The Urge: Our History of Addiction by Carl Erik Fisher; Penguin Press, 400 pp., $30
A young doctor is engaged in a mighty struggle with alcoholism. One night, exhaustion and amphetamines push him so far over the edge that he cries out for help. A neighbor calls the police. When the officers arrive, the doctor admits that he can’t trust himself to cooperate. We might hope that the officers would respond with compassion, perhaps a call to a mental health professional. Instead, they stun the young man with a taser.
The scene is a jarring reminder of the desperation of our times. Even in the midst of an addiction crisis that is straining our society to the limit, affecting everyone from first responders to doctors to people who use drugs and their families, we have only rudimentary understanding of what addiction is and what we can do about it.
Carl Erik Fisher, an assistant professor of clinical psychiatry at Columbia University, spent a decade researching and writing The Urge in an effort to explain how and why we have long sought—and fought over—definitions, explanations, and treatments. “Addiction is baffling,” he writes, and he knows it firsthand: Fisher is the young doctor in the story, and he bravely weaves his own struggle with addiction into the narrative.
The search for the nature and treatment of addiction brings us to the heart of human suffering. We are all the subjects of this book—not just those of us struggling with a recognized disorder. The “primal addiction,” Fisher reminds us, reaching into Buddhist traditions for an unforgettable expression, “is the mind grasping at itself,” seeking comfort among the uncertainties and perceived dissatisfactions of life. Fisher’s work is a challenge and an invitation to discard narrow conceptions, abandon punitive strategies, and “free ourselves to look instead at the full variety of interventions available to help.”
As the child of alcoholics, Fisher recalls that he “learned to pay exquisite attention” to his parents’ moods, enunciation, and behavior. His sense of safety depended on accurate divination. The same quality of attention is present in the book’s accounts of his own behavior: as often as he is drinking, or experiencing the unpleasant aftermath of one of his binges, he’s thinking about his drinking, questioning it, defining and redefining it, doubting, lying, confessing, promising, and trying again, with varying degrees of compassion and self-hatred—much like the rest of us when confronted with addiction within our families, our communities, or ourselves.
From Saint Augustine’s lust to tobacco, “rotgut gin,” opium, and pills, Fisher tracks the experience and science of addiction, detailing how humans have tried, time and again, to organize themselves and each other in resistance or support. The problem, Fisher asserts, is that “few other fields of medicine are so powerfully driven by cultural bias and ideology.” Moreover, addiction has always been viewed through a narrow lens, its perception dependent on the assignment of blame. Is it a personal failure of morality? A brain disorder? A medical disease? The inevitable consequence of certain substances? To Fisher’s credit, he considers not merely the substantive merit of each proposition but also the effect it has on a crucial, intangible factor: hope.
As physicians long have suspected, there is “not one addiction but many,” and Fisher argues that “no single explanatory framework or set of risk factors … will hold all the answers.” He rejects deterministic theories based on genetics or so-called addictive personalities, and notes that “biology does matter, but it is only one of many factors influencing addiction, along with environment and even choice.”
Fisher tells his story through a rich and lively cast of characters. They include early American physician Benjamin Rush, the father of American psychiatry, who was the first to name addiction as a disease but whose legacy is tainted by adherence to racist science; English writer Thomas De Quincey and his opium diaries; American physicians Marie Nyswander and Vincent Dole, who directed pioneering research on methadone; and Marty Mann, whom we first meet on a stretcher and who deserves to be better known for her keen, visionary public relations work on behalf of Alcoholics Anonymous. Fisher skillfully portrays his subjects and their work with both concision and humanity, never shying away from moral ambiguities.
Among the intriguing historical surprises reserved for the reader is the emergence in 1935 of the United States Narcotic Farm, or “Narco,” a federally funded substance abuse treatment and research center based in Lexington, Kentucky, that served as a hub for innovation until its funding and services were cut “under the onslaught of decades of prohibitionist drug policies.” Although early patients had benefited from group psychotherapy and apprenticeships, the ’60s generation found a “chaotic and hopeless mess.” By the time Fisher details the failings of our current “treatment industrial complex,” a “relatively deregulated, and often exploitative system,” we’re ready to respond to his plea for investment in medication therapies, harm reduction strategies, and other concrete factors (such as money, housing, knowledge, skills, relationships) that might support recovery and save lives.
Fisher treads carefully around recent calls for the decriminalization of drugs. “Oppressive prohibitionist policies” need to go, he argues, but “we still need some small dose of regulation, at least in the form of commonsense oversight of harmful products, especially when they are pushed on us by asymmetrical forces.” But it is power—more than politics—that preoccupies him: the power we have over each other, and the power we have over ourselves.
Once in recovery, Fisher discovers that the battle between his own “best instincts” and his compulsions is far from over: eating, striving, and bingeing “all felt dangerously familiar.” Worse yet was the voice in the back of his head, warning that he was doing it all wrong. “I didn’t really start to let go of that voice,” he writes, “until I started working on this book and learned about the wide variety of recovery experiences.”
Of course, as Fisher realizes, not everyone is blessed with such opportunities to reinvest in life and learning, but he puts his “recovery capital” to work for others. We are fortunate that his book is here, now, within reach of
policymakers, prosecutors, family members, people who are suffering from addiction, and those in recovery. It’s a marvelous gift of hope.
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