More than a disease: How addiction reflects injustices

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Dr. Carl Erik Fisher discusses the history and science behind diagnosing addiction and how the disease is also a reflection of social and cultural injustices in society. Photo by Shutterstock.

Addiction is not a new phenomenon to Americans. Heroin, alcohol, meth, and opioids are among the substances complicit in destroying far too many lives in recent years, with drug overdose deaths now topping 100,000 annually in the U.S Historically and in the rest of the world, addiction is nothing new either. Some of our earliest South Asian texts describe men with gambling addictions. The Greek philosopher Aristotle describes those who were unable to act in their own best interest as having an “incontinence of will.”

Modern research ushered in new schools of thought — compulsive and addictive behaviors began to be labeled as mental and physical diseases, treatable with psychiatric medication and therapy. But do we need to hit the pause button and broaden out that definition? Dr. Carl Erik Fisher, assistant professor of clinical psychiatry at Columbia University, says labeling addiction as a disease might be misleading. Fisher, the author of “The Urge: Our History of Addiction,” says society, race, suffering, and abuse also play key roles in addictive behavior.  

Jonathan Bastian talks with Fisher about his own personal experience with alcohol and Adderall addiction while he was a driven young medical student. Fisher explains that his addiction and subsequent treatment was a lightbulb moment for him that opened his eyes to realizing  addiction is “not something scary” but something that “exists in all of us.”

The following interview has been edited for length and clarity.

KCRW: When did we begin to think of addiction as a disease? 

Carl Erik Fisher: I'm glad you asked about the term “disease,” specifically, because it's a real stumbling block. And different people mean a lot of different things by disease. I wrote a piece in The New York Times about being skeptical about the label disease. And a lot of people took that as a personal affront, like I was questioning the reality or the way they make sense of disease. And that wasn't my intent at all. 

The problem I see is that disease can mean, at a baseline, that something is amenable to medical treatment, that medicine has a role to play in helping folks, and that is absolutely the case for addiction. We can save so many lives by expanding or improving medical treatment. But there are many other levels of disease that have been, at various times throughout history, superimposed on that more basic and defensible position. So for example, addiction as a disease might be taken to mean that biology is the best — that through a reductionist lens, we're going to figure it out that brain science or some sort of chemical understanding is the way that we're going to crack this nut and finally cure addiction. And that's misleading. 

And then there are other notions like addiction as a disease is permanent, or that all people with addiction have the same kind of addiction. And that's also untrue. We have very good data establishing the heterogeneity and the diversity of addictive experiences. So when you ask, “When did we start thinking of addiction as a disease?” I was curious about this too. And what I found is that it wasn't one question, it was many questions with many threads that appeared in different ways, sometimes helpful, sometimes harmful, and that there was a lot of use even just in making sense of my own situation to unravel those threads a little bit.

With this multiplicity of definitions, how are you now making sense of the word “addiction” and the field in which you work? 

I like a really broad and capacious understanding of the word “addiction.” I like the way that we used it 500 years ago, back when it first entered the English language — that it was a strong devotion that had some element of an impairment in self control. That's not a neat definition. It's not something that you could put in a medical textbook, but I don't think that medicine is the only frame for understanding this. I think there's a lot of danger if we police the borderlands of addiction too tightly. In the end, I think it has a lot to do with self-definition, and one's own personal identity.

“I think there's a lot of danger if we police the borderlands of addiction too tightly … it has a lot to do with self-definition, and one's own personal identity.”

I've seen people who have really struggled with substances, and they say, “Addiction doesn't make sense to me. And I don't see that as my problem.” And I would never try to force that identity on them. I think that as a clinician, it's really important to support someone's self determination and not put my own belief system or my own labels on them. 

And then I've seen other people who have what might be considered a relatively mild problem. And they say, “I feel like I'm suffering with addiction.” And I fully support that, because in the end, I do think that it's universal enough that everybody has a right to say it. One of my Buddhist teachers once said, “If you're not a Buddha, you're an addict.” And my understanding of what that means is that as long as there's something in you that is impairing your self control, or you struggle with ambivalence, then you're not free of that part of ourselves that is not always in charge all the time.

What else do Buddhist teachings have to say about the nature of addiction?

In the West, in a particular kind of addiction advocacy, we have grown up with this idea of suffering as something to be conquered, or addiction as a disease, meaning a special case of human suffering. And there are good reasons for that, involving trying to force open the doors of hospitals and trying to get the word out about addiction and raise compassion. And I understand the reasons for that, and describe that a little bit in the book. But it is a way of understanding human psychology that's a bit opposed to some of these other more spiritual understandings, which I got a lot from. 

I'm not a Buddhist teacher. It's my personal religious practice, but I'm not qualified to teach on it. But I'll say [that in] my own understanding of it, a key form of human suffering [is] what's referred to as dukkha, which is sometimes translated as “suffering,” but it's probably better translated as “unsatisfactoriness.” And so the mind clings [for] a way to try to make that satisfactory, a sort of attachment to the way things could be rather than the way things are. 

There are plenty of other folks, like Johnson Brewer for example, who then use the addiction model or description as a way of making sense of anxiety. For example, worry can be addictive. Sometimes compulsively engaging in a worry loop or trying to predict the future or anticipate any problem is volitional. It has something to do with my own quest to manipulate reality, or to make things otherwise, or avoid danger. And so I think that these sorts of philosophical and psychological insights are sometimes really diametrically opposed to our Western understandings, which are all ultimately a legacy of Judeo-Christian philosophy. So it's worth interrogating [things] like, what is our operating system? What is our working model of how the mind works and what suffering is? 

There can be a huge spectrum here, but the way that some drugs are presented to us these days, like fentanyl or the opioid crisis, is that we simply don't have control. That in certain cases, there are things that are just too strong for us out there to handle. How you make sense of that or parse that question?

Fentanyl is a great example with a lot of historical antecedents as a killer drug, or almost a “magic” drug. One classic example from the more recent past is crack cocaine. When crack cocaine first appeared, it was described as a super drug, something that totally eradicated agency. The most addictive drug to man. One researcher at the time was quoted as saying, “If my daughter could try heroin or crack, I would rather they try heroin.” Which was remarkable. It's unthinkable nowadays in the context of the current opioid overdose crisis. 

But it just goes to show the ideas we had about that particular drug, crack cocaine — which is ultimately just a different formulation of powder cocaine — as if it had some sort of special agency in itself. And one thing that came up for me over and over throughout the book is this sort of “demon drug” idea, where we lose sight of human factors and even the individual factors, let alone the social, economic, political, and cultural factors, and put all the power in the drug. 

“We lose sight of human factors and even the individual factors, let alone the social, economic, political, and cultural factors, and put all the power in the drug.” 

And we have a particularly American strain of doing that, which is very strongly represented in the temperance movement, when advocates first tried to ban alcohol in the 19th century, and came up with this idea of “demon rum” — that there was something special in alcohol, alcohol was like a possessing force itself, and it came into you. And it did something to you that took over your agency and sort of zombified you. 

That's a really dangerous notion, because, especially in the case of the crack epidemic, it served as a cover for law enforcement. It served as a way of saying, “This is an individual problem and people are broken. And they're irretrievable once they've been subjected to this contagious force of crack cocaine,” and ignores all of the social and economic and political factors that also enabled the epidemic. 

What I found is that drug epidemics are nothing new. We've had them for 500 years. And every time a human society has an epidemic, they tend to want a villain. The natural question is, where's this from? Is it the bad drug company? Or is it the bad drug? Or is it something bad in the people who are using it? And ultimately, it's much more complicated than that. We have to be able to think on multiple levels or have no hope of any resolution here.

Do you think with fentanyl, as an example, that there really is no such thing as this kind of demon, all-powerful drug where any person who takes a little taste of it is addicted forever? That's that's all fictitious?

I know for sure that's not true for fentanyl, because fentanyl is an FDA-approved drug that people use for pain control. So there's plenty of people [who disprove that]. And in fact, the demonization of fentanyl, and opioids in general, is leaving a ton of pain patients in the lurch right now. The narrative that the opioids themselves are the problem and they are the thing that has all of the power has led to, in some cases, unnecessary restrictions on opioids that leaves people with legitimate pain and really suffering. 

At the same time, the opioid epidemic shows us that we need some regulation. It can't be laissez faire, it can't be a free-for-all, especially when we have these powerful, asymmetrical market forces, like drug manufacturers that are very well documented. That did awful, awful things during the marketing of opioids in the ‘90s, 2000s, and so forth. So thinking across these multiple levels, and being skeptical about this sort of “demon drug” idea, while also trying to hold in mind the social and economic forces is maybe a path to finding a middle ground where we can be comfortable with a little moderation, you could say.

“Every time a human society has an epidemic, they tend to want a villain … And ultimately, it’s much more complicated than that. We have to be able to think on multiple levels or have no hope of any resolution.” 

Dr. Carl Erik Fisher. Photo by Beowulf Sheehan.



  • Carl Erik Fisher - Assistant professor of clinical psychiatry, Columbia University. Author, “The Urge: Our History of Addiction” - @DrCarlErik


Andrea Brody