The Urge

Hearing mention that someone is “staging an intervention,” “hitting rock bottom” or “having a relapse,” few people reading this will need to do a search to follow the implications. Ideas and idioms pertaining to addiction and recovery have become fully incorporated into the common culture, the shared references by which we comprehend and navigate everyday life.

That is, all in all, kind of strange. It wasn’t always like this. And it has been accompanied by an inflation of the term “addiction” itself. Originally limited to dependency on a pretty narrow range of substances, it now applies to just about any compulsive behavior regarded as undesirable. (As usual, The Onion’s satirists nailed this trend early on with a headline: “I’m Like a Chocoholic, but for Booze.”)

Such casualized reference to addiction might reflect an overall increase in public awareness of the problem, which in the United States includes some 14.5 million people with alcohol-abuse disorder, as well as three million opioid addicts. But acknowledging the reality of addiction and directing rational attention to it are very different matters, and Carl Erik Fisher’s The Urge: Our History of Addiction (Penguin Press) underscores that difference through an absorbing narrative full of promising developments and missed opportunities.

The author is an assistant professor of clinical psychiatry at Columbia University, and he is also an addict. He acknowledges as much from the start and fills in the details along the way, while keeping the memoiristic aspect secondary to his project. The Urge is a narrative history of the ideas, policies and practices that have emerged over the centuries. For the most part, the book focuses on substance dependencies, but it does quote “The Gambler’s Lament” from the Rig Veda, an ancient Indian scripture, as a recognizable evocation of the addict’s experience: “The dice are characterized as goading, debasing, scorching, seeking to scorch, giving (temporarily) like a child, then in turn slapping down the victor, infused with honey, with power … Downward they roll, and then spring quickly upward, and, handless, force the man with hands to serve them.” The same words might apply to a syringe or a pipe.

That struggle to gain control after losing it (again and again) runs throughout Fisher’s account of being a young resident psychiatrist at a prestigious university hospital while in thrall to various substances to tamp down the stress. He did not destroy his career, or himself, thanks in large part to the medical community’s provisions for taking care of its own: special treatment programs exist to cope with addicted doctors. “In rehab,” Fisher writes, he “met doctors who were back there for the second or even the third time, who had relapsed, right on schedule, after their own five-year monitoring contracts finished.” (Status has its privileges.) A recurrent emphasis in the book falls on social inequality as wrapped up in the stigma attached to certain intoxicants—gin in the 18th century, for example, or crack cocaine more recently—and repression brought down on their users, while others enjoy good reputations when backed by established industries, such as … heroin?

Yes, heroin. “First widely produced on a commercial scale in 1898, by the Bayer company,” Fisher notes, it was “initially praised as a safe, modern alternative to morphine” until it became associated with “[the] poor teenager, often of immigrant parents, unintelligent, greedy, and rude, and increasingly joining forces with others like him in the new urban phenomenon of menacing ‘gangs.’” With the moral alarm sounded, “medical providers controlled access much more tightly, which pushed people with fewer resources toward smaller, informal markets in vice districts—poorer, racially mixed urban neighborhoods where authorities segregated gambling, prostitution, saloons, and other disapproved trades.” A drug becomes known as dangerous when people considered dangerous take it up, and so the vicious circle spins.

To close what is admittedly too short an article to do The Urge justice, I should note that its layering of literary, social, medical and political narratives poses a challenge to any understanding of addiction reducing it to one-dimensional causes or promoting a single therapeutic approach or outcome. “It is not that addiction is or is not a brain disease, or a social malady, or a universal response to suffering,” Fisher writes. “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.” He finds “no one dominant cause of addiction, or even a set of causes that reliably explains why some people develop addiction.”

That is not to say that nothing can be done about it. Chapter after chapter presents accounts of what have in many cases been useful treatments. But the other side of the story consists of efforts to impose one approach, or proscribe another on various political, economic and moralistic grounds. “The best we can say,” Fisher concludes, is that “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 should be part of the common understanding of addiction that one size does not fit all.