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Daphne Merkin

Will We Ever Understand Addiction?

This article appeared in the New York Times.

THE URGE

Our History of Addiction

By Carl Erik Fisher


Our culture, ever on the lookout for easy, unambiguous answers to the predicament of being flawed and often unhappy humans, is a sucker for all-encompassing, reductive paradigms like “addiction” and, more recently, “trauma.” What these tropes share is a medley of explanations, depending on whom you listen to, some of them leaning toward nurture and some toward nature and some again toward a perfect storm of both. The nurture camp depends on an elasticized frame of psychological reference that aims to link addiction to psychic wounds and self-destructive behavior going back to family dysfunction and socioeconomics. The nature camp posits neuroscience as the cause, making wobbly claims for an as yet unprovable biological origin of addiction — some sort of neurological dysfunction — predicated on inconclusive interpretations of brain imaging that focused not long ago on dopamine as the culprit. (A 1997 Time cover story described dopamine as “the master molecule of addiction.”) And sometimes the travails of addiction are ascribed to an intrinsic vulnerability that is exacerbated by external factors. Indeed, books on addiction appear so frequently that one might wonder whether there is anything new to say or report. Just to name several that come to mind, in 2018 there was Leslie Jamison’s careening but also absorbing “The Recovering: Intoxication and Its Aftermath,” about her struggle with drinking even as she created a blazing career as a writer. In 1995 there was the poet Michael Ryan’s harrowing “Secret Life,” about his sexual addiction. And some years before that Tom Dardis’s ingeniously titled “The Thirsty Muse: Alcohol and the American Writer” appeared.

Sometimes it seems that around every corner there is someone pretending to function who’s ingested bottles of whiskey or sniffed lines of cocaine when no one was looking. So it’s hardly surprising that the quest to understand our own impulses to overeat, abuse drugs and alcohol, shop compulsively or fall repetitively for the wrong sort of love interest is such that we can never have enough of these accounts, whether personal or scientifically oriented or both.


Carl Erik Fisher’s new book, “The Urge: Our History of Addiction,” follows two journeys: One is a memoir of his own addiction to alcohol (he grew up with two alcoholic parents), and the other is a detailed overview of the approaches that have been used to understand, control and treat addiction over time. This last includes the relatively contemporary idea of “recovery,” which suggests that it is possible, with the right medications, such as naloxone, buprenorphine or methadone, and thoughtful care, to break its hold.

Fisher, having decided to study the psychology and neuroscience of addiction while he was studying to be a psychiatrist, writes from inside the hall of mirrors that discussions of addiction can often turn into. “The field seemed to be in chaos,” he observes in his introduction. “Scientists and other scholars seemed bitterly divided, always talking past one another. Some insisted that addiction was primarily a brain disease. Others claimed that this brain-centric view blinded us to the psychological, cultural and social dimensions, including trauma and systems of oppression.” Fisher then proceeds to wade bravely into the muck of information and theories to try to give us a more lucid view of a disease that has often been attributed to “a stark binary … a confusing middle ground between free choice and total loss of control.”


As long ago as ancient Greece, it seems that Aristotle, Socrates and Plato were arguing over the problems of self-control, internal conflict and resolve, passing judgment on which factor played a greater role in what Fisher refers to as “disordered choice.” Today we think more in terms of “the divided self” as a pivotal cause in making wrong choices, the result of something called “‘delay discounting,’ in which smaller but more immediate rewards are favored over larger, delayed ones.” (Although Fisher doesn’t mention it, I was reminded of “the marshmallow test,” a study led in the 1960s and ’70s by a professor at Stanford University, in which children were offered a choice between one small but immediate reward — either a marshmallow or a pretzel stick, depending on which they preferred — and two small rewards if they waited for a period of time.)


Fisher refers to Augustine’s “Confessions” as “the first addiction memoir,” although he observes that Augustine viewed addiction as inseparable from other forms of suffering — “it was all of a piece with the bigger problem of that misdirected will, a central preoccupation of his life.” He brings up examples of people who lost their way in the brambles of addiction, from Thomas De Quincey to Edgar Allan Poe, and cites one of those endless, caboose-like German terms, this one coined decades ago for “the inability to stop” (which was thought to characterize addiction): Nichtaufhörenkönnen.


We learn that the first person to use the word “addict” was apparently John Frith in 1533, who secretly belonged to the Protestant Reformation and was burned alive for heresy. The sense in which he used it, Fisher explains, was not as a helpless compulsion but as “an active process of giving over one’s agency, a choice to give up choice” — which mirrored Augustine’s preoccupation with “the bondage of the will.” From here on, the book widens out to discuss the notion of “epidemics” — what one historian who is quoted called “the psychoactive revolution,” which included opium (most notably and creatively used by Samuel Taylor Coleridge), tobacco and coffee.


Although Fisher wears his compassion for substance abusers prominently on his sleeve, he is also capable of throwing out some controversial observations that go against received wisdom. Of the OxyContin epidemic, for instance, he notes that “even though they were masters of the craft, there was nothing really new in what Purdue’s leaders did — they were simply playing a role in a larger system that has existed and evolved for generations.” Similarly, he points out that a pharmaceutical company named Parke, Davis “began promoting the use of cocaine for ‘exhaustion’ and ‘overwork’ in the 1880s.”

In other words, however morally reprehensible the intentions behind the actions of both the manufacturers and dispensers of addictive drugs, they do not entirely explain the process of addiction in and of itself, much as we might wish to put all the blame on them; other factors, such as personal agency and environmental influences, are inevitably involved. Fisher underlines this dispiriting reality even further a third of the way through his book: “Addiction does not proceed inevitably from use. Most people who use drugs — including crack, methamphetamine and heroin — do not develop significant problems. In studies spanning decades, no more than 10 to 30 percent of people who use drugs develop significant substance use disorders. Drugs are not ‘addictive’ in themselves; they don’t cause addictions in isolation.”


No story of addiction would be complete without a history of the temperance movement (which originally argued for moderation before favoring total abstinence) as well as Alcoholics Anonymous and its 12-step program. Fisher provides a very detailed history of A.A., much of which information is out there already, and delves into rehab and outpatient programs. He is against the “confrontational practices” used in many rehab facilities and “in many prison-based programs, boot-camp-like wilderness programs and the troubled-teen industry,” and comments almost gleefully that his alcoholic mother “hated A.A.” Although he manages to remain in his residency despite the fact that “drinking had become a core part of my identity,” Fisher suffers a drug-induced manic episode, brought on by a combination of Adderall, alcohol and “days of sleeplessness”; when he starts screaming for help, a neighbor calls the police, “reporting an ‘emotionally disturbed person.’” Fisher refuses to comply with a police officer’s request “to come along nicely,” and is Tasered and brought into the emergency room in handcuffs.


After entering a monthslong inpatient rehab program (his residency program obligingly saved his spot for him) and getting used to identifying himself as an alcoholic, which he had initially resisted along with other aspects of rehab, Fisher still finds himself questioning the basic assumptions behind his dilemma: “But did I have addiction? Was it a thing — something I caught, or that took hold of me — or was it inseparable from who I was, lurking there in my personality or biology or karma for all time? Was it a separate entity that had attached itself to my healthier being, or was my self inclusive of the disorder? And would I have it for the rest of my life, even if I never drank or used again?”


Finally, Fisher addresses the shift from the therapeutic approach to treating addiction that had marked the 1950s and ’60s toward a more punitive model, including mass incarceration, that began with Richard Nixon’s administration. In part this model had to do with the fear among the ’60s middle class “that the drug culture was spinning out of control,” and in part it had to do with Nixon’s puritanism. Fisher writes that whatever treatment system had been in place “crashed in the late ’80s and early ’90s,” leading to an intensification of the stigma attached to addiction and criminalization of drug use. And still, after all the history and analysis he serves up, the original questions about addiction continue to hover in the air without definitive answers: “Was it a physical disease, a character disorder, a spiritual sickness or something else entirely?” Although Fisher holds out hope for the “multiple pathways of recovery,” he returns at the end of this sprawling, irresolute book to stressing the complexity of addiction and the need for a corrective context of personal responsibility and individual change. How some people get beyond their addiction remains withal mysterious and elusive; it’s not even clear how the author managed to escape his own entrapment.


From the beginning of “The Urge,” one of Fisher’s primary intentions seems to be to humanize the way we perceive addiction, suggesting that we evince empathy instead of casting blame. This is a laudable goal but it also blurs some of the specific, tougher issues he raises about what role choice plays in what looks to be an innate, helpless predilection; instead of focusing on the problems that come with naming and treating this condition, he offers a survey of everything under the sun that has been thought or done about addiction. The book is something of a tangle as a result and would certainly have benefited from a less amorphous sense of the message, or messages, it wishes to convey. As it is, the situation the author describes looks irremediably bleak: One comes away with the overwhelming impression that the propensity for addiction is part of the human condition, “the blight man was born for.”