Book Review: A Sweeping — and Personal — History of Addiction

At age 29, Carl Erik Fisher, a newly minted physician, arrives at Bellevue, the public hospital in Manhattan best known for serving the most challenging cases of mental illness. Only Fisher comes as a patient, and he’s locked in a dual diagnosis ward after a manic episode involving alcohol and Adderall. If you passed him in the hall, you might have pegged him as a “Nurse Jackie” type: the doctor with a drug problem.

Fisher’s meticulous and meticulously researched new book, “The Urge: Our History of Addiction,” is deeply informed by his experience as both a self-described alcoholic and a specialist in addiction medicine. For years after his release from rehab, he was forced to pee in a cup in front of a urine monitor. As Fisher reflects on the surreal, and galling, situation, he begins to wonder about how he — or anyone else — gets better. “I knew that the addiction treatment system was broken, having experienced it firsthand, but the why was mystifying: Why was there a totally separate system for addiction treatment? Why do we treat addiction differently from any other mental disorder?”

BOOK REVIEW“The Urge: Our History of Addiction,” by Carl Erik Fisher (Penguin Press, 400 pages).

“The Urge” ultimately unfolds as far more than an addiction memoir. Arriving at a time when the so-called opioid epidemic has become a defining crisis of our time, it presents both the personal history of someone reckoning with mind-altering substances and an argument for a reframing of the idea of addiction. “It is,” Fisher writes, “the story of an ancient malady that has ruined the lives of untold millions, including not only those of its sufferers but also the lives touching theirs, and yet it is also the story of a messy, complicated, and deeply controversial idea, one that has eluded definition for hundreds of years.”

Among the misconceptions, Fisher writes, is the strangely persistent belief that addiction can somehow be eradicated or fixed. “The primary goal should be not victory or cure,” Fisher writes, “but alleviating harm and helping people to live with and beyond their suffering — in other words, recovery.”

The book’s main text clocks in at just over 300 pages, and it condenses anecdotes and detail into engaging, tightly woven vignettes. In the first chapter, Fisher introduces one of his patients, a woman who resolves not to drink but then gets sick drinking vanilla extract from the corner store. Then, he introduces one of the earliest known references to addiction in the “Rig Veda,” a Sanskrit hymn about a gambler who struggles to quit playing, before moving on to Augustine (the early Christian philosopher), the author’s own magical first sip of beer, and the etymology of addiction. 

Fisher places readers into evocative scenes, weaving historical snapshots with his own memories. You almost want to roll down the window and find some fresh air as he describes the experience of inhaling secondhand smoke in his parents’ car as they head to the Jersey shore. That scene follows a pithy account of punishing European tobacco users in the 1600s — an early example of an anti-drug scare that had xenophobic undertones and practically no connection to the actual medical harm. Scaring people straight didn’t stop addiction then — or now, for that matter. Indeed, Fisher notes, under the 17th-century Ottoman ruler Murad IV, the punishment of death didn’t stop soldiers from smuggling pipes in their sleeves to sneak a puff.

Fisher, now a practicing clinical psychiatrist and a professor at Columbia University, relies on a range of previous scholarship. He’s not interviewing researchers or sifting through archives to uncover some lost history. But, in retelling some of the more familiar stories involving drugs, including Thomas De Quincey (Romantic writer, and a requisite feature in practically any book on opium), Benjamin Rush (a founding father and among the first to characterize addiction as a disease), Alcoholics Anonymous, Narco (the sprawling prison hospital and treatment center in Kentucky), and Synanon (a cult-like group that laid the exploitative framework for drug rehabs), Fisher turns to sources both obvious and obscure.

Arriving a time when the so-called opioid epidemic has become a defining crisis of our time, “The Urge” presents both the personal history of someone reckoning with mind-altering substances and an argument for a reframing of the idea of addiction.

The writing is brisk without being breezy, and Fisher draws fresh insights, particularly when it comes to alcohol. For instance, he describes Samson Occom, a Mohegan preacher, as “far ahead of his time,” for linking alcohol with the oppression of Native Americans in the 18th century. Pairing abstinence and mutual aid, many Native American leaders at that time emphasized community healing — principles that predate AA and today’s peer-mediated support groups. The look back also helps Fisher understand his own family’s addictions. Later, when he’s coerced into rehab and forced into a feedback session, he comes to appreciate the concept underlying these groups: a shared fellowship and support from people who understood addiction because they too experienced it firsthand.

At times, “The Urge” can seem almost too concerned with nuance. Fisher explains that he’s avoided stigmatizing language, such as “addict” and “junkie.” He dismantles commonly used terms like “non-medical,” which place “recreational” drug use outside of medically sanctioned contexts. (Fisher argues that the definition is historically misguided since “the instrumental use of intoxication long predates modern medicine.”)

Taken as a whole, these critical points reinforce his central argument, which builds off the growing consensus that addiction does not stem from a moral failing, and that it is more than simply, or primarily, a brain disease. Fisher redefines addiction as more than a substance acting on the brain. Narrowly defining addiction as a disease, or a discrete biological phenomenon, he writes, fails to encompass its multidimensional aspects (e.g. spiritual and psychosocial). The therapeutic response, he continues, fails to appreciate recovery as “a process of ongoing positive change,” not just the absence of pathology. More importantly, he argues, “Drug use is not synonymous with addiction, and criminalization is not a rational way to reduce drug harms. In fact, it is often a central driver of those harms.”

The argument is persuasive. Despite a catastrophically failed war on drugs, the U.S. has primarily operated in punitive mode. It does not need to be this way: Drug use does not have to be so deadly. While some may see treatment as a step in the right direction, Fisher argues that the therapeutic approach takes the focus away from the oppressive forces of racial injustice and mass incarceration, which shaped the system treating people with addiction. (It’s not entirely clear how such a reframing and redefinition of addiction would play out, but Fisher says he would prioritize policies and approaches that recognize drug use and addiction as facts of life, focusing on practices that reduce harm.)

A sprawling history of a concept, spanning decades of prohibitionist thinking and the latest in recovery research, could easily fall apart were it not informed by Fisher’s experience. I won’t say too much about what happens inside his fifth-floor walkup in New York after he checks himself out of the hospital the first time — against medical advice. It is shocking, but sadly not surprising. Later, Fisher recognizes that his punishment at the time was not the norm: As a clinician, he sees how people caught in the criminal legal system are denied lifesaving medication, and realizes he could have ended up incarcerated, or shot dead, had he not been “a white guy living in an upscale Manhattan neighborhood.”

“Drug use is not synonymous with addiction, and criminalization is not a rational way to reduce drug harms,” Fisher writes. “In fact, it is often a central driver of those harms.”

Ultimately, the takeaway isn’t so much prescriptive policy advice (though there’s some of that), or practical tools to narrow the gap between people who want help and — in the lingo of harm reductionists — responses that meet them wherever they’re at.

And maybe that’s the best part about “The Urge.” Fisher doesn’t pretend to have the solution to addiction, a way of being that, in his telling, has always existed as an ordinary response to human suffering and “a desire to break free.” He’s rigorous without sounding preachy. He doesn’t drink, yet acknowledges that abstinence is not for everyone.

In one telling section, Fisher says he poured over the scientific literature on addiction — despite admonitions from authorities. “The counselors in rehab had warned me that it could be dangerous to look too closely at the science of addiction — they said my disease could twist that information into a basis for denial — but I still felt drawn to learn more,” he writes. “I wanted to see how the research could help me understand who I was and who I might become.”

If his account seems to urge readers towards anything, it’s the one thing most sorely lacking in the discourse around drugs: curiosity.

Peter Andrey Smith is a freelance reporter. His stories have been featured in Science, STAT, The New York Times, and WNYC Radiolab.

Peter Andrey Smith is a senior contributor at Undark. His stories have also been featured in Science, STAT, The New York Times, and WNYC Radiolab.