trace through especially the history of people's individual recovery stories, but also some of the philosophical conceptions of addiction is we don't diagnose people with addiction as psychiatrists.

We diagnose them with substance use disorders.

And part of the reason we do that is that's something observable from the outside.

We can say, this person is having severe consequences that we can see that they're trying to cut down, but they're unable.

Addiction traditionally is something more internal.

It's more about someone subjective experience, a powerlessness of the sense that I'm out of control.

There are some extreme cases youlook from the outside and you say, this person probably is suffering from addiction.

But I really think it's an identity.

I really think it's something that people recognize for themselves.

And again, we shouldn't focus on addiction to the exclusion of the whole range of mild to moderate substance use problems.

That's what one group of alcohol researchers called the underserved majority, because it's such a bigger portion than say, people with extreme severe addictions.

HEFFNER: Looking at the stories of rehabilitation from your book, and broadly, as someone who has the experience to guide the policy approach, how do we overcome the tropes and cliches about rehabilitation?

FISHER: There's a lot there.

How do we overcome in policy?

The most important thing about policy I think is to avoid the search for quick fixes.

I don't think that we'll see the end of addiction per se.

There's no solution to addiction.

There's no cure for addiction.

If what I said earlier is true, and it's something universal to humankind, if it's just something that exists on more of a spectrum, then say, for example, some neatly boundaried condition where some people are normal and some people are sick.

If all of that is true then we'll always have addiction as a part of us.

And that cultures will evolve to create more addictive substances, new synthetic drugs new forms of information, technology, et cetera.

And so abandoning the search for some sort of solution or quick fix is in some ways the most important step.

But like I was saying before, I also think we simultaneously urgently need much more investment in medical care.

Substance use disorders are drastically underserved compared to even other mental disorders.

And we also need to go beyond medicine to comprehensive and holistic responses for people who need help with addiction.

Things like housing support, vocational support and the other basic needs, because often addiction is just a final common pathway or the final expression of some of those social problems.

HEFFNER: Carl, we do seem to be at a crossroads now when it comes to whether drug addiction or addiction is a carceral issue or a societal issue.

If we want to think of the carceral angle as in, in effect, extra-societal to the extent that the carceral state is not indicative of what we aspire America to be as a country.

So, on that level, that's not really a trope or a cliche.

It's a question of incarceration or alternatives to incarceration, whether that's probation, parole, other means of discipline or community development and support systems.

And then the other layer of this is regulatory versus deregulatory approach to making substances more available or less available.

And there does seem to be a growing consensus in America that the war on drugs was a war on American society.

It was a war on individuals, actually has not birthed the kind of freedom and security that we want as a people.

FISHER: Absolutely.

I would go farther and say that there's a growing recognition that the war on drugs, there's a war on black people, indigenous people, other people of color and that an example of how a notion of addiction is invoked to serve a totally different aim, and by just casually associating all drug use with addiction.

That's the thing that allows for ramping up the war on drugs.

It's that sort of sloppiness about what addiction is.

And so that's, you know, that's a way it becomes really important to pay attention to the specifics.

One of the things that history gave me was the cyclical sense of a complex multifactorial process.

And there's no magic bullet.

Nobody has solved addiction, but society seemed to get into the most trouble when they focus on a simple monocausal explanation and a simple monotrack solution.

So, in other words, prohibition has generally never worked, and we've had multiple ways of even alcohol prohibition and different types of prohibition.

That's not to say that there doesn't have to be some sort of control or regulation.

In some ways, alcohol is under-regulated.

Alcohol taxes, for example, if not kept pace with anything even approaching a public health aim for limiting the harms of alcohol.

So what we need is a balance across all of the many different spheres that matter to addiction.

Not just medical, not just scientific, not just mutual help and not just prohibition.

That we need to acknowledge the nuance in order to in order to effectively adopt that kind of pluralistic approach.

HEFFNER: You say cyclical.

Is there a period in history that you think we could aspire to emulate now in shifting from punitive to supportive?

FISHER: There's a few.

There are a few times where the cycle has swung to a pluralistic and multilevel approach.

One of the examples that I love is the early Nixon years.

And so Nixon, of course, is, is thought of today as a terrible villain when it comes to ramping up the war on drugs and incarceration policies in general.

In the earlier part of his presidency, though, he adopted such wide-ranging and open-minded policies and also policies aimed toward treatment rather than punishment that one scholar called him the first therapeutic president, that he was the first one who really focused on therapy rather than punishment for addiction problems.

And because of that, he, he tapped really fascinating characters like Jerry Jaffe, who is a young doctor totally outside the medical mainstream, and brought him to be the first drug czar.

The first drug czar was a physician who was really interested in integrating different types of treatment, not just methadone, but also the early therapeutic communities, and trying to find ways of meeting patients with an array of different types of therapies.

And so bottom line in abstract, I think the thing that made that period work was an open-mindedness and a sort of receptiveness to many different types of responses.

HEFFNER: You said multiple periods.

Is there another that also comes to mind?

FISHER: You know, I also really love the Inebriety Period.

You know, addiction has gone through all these different shifts and terminology, and so at the time of the American Revolutionary War, it was called habitual drunkenness.

And then other times that it was called addiction, but really only recently.

Inebriety was sort of the buzzword in, say like the 1860s, 1870s, 1880s, sort of post-civil war in a time of rapid, rapid industrialization.

And that's another example where there, there was a really broad notion of addiction as something universal.

Inebriety wasn't just about what we today call drugs.

It also included sugar.

It also included coffee.

It also included palatable foods.

Of course nobody was saying that sugar is on par with morphine.

But there was a recognition that there was a sort of graded spectrum, and that all these things were related, that addiction was something like a learning process rather than say just a thing that happens to you that you get hijacked by a bad chemical.

HEFFNER: We're running out of time, Carl, but pre-United States, is there a period where non-punitive, I'm calling it supportive treatment and societal response.

FISHER: From the start of the early modern period and transoceanic commerce, like really ever since Christopher Columbus, when people become introduced to different substances and different patterns of use there have been waves of drug epidemics.

That was another lesson from the book is that drug epidemics were nothing new.

We've had drug epidemics since the 1500s, 1600s, and all the rest.

Where my mind went was actually to a time when addiction was not under control but there were very thoughtful and compassionate responses to it.

It was the American indigenous response to the sort of pre-revolutionary American history.

That was a time of tremendous upheaval just outright manipulation and oppression, war, famine, disease.

And so indigenous communities were suffering a tremendous amount.

And some of that was suffering from alcohol problems.

Alcohol was a tremendous problem, often because it was deliberately introduced as a way to undermine indigenous societies.

But even there, we see in the different laboratories of different indigenous peoples across different tribes and places.

There were almost like prototypes of things like mutual help.

There's sort of a pre-AA group in the Seneca.

There are different sort of compassionate approaches to policing and control.

But I, I don't, I don't have that sort of holy grail answer that says these people solved it.

I don't think it's a thing that we solve.

HEFFNER: Understood.

There is not a utopia in any sense of the word.

Carl Eric Fisher, thank you for your time today, author of The Urge: Our History of Addiction, and professor of Psychiatry at Columbia University.

Appreciate your insight.

FISHER: Thanks very much, Alexander.

Great to see you.

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