Psychiatrist says calling addiction a disease is misleading: NPR

Carl Erik Fisher, psychiatrist and author of The Urge: A History of Addiction. Beowulf Sheehan/Beowulf Sheehan hide the caption

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Beowulf Sheehan/Beowulf Sheehan

Carl Erik Fisher, psychiatrist and author of The Urge: A History of Addiction.

Beowulf Sheehan/Beowulf Sheehan

Shortly after graduating from medical school, Carl Erik Fisher was on top of the world. He won awards and worked day and night. But much of this hectic activity really masked his addiction problems.

Fisher – who says he comes from a family with a history of addiction – fell into an alcohol and Adderall binge during his stay. A manic episode led to his committal to the psychiatric ward at Bellevue Hospital in New York, where he interviewed for a residency a few years ago.

“Because I was a doctor, because I’m white, because I lived in an upscale neighborhood, when the NYPD came to get me from my apartment — I got a lot of treatment and a lot of sympathy,” he says. “Unfortunately, many people with addiction don’t even have access to services, let alone the types of services that I have been able to get.”

Fisher is now in recovery and is an assistant professor of clinical psychiatry at Columbia University. His new book The Urge: Our History of Addiction — part memoir, part history — explores the importance of careful language when discussing addiction and how treatment has historically ignored its complex sociocultural influences.

Interview Highlights

Why it matters whether addiction is considered a disease

I think addiction is not a disease. Calling it a disease is misleading. Well, I say that with the understanding that the word “disease” is really powerful and liberating for some people. It [can] provide an organizational framework to give meaning to their struggles and instill a sense of security. And I would never want to monitor a person’s understanding of the Word. But overall, if we look at it as a sociocultural phenomenon, I think the term illness can be misleading because it diverts focus from the forces of racism and other forms of oppression that are so often associated with addiction. Originally, the word disease was introduced to try to open hospital doors and otherwise get medical treatment for people with addiction. Because the medical profession has largely evaded their duty to care for people suffering from addiction. So this lobbying was absolutely necessary. But people are still struggling to access medical care. People still struggle with stigma. People still struggle to get insurance benefits for addiction problems. There’s a useful version of the word “disease” when it comes to addiction that says therapy and medication can save lives. But the term is messy, and it also places all causes in biology and overlooks some of the other determinants of people’s health.

How racism has historically influenced addiction treatment

For centuries, people have tried to divide people into good and bad drugs, saying that certain drugs are dangerous, contagious, or inexorably leading to vice and social problems. Often this kind of gross exaggeration of the harms of one drug and the perceived benefits of other drugs backfires on hurting everyone. A great example from the turn of the 20th century: there was all this strong effort to criminalize certain drugs because they were associated with certain racist and xenophobic panics, like the Chinese opium-using panics or the black cocaine use. Even just urban poverty was a major development at the time, and an association with heroin drove many of these attitudes. At the same time, a form of entitlement allowed the continued use of certain drugs. First things like morphine and more regulated opioids, and later stimulants that were only invented shortly after. And whites and the privileged have also been harmed by such claims. So drugs are such a powerful example of racism rebounding to hurt us all that whenever we create these kinds of divisions and try to put the good and bad categories into different forms of drugs, we inevitably end up doing widespread harm .

How the medical model should change to get more people into recovery

A simple fulcrum we could do would be to shift our focus away from controlling people’s consumption to meeting people where they are and helping them with what matters most in their lives is. Medicine has been dominated by a pure abstinence model for too long. Now I’m in an abstinence model myself. I don’t think I should drink or reuse. And this is necessary and life-saving for many people. But addiction is also deeply multifaceted, and we have new evidence that there are some people who can actually improve their functioning, even if they have a substance use problem, without stopping use entirely. Or they are in a kind of partial abstinence when they stop using heroin. I don’t think it’s wise to be complacent about using drugs, especially if someone has had a problem before. But there are many people who don’t want treatment because their current treatment system is really dominant. For example, it is a crisis that people are being discharged from treatment for continued use. One definition of addiction is continued use despite negative consequences. So I think it’s imperative that we as medical professionals work harder to work with people where they are while also recognizing the profound dangers of addiction.

About the approach he uses with his own patients

The bottom line about working with my own patients is – they call the shots. The most important lesson I’ve learned from looking at the history and science behind addiction healing is a respect for the many different pathways there are to recovery. I felt that myself – I felt a lot of embarrassment because I didn’t think I was recovering properly or I thought I could do a better job. And I think a lot of people have that shame. That if they’re not recovering in the traditional sense, maybe it’s not so good. And you know, I think that can be a real distraction and unnecessary because there’s a lot of opportunity to grow and improve and work toward solving the types of serious substance issues that we work with.

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

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