The Urge

Author: Carl Erik Fisher

Rating: ⭐️⭐️⭐️⭐️⭐️

I was only a few chapters into this book when I realised it would likely become one of my favourites of the year. Fisher combines his personal expertise as an addiction physician with his personal experience as a former alcoholic to discuss the history of addiction, and, more specifically, how it is dealt with on a societal level. The book oscillates between discussion of addiction as a concept in both ancient and more recent historical periods (episodes such as the Gin Craze) as well as the responding temperance movements in the US and UK and how that shaped our understanding of addiction.

This book did a good job at not just discussing history of social movements surrounding addictive or intoxicating substances but really getting into the varied angles by which we need to understand addiction. In the recent past, and still to some degree today, we often see addiction as a medical issue. There is evidence that genetics can play a part in addiction and that different substances have different biological effects on people. While all this is true, Fisher points out that by concentrating on this angle, we ignore the socio-economic causes of addiction—the things that drive people to rely addictive substances in the first place.

“Not only is there no one biological cause; there is no one dominant cause of addiction, or even a set of causes that reliably explains why some people develop addiction. The best we can say today is that all these variegated influences intersect in a complex and dynamic matrix, changing drastically from person to person, and even changing over the course of an individual’s lifetime. 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.”

The Urge (p. 281)

He points out that a lot of the rhetoric around the disease view of addiction is in some way a backlash against previous eras that saw addiction as a personal failing, a sign of a lack of self-control. And he points out that while this can be well-meaning, to see addicts as sick rather than too lazy or stupid to put down the pipe, this pigeonholes treatment into medical treatment, which, for some people, if not followed up with other structural changes in their lives, will not last.

He also explores how capitalism has impacted addiction treatment, with some addiction treatment centres not concentrating on long term recovery for patients but rather on getting people in the door, through a prescribed set of steps that may or may not work for them and then sending them on their way.

“From rehabs to outpatient programs, far too many offer a cobbled-together assortment of therapies organised around a one-size-fits-all model profoundly disconnected from evidence-based practices […] Even the more respectable programs are largely built around an acute-care model that treats program ‘graduation’ as if people should be able to manage a perfectly abstinent recovery from that point onward—despite the fact that, depending on the substances involved, between 50 and 70 percent of people will resume substance use in the first year after treatment, up to 35 percent will be readmitted to a treatment program within a year, and nearly 50 percent will be readmitted within two to five years.”

The Urge (p. 259-260)

He, of course, also touches on other prominent themes in addiction discourse such as harm reduction and the criminalisation of addiction and use of regulation addictive substances as a way to exert power over certain communities (the whole crack vs powder cocaine mandatory minimum sentencing situation).

Addiction is a hugely complex issue that impacts not only people with addiction but those around them as well, and tackling it requires measures that address the biological, societal and economic causes and effects of addiction. Fisher does a splendid job summarising a lot of the recent history, discourse and policy around addiction in a way that is both engaging and succinct. I highly recommend this book to anyone with an interest in the subject.