Psychiatrist says calling addiction a disease is misleading A psychiatrist says calling it a disease takes important attention away from racism and other things that are often associated with addiction.

'The Urge' says calling addiction a disease is misleading

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It can be hard to find the right words when talking about substance abuse, but Carl Erik Fisher, an assistant professor of clinical psychiatry at Columbia University, believes language matters. He himself hit bottom a year after graduating from medical school.

CARL ERIK FISHER: I thought I was on top of the world. I was a real workaholic, you could say - had won some awards coming out of medical school. I was a real grinder. But a lot of that frantic activity was really covering up for deep problems with alcohol and with stimulants. And so I wound up in a really dramatic descent into an alcohol and Adderall binge. I wound up having a manic episode where I completely lost touch with reality and was admitted to the Bellevue Hospital psychiatry ward.

ELLIOTT: Today, Fisher is in recovery. His new book, "The Urge: Our History Of Addiction," is part memoir, part history. It looks at how treatment has historically ignored an individual's unique social and cultural influences. For instance, in his case...

FISHER: Because I was a doctor, because I'm white, because when the NYPD came to get me out of my apartment, I was living in an upscale neighborhood, I got a lot of treatment, and I got a lot of compassion. And in many states - unfortunately, not all - but in many states in the U.S., there are these specialized programs for doctors who have addiction problems. And we get a case manager and a lot of really careful and nuanced encouragement. And sadly, many, many people with addiction can't even access services, let alone the kind of quality of services I was able to get.

ELLIOTT: Can you explain why it matters whether addiction is considered a disease or a vice?

FISHER: I think addiction is not a disease, so to call it a disease is misleading. Now, I say that with the understanding that for some people, the word disease is really powerful and even liberating. And I would never want to police an individual's understanding of the word. But on balance, I think the notion of disease can be misleading because it takes focus away from some of the broader, interconnected factors - the forces of racism and other forms of oppression - that are so often bound up in addiction.

ELLIOTT: But hasn't looking at addiction as a disease opened up new and more opportunities for treatment?

FISHER: You know, to be honest, I'm not sure about that. Initially, the word disease was introduced to try to force open the doors of hospitals and otherwise get medical treatment for people with addiction. But the specific notion of disease - I just don't know how far it has gotten us. I would argue that now, 50, 60 years later, people still struggle with getting access to care. People still struggle against stigma. People still struggle to get insurance benefits for problems with addiction. There is, I think, a useful version of the word disease when we're talking about addiction that says it's a medical condition, that therapies and medications can save lives. But the term is messy.

ELLIOTT: Can you talk a little more about how drug and alcohol use has been viewed over the years and how treatment is influenced by racist views of the past?

FISHER: Yeah, absolutely. For centuries and centuries, people have tried to divide folks according to good drugs and bad drugs, to say that certain drugs are dangerous. They lead inexorably to vices and social problems. You know, often, that kind of stark exaggeration of the harms of one drug on one hand and the supposed benefits of other drugs on the other hand, they rebound to hurt everybody.

For example, the turn of the 20th century, there were all of these powerful, powerful efforts to criminalize certain drugs because they were associated with certain racist and xenophobic panics, like the panics associated with Chinese opium use and Black cocaine use. Even just the urban poor was a major development around that time, and an association with heroin drove a lot of those attitudes. At the same time, a sort of entitlement allowed the continued use of certain drugs - at first, things like morphine and more tightly regulated opioids and then later stimulants. White people and privileged people were harmed by those sorts of entitlements, too. So drugs are such a powerful example of how racism rebounds to hurt all of us.

ELLIOTT: So if you're arguing that the framework that we have right now is not really working, how should the medical model change to get more people into recovery?

FISHER: One simple pivot that we could do is to shift our focus away from controlling people's use to meeting people where they are. 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 that's lifesaving. But addiction is also profoundly diverse, and we have emerging evidence - more and more, year by year - that there are some folks who can really improve their functioning, even when they have a substance problem, without totally cutting out use. It's not true for everyone. We have to be very wise and really exercise discernment here.

ELLIOTT: Yeah. I think there's a lot of people who might be hearing you say that and saying you're giving people an excuse not to try to tackle their problem.

FISHER: Right. And I would hate to do that. I don't think that it's wise to be cavalier about drug use, but we have to face facts that there are a lot of people who don't want treatment because our current treatment system is really domineering. And it's a crisis that people are, say, for example, discharged from treatment because of continued use. One definition of addiction is continued use despite negative consequences. So I think it's imperative that we, as medical professionals - we work harder to work with people where they are while also recognizing the profound dangers of addiction.

ELLIOTT: How do you use this approach that you are arguing for in your book? How do you use that with your own patients?

FISHER: Well, the bottom line in working with my own patients 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 diversity of recovery. That's something I felt myself that - I had a lot of shame around thinking I wasn't recovering in the right way. And I think a lot of people carry that shame, that if they're not doing recovery in the traditional sense, maybe they should be doing better. And, you know, I think that can be a real distraction and unnecessary, because there are lots of opportunities to grow and improve and to work toward resolving the kinds of severe substance problems that we're working with.

ELLIOTT: Carl Erik Fisher - Assistant Professor of Clinical Psychiatry at Columbia University. His new book is called "The Urge: Our History Of Addiction." Thanks so much for sharing your story with us.

FISHER: Great to talk with you.


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