When Addiction Fails: On Carl Erik Fisher’s “The Urge”

By Gordon MarinoSeptember 18, 2022

When Addiction Fails: On Carl Erik Fisher’s “The Urge”

The Urge: Our History of Addiction by Carl Erik Fisher

CARL ERIK FISHER, author of The Urge: Our History of Addiction, an artfully combined personal narrative and genealogy of the title concept, became an alcoholic and dependent on Adderall during his medical residency. After finishing medical school at Columbia University, he started drinking regularly and heavily. An overachiever whose first addiction may have been his relentless need to shine, Fisher began big-league boozing, and, day by day, it got to the point where the promising young doctor was coming in late for shifts with the disheveled looks of a New Year’s Eve reveler. The fledgling physician tried to hide the hole he was digging himself into, but his supervisors did not miss the symptoms and talked with him. At the time, however, the wall of blithe denial was impenetrable.

Rather than abandoning his liquid isle of peace, Fisher secured a prescription for the stimulant Adderall. For all their liabilities, uppers are a veritable steroid for bar-hopping endurance while retaining the ability to function, at least for a while. Temporarily, the Adderall provided enough internal backup for Fisher to find his Lethe in the bottle and still take attentive care of his patients. But the drug and alcohol eventually tipped him over the razor’s edge. And he knew it.

One night, Fisher burst into his apartment building howling for help, prompting a neighbor to dial 911. When Fisher resisted, a SWAT team was called in, and after finally gaining access to his abode, the Kevlar-clad lead officer calmly asked: “[A]re you going to come along nicely?” Fisher barked: “Probably not!” He was promptly tased, strapped down, and whisked off to the hospital. Fisher, who still considers himself in recovery, was eventually sent to a rehab center reserved for doctors, and with some setbacks and long periods of probation, he has cobbled together years of sobriety.

Among this study’s many virtues is Fisher’s heartfelt acknowledgment that, in his prolonged dalliance with self-destruction, he was ultraprivileged with what he terms “recovery capital” — the money, prestige, and patience of work supervisors. This capital is precisely what most people lack in the chokehold of their own conflicting desires. For that reason, Fisher observes, the “suffering of addiction is not an individual malady — it also comes from deep, ancestral wounds,” i.e., inequality.

As for the general history of mind-altering concoctions, Fisher reminds us that booze played an important role in subjugating Native Americans, by getting them hooked on spirits and into debt, and by hobbling their ability to wage war. Of course, whites also became swept up in their own trap. According to Fisher, some of Washington’s troops got so plastered from the rum they filched in their surprise Christmas Eve victory at Trenton that they literally fell overboard going back across the icy Delaware River.

During the early 19th century, most Americans didn’t meet the morning with coffee but with a stiff drink. “By the 1820s,” Fisher writes, “drinking had reached its all-time high: the average American drank around seven gallons of pure alcohol a year.” Translated into daily consumption, that amounted to “more than five standard drinks daily for everyone aged fifteen or older.”

From liquor to opiates to crack to the veritable army of legally prescribed “mood stabilizers,” Fisher deftly describes the United States’ schizoid response to drunkenness and, later, drug use. In the early 1800s, there were wildly popular abstinence movements, and much later, among many other things, Prohibition, Alcoholics Anonymous, Nixon’s war on drugs, Nancy Reagan’s “Just Say No,” and ultimately the crime of “the criminalization cure.” Not to blow his anonymity (or mine, as I also go to meetings), but perhaps the most compelling pages of Fisher’s history are those devoted to Alcoholics Anonymous — to its complex roots, its development, its pros and cons.

A teetotaler, Nietzsche taught that “the truth is a mobile army of metaphors.” For binary-minded Americans, the main metaphorical combatants have long been the notion that drunkards lack the muscle of willpower, and the conviction that alcoholism is a “sickness” in which whiskey, wine, or whatever has “hijacked” the brain. The disease model is regnant today, perhaps sprouting from the widespread belief that it destigmatizes substance abuse and spurs troubled souls to seek help. Fisher, however, remains unconvinced that hypnotizing people into believing they have lost their agency is destigmatizing. He cites research indicating that the “sickness” label and narrative are largely ineffective in helping people avoid robotic trips to the liquor store. Maybe so, but just as the ubiquitous ADD diagnosis has provided a narrative that some have used to stop lacerating themselves for their inability to focus, so has the “disease” label liberated many heavy drinkers from signing over their lives to Mr. John Barleycorn.

Fisher reduces purely reductionistic accounts of substance abuse to rubble. First, there was the widespread fantasy that addiction is all in the neurotransmitters. Then came the notion that whiskey cravings are lodged in the genes. On Fisher’s reckoning, the “causes of addiction are impossible to bring under one conceptual roof.” He writes:

Some addictions are […] driven by nothing more than how rewarding the substance or behavior is […] Some addictions are […] determined by trauma, whether it be personal, intergenerational, or societal […]

[A]ll these variegated influences intersect in a complex and dynamic matrix, changing drastically from person to person […] It is not that addiction is or is not a brain disease, or a social malady, or a universal response to suffering — it’s all of these things and none of them at the same time, because each level has something to add but cannot possibly tell the whole story […]

Addiction is profoundly ordinary: a way of being with the pleasure and pains of life, and just one manifestation of the central human task of working with suffering.

Though Aristotle might consider it an exaggeration, for Fisher habitual means of self-regulation such as the almost obsessive need to ride your bike 75 miles per week, to knit, or to write every day would be classified as addictions.

The way we talk to ourselves about ourselves plays a decisive role in forming the self. This is a truism but one deserving of an amen. Those of us who turn to the medicine and/or liquor cabinet to escape the funk should resist thinking of ourselves as “sick,” and instead remind ourselves that we have simply fallen into an all-too-human misguided pattern of coping with life’s demands, disappointments, and sometimes successes.

Truly, is it any wonder then that a single mom, working two jobs, with bosses as cheap with their wages as with their praise and compassion, might crave a couple of hours of inebriated peace? Or, again, is it any wonder that a lonely fellow, rife with anger, fear, and disappointment, might slide into the habit of seeking solace in the dark, cool cavern of a local bar?

For all his critiques of the disease model, Fisher emphasizes that the medical community has the means, some of them pharmaceutical (e.g., methadone), for helping people exit the path to perdition and liver failure. Yet, on his judgment, that same community has been criminally negligent in making its “rich recovery resources” available, especially to those unable to hand over an insurance card at the clinic desk. Indeed, today, even with an insurance card, it can take months to arrange a simple half-hour Zoom meeting with a psychiatrist. All this time the chant continues: “What the country needs is more mental health resources.”

According to the National Institutes of Health in 2018, “approximately 6.6% (or 16 million) of U.S. adults used prescription stimulants in the preceding year.” That is not counting the millions of young people these potent psychotropic drugs were originally intended for. The author is somewhat reticent about his former dependence on stimulants, save to say that, on his account, when it comes to this class of medications, there are even fewer resources or strategies for trying to help people withdraw from what used to be termed “pep pills.”

It is a Foucaultian point, but if there is a lacuna in Fisher’s historical narrative, it is the lack of emphasis on the impact of insurance companies and Big Pharma in dictating the vocabulary and the way in which we think about our inner lives. It is no coincidence that the neurochemical understanding of our very selves has been molded by changing insurance reimbursement policies for psychotherapy in concert with inflated claims about the efficacy of new psychotropic drugs.

“Studies show” is one of the pieties of the day. The Urge is chockablock with citations from scientific studies, some of which come to fairly radical conclusions, such as this: “Approximately 70 percent of people with alcohol problems improve without any interventions.” Likewise, almost the same percentages of self-healers hold for drug abusers, the subtext being that the need for recovery groups is overrated.

Maybe it is a product of Fisher’s long Zen practice, but for all the finger-wagging in this wide-ranging text, his authorial voice is clear and gentle. Brimming with common sense and wisdom, a salmagundi of history, science, and informed opinion, The Urge should ignite the urge for invigorated conversation and debate about our current understanding and treatment of the malady you can catch from the corner dealer — or a lab-coated doctor.


Gordon Marino received his doctorate from the Committee on Social Thought, University of Chicago. He is professor of philosophy and director of the Hong Kierkegaard Library at St. Olaf College. He is the author of The Existentialist's Survival Guide: How to Live Authentically in an Inauthentic Age (Harper, 2018).

LARB Contributor

Gordon Marino received his doctorate from the Committee on Social Thought, University of Chicago. He is professor of philosophy and director of the Hong Kierkegaard Library at St. Olaf College. He is the author of The Existentialist's Survival Guide: How to Live Authentically in an Inauthentic Age (Harper, 2018).


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