The Current

How one manic episode helped a physician see addiction differently

Addiction psychiatrist Carl Erik Fisher looks at how society’s understanding of addiction has changed over the centuries, and what that taught him about his own recovery.

Modern views of addiction could be limiting the ways we can help those affected, says Carl Erik Fisher

In his new book The Urge, Carl Erik Fisher highlights the importance of looking at sociological influences behind addiction — such as history and race — in order to better understand how to treat it. (Beowulf Sheehan, Penguin Random House)

Addiction physician Carl Erik Fisher was embarking on a bright future as a psychiatrist in 2009, after graduating with honours from Columbia University.

But beneath the veneer of his accomplishments, Fisher was losing control of his life.

"I had a real problem with alcohol and stimulant addiction," he told The Current's Matt Galloway.

Fisher was drinking heavily at the time, and using stimulants like Adderall and cocaine to counteract the hangovers, so he could continue working. But he was clinging so tightly to his identity as a doctor and psychiatrist that it blinded him to his own problems.

"I wasn't supposed to be one of the 'crazy ones,' in the way that I thought about it back then," he said.

Addiction is so complex and exists across all of these different levels: the social, the cultural, the individual, the humanistic, the spiritual.- Carl Erik Fisher

That changed when Fisher had a manic psychotic episode prompted by an alcohol and Adderall binge in November 2010. Police were called to Fisher's Manhattan apartment, and Tasered him when he wouldn't co-operate.

"That's the thing that ultimately got me into treatment and forced me to come face to face with my problems," he said.

Fisher has written about the experience in his book, The Urge: Our History of Addiction, which also looks at how society's understanding of addiction has changed over the centuries.

He said our modern understanding of addiction, seen largely through a medical and scientific lens, could be limiting the ways we can help those affected. 

"There's a lot of value in … recognizing the way that addiction is so complex and exists across all of these different levels: the social, the cultural, the individual, the humanistic, the spiritual," he said.

"Just to do that … to bring in more compassion and nuance and complexity would be a major step forward and free us up to respond in a more flexible and helpful way." 

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'Common to humanity'

Fisher's book looks at how addiction has been understood and defined over time, and how that's shaped approaches to it today.

"For most people, I think addiction summons up a picture of being taken over by some substance," he said.

"Addiction nowadays is often framed in that binary: you're either hijacked and compelled, or somebody [who] has free choice. And I think that's wrong."

Dr. Ryan McNeil, an assistant professor of Internal Medicine and Public Health at the Yale School of Medicine, agreed that this framing is problematic, and can be harmful to the people who need help.

"If you treat people as having their agency hijacked ... then it's really easy to pursue approaches that strip them of agency and don't allow them a voice and role in determining the direction of their life," he told The Current.

[Addiction] was something that was common to all of humanity. It wasn't some special, extreme illness or sickness.- Carl Erik Fisher

He added that there could be a inclination to view drug users as criminals because drugs are criminalized, which could lead to "a tendency to want to pursue approaches that punish people on the basis of their drug use."

"All of these things are both horribly stigmatizing, but also lead to real-world responses that place people at risk, and very specifically drive their risk of overdose," he said.

Fisher said the negative framing of addiction is recent, and history didn't always view addiction in such a black-and-white way.

"Around, say, the 1500s … addiction meant something totally different," he said. "It was an action, it wasn't a status. It was something that was common to all of humanity.

"It wasn't some special, extreme illness or sickness. It was something that anybody could do …in the process of strong devotion, to lose their willpower."

'Right' and 'wrong' drug use

In the centuries that followed, Fisher noted the rise of "really powerful stereotypes about the right and wrong type of [drug] users, dating back to colonial times," and rooted in racism.

One of the first drug epidemics he identified centred on tobacco in Europe, shortly after Christopher Columbus's expeditions to North America.

"It very rapidly switched from the 'right' sort of users, where tobacco was held up as this almost mystical, aristocratic medicine reserved for the elite … to a barbarous drug, a beastly drug, something that was associated with, in their words, savages," he said.

Fisher said these views about the "right" and "wrong" drug users carried into the early 20th century, "when Mexicans were associated with cannabis use, and Black Americans … were associated with cocaine, and Chinese immigrants in the West were associated with the wrong kind of opioid use." 

"You can almost visualize, geographically, the way that the states were just sort of hemmed in by all of these xenophobic and racist ideologies that infected our understanding of addiction," he said. 

In Canada, McNeil said the war on drugs has historically led to horrible consequences for Indigenous people in particular — consequences that still live on today.

"Things like denial of health care, being subject to intensive policing, rendering people more vulnerable to incarceration, or leading to people [taking] steps to evade these systems that can place them at greater risk," he said.

"That's not even getting into much larger issues around child separation disruptions, family displacement, and all of the harms that then may stem from engagement with the criminal, legal or welfare systems."

Fisher said these racist associations formed the basis of society's stereotype of the average drug user as "out-of-control and dangerous."

"We're still living with that legacy today."

Shared suffering

Fisher hopes society can come to understand that "addiction is in all of us."

"Once people get past the surface-level ideologies and connect around the issue that matters most, there's tremendous capacity to come together and recognize our shared suffering," he said.

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"Immediately, when you give people a voice in discussion about the things that impact their lives, you have the potential for solutions that are actually responsive to their needs and their lived realities," he said.

"Given how disempowered people who use drugs are, by systems that do things to them as opposed to reflecting their needs, I think that's quite a powerful thing."

Written by Mouhamad Rachini. Produced by Idella Sturino.

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