Psychiatrists say it is misleading to call addiction a disease: NPR

Carl Erik Fisher, psychiatrist and author of The urge: A story of addiction.

Beowulf Sheehan / Beowulf Sheehan


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Beowulf Sheehan / Beowulf Sheehan


Carl Erik Fisher, psychiatrist and author of The urge: A story of addiction.

Beowulf Sheehan / Beowulf Sheehan

Right after graduating from medical school, Carl Erik Fisher was at the top of the world. He won awards and worked day and night. But much of the hectic activity really covered up his addiction issues.

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 admission to Bellevue Hospital’s psychiatric ward in New York, where he had just been interviewed for residency years ago.

“Because I was a doctor, because I’m white, because when the NYPD came to get me out of my apartment, I lived in an upscale neighborhood – I got a lot of treatment, and I got a lot of compassion,” he says. “Unfortunately, many addicted people can not even access services, let alone the kind of quality of services I was able to get.”

Today, Fisher is in recovery and assistant professor of clinical psychiatry at Columbia University. His new book The urge: Our history of addiction – partly memoir, partly history – looks at the importance of a careful language when talking about addiction, and how the treatment has historically ignored its complex socio-cultural influences.

Interview highlights

About why it matters, whether addiction is considered a disease

I believe that addiction is not a disease. Calling it a disease is misleading. Now I say this with the understanding that for some people the word “disease” is really powerful and liberating. That [can] provide an organizing framework to make sense of their struggles and a sense of security. And I would never want to check a person’s understanding of the word. But all in all, when we look at it as a sociocultural phenomenon, I think the concept of illness can be misleading because it removes focus from the forces of racism and other forms of oppression that are so often tied to addiction. Initially, the word disease was introduced to try to force the doors open on hospitals and otherwise get medical treatment for people with addiction. This is because the medical profession has largely given up its duty to take care of people with addiction. So that advocacy was absolutely necessary. But people are still struggling to access care. People are still struggling with stigma. People are still struggling to get insurance benefits for addiction problems. There is a useful version of the word “disease” when talking about addiction, which says that therapy and medicine can save lives. But the term is messy, and it also locates all the causes in biology and overlooks some of the other determinants of people’s health.

About how racism has historically affected addiction treatment

For centuries, people have tried to divide people according to good drugs and bad drugs, to say that certain drugs are dangerous, they are contagious, or that they inexorably lead to vices and social problems. Often, those kinds of sharp exaggerations of the harms of one drug and the supposed benefits of other drugs go back and hurt everyone. A good example from the beginning of the 20th century: There were all these powerful efforts to criminalize certain drugs because they were associated with certain racist and xenophobic panics, like the panic associated with Chinese opium use or with black cocaine use. Even the poor in the cities in particular were a great development around that time, and an attachment to heroin drove many of these attitudes. At the same time, a kind of justification allowed continued use of certain drugs. First things like morphine and more tightly regulated opioids and then later stimulants, which were only invented shortly after. And white people and privileged people were also harmed by those kinds of rights. So drugs are so strongly an example of how racism returns to harm us all, that when we create those kinds of separations and try to assign good and bad categories to different kinds of drugs, we inevitably end up causing extensive harm.

About how the medical model needs to change to get more people in recovery

A simple focal point we could do is shift our focus away from controlling people’s use of meeting people where they are and helping them with what matters most in their lives. For far too long, medicine has been dominated by a model that has only abstinence. Now I myself am in an abstinence model. I do not think I should drink or use again. And for many people, it is necessary and life-saving. But addiction is also deeply diverse, and we have new evidence that there are some people who can really improve their functioning even when they have a drug problem without completely interrupting its use. Or they may be in a kind of partial abstinence when they stop using heroin. I do not think it is wise to be cavalier about drug use, especially if someone has had a problem before. But there are many people who do not want treatment because their current treatment system is really dominant. For example, it is a crisis that people are being discharged from treatment due to continued use. A definition of addiction is continued use despite negative consequences. So I think it’s imperative that we as doctors work harder to work with people where they are, while acknowledging the deep dangers of addiction.

About the approach he uses with his own patients

The bottom line in working with my own patients is – they have the responsibility. The most important insight that looking at history and looking at the science behind addiction recovery has given me is a respect for the many different paths that are improving. It’s something I felt myself – I was a lot ashamed to think I did not get it right or thought I could do a better job. And I think a lot of people carry that shame. That if they do not do recovery in the traditional sense, then it might not be so good. And you know, I think it can be a real distraction and unnecessary because there are a lot of opportunities to grow and improve and work towards solving the kind of serious drug problems that we work with.

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

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