Carl Erik Fisher: Moving Past the Binaries of Addiction
Carl Erik Fisher is an addiction psychiatrist, bioethics scholar, author, and person in recovery. Carl is also an assistant professor of clinical psychiatry at Columbia University, where he teaches law, ethics, and policy relating to psychiatry and neuroscience, particularly where they converge with substance use disorders and other addictive behaviors. He hosts a podcast called Flourishing After Addiction and is launching a Substack, where he’ll organize his thinking around treatment paths and modalities. Most pertinent to our conversation today, he’s the author of The Urge: Our History of Addiction, which is a fascinating deep dive into our long cultural fascination with addictive substances, interlaced with his own story, and stories from his practice: In fact, the book opens in Bellevue where Carl is not functioning as a doctor—in this case, he’s the patient, after suffering an addiction-induced manic episode that put him into recovery. Carl is brilliant and kind, and also fluent in all the prevailing science about addictive behavior…science that hasn’t really ruled the day until recent years. Instead, the addiction space has been one of binaries—you’re compulsive, or you exercise choice; you’re normal, or an addict; you have no control to stop, or you have all the control and refuse to use it; and on and on and on. We get into all of this in today’s conversation.
MORE FROM CARL ERIK FISHER:
The Urge: Our History of Addiction
Carl’s Podcast: Flourishing After Addiction
Carl’s Website
Follow Carl on Instagram
Carl’s Newsletter
Carl’s Substack
Further Listening on Pulling the Thread:
PART 1: Holly Whitaker, “Reimagining Recovery”
ADDICTION: Anna Lembke, M.D., “Navigating an Addictive Culture”
TRAUMA: Gabor Maté, M.D., “When Stress Becomes Illness”
BINGE EATING DISORDER: Susan Burton, “Whose Pain Counts?”
TRANSCRIPT:
(Edited slightly for clarity.)
ELISE LOEHNEN: So, first, thank you. I mean, I learned so much about the history of addiction and I could, I loved watching your mind in the process of writing this book and we're primarily going to talk about the beginning of the book and the end of the book and how you think about addiction as a practitioner and someone in recovery today. But I do want to know, as you explored the history of addiction, was that really to understand your own mind? Were you looking for examples of people who you could map your own experience to?
CARL ERIK FISHER: More the former than the latter, I would say. It was definitely to understand my own mind and my own situation and the problems I was confronting. It was less to find models. I did find models and there were interesting people throughout history that I identified with and I think a lot of the stories are beautiful grounds for hope. And the prospect of change and the prospect of living with and working through addictive behaviors, you know, like Chinese scholars in the 16th century and the funny pre AA 12 step like pre modern era, mutual help groups. Those are really beautiful stories, but it was more the first part of what you said it was more about just understanding the intellectual history of addiction, what is this idea of addiction? How do I make sense of the notion of addiction? What does addiction mean to the extent that I have an addiction? What does that say about me? Because I saw in myself and in the people around me And in some of the problems I was navigating, just a lot of different ideas about what addiction was and very early on in the process of making sense of my own addiction, felt like it would be useful to go back and to sort through some of those, messy, conflicting you know, sometimes in like direct opposition to one another ideas.
ELISE: I mean, you start with this essential binary, right, which creates certainly confusion and also probably inhibits a lot of people from seeking help or pursuing moderation or even engaging in that introspective question of, is this too much or do I have a problem, right? Which is the way that our culture characterizes people as either Addicts or somehow safe or more complete or is it called a crisis?
CARL: Yeah. I've heard professional philosophers describe it both ways, which makes me feel more comfortable about my own pronunciation, acrosia or acrasia but yeah, that weakness of the will, that sort of loss of control. Yeah.
ELISE: Yeah. Which is this idea that an addict is somehow an aberrant or deviant individual who lacks all self control rather than, I think we're getting to the place where we can acknowledge that we all live on this spectrum, but it's still so bound, yeah, like you are or you're not. And it's still a concept that escapes an easy definition.
CARL: So I got into recovery because And I'm grateful for the fact that this happened to me safely, and it's a function of privilege that it happened to me safely. But I was psychiatrically hospitalized for a substance induced manic episode during my psychiatric residency. And so I was brought to NYU, and I was hospitalized there where I'd interviewed for a residency. And so up to that point, had been thoroughly baked in the notion that I was one of the healthy normals. And I was always on the other side of that glass, or the other side of that interviewing table, and then all of a sudden I was one of them. And so I met that essential binary, and it really helped me to break down that binary, because I saw very quickly how it wasn't working. It wasn't working for me or for other people to have this clear, bright, dividing line between, you know, there's lots of things you could put in opposition to addiction. Addiction versus healthy, addiction versus safe, addiction versus free. But I think the most toxic form of that binary is addiction versus normal, as if there is a normalcy apart from addiction.
Because as you mentioned, in ancient times up to the present, the most nuanced and thoughtful philosophy says that we all have this thing inside of us that we have some impairment to control. Our control is not unlimited. It's actually a modern fantasy. It's a neoliberal notion of like the perfect economic actor in some ways that we should be able to perfectly control all of our little actions and plans. So that's one of the ways that looking at the history helped me to unravel ideas about addiction, you know, that I needed that historical context. It was very helpful for me, not just in like understanding the nuts and bolts and the logic of it all, but to get a really clear, like heartfelt, visceral sense that something had gone wrong in the way we think about humans as agents, as people, as people who are struggling with something.
ELISE: Yeah, that's a beautiful way to, to think about it, and so helpful. Because it's interesting, I think you note that denial, It's not part of any sort of DSM, I don't know how helpful the DSM is really anyway, but it's not part of a criteria of diagnosis, but this was a stunning statistic in your book that only 5 percent of people with substance use disorder admit or acknowledge it and some of the stories are just stunning, you know, the young, I think it was in his thirties, the man who ultimately died from hypothermia, but had been in the ER hundreds and hundreds of times. Is the denial entrenched simply because the binary exists and there's no room for people to explore the question without feeling like they're stepping into an identity that they don't want?
CARL: That's a big part of it. I don't think it's all of it. I think that denial can certainly be exacerbated by a overly reductionistic essentialist idea that there are sick people over here and healthy people over there. So when there is a really strong focus on normalcy, and when having an addiction or another form of mental suffering is held up as some sort of awful outcome, then yeah, people will cling really tightly to a story of themselves about normalcy, they'll say, I couldn't possibly identify as somebody with an addiction problem because that'll be, you know, terrifying. That feels life ending. It's a fate worse than death, and that's a function of stigma, and even more fundamentally, it's a function of that really clear division between us and them. But I don't think in some perfect future, if we somehow arrived at a much more compassionate view of addiction that nobody would have denial. I think there are many examples of people struggling with denial, including at times where I would say in the past there was a more nuanced and thoughtful view of addictive problems.
And I think that's just basic human delusion that people can have a sense that they are engaging in a harmful behavior that is really hurting them, and yet they see no other option, and it feels unsafe to even look at the the pattern. You know, I see that over and over again as a clinician, and you have to be deeply, deeply compassionate about that. That's just a part of the self that's just like clinging on to some sort of imagined safety, even if it's not actually safe.
ELISE: Right. And your exploration of sort of choice and choosing, I think is so beautiful because sometimes there's this idea of automatons, right? I think it's Susan, I can't remember the name of the woman, the patient that you write about and you write about her in the context of just like the desperation that she feels as she's watching herself choose something that she doesn't want. Can you talk a little bit about Choice here and you tease this out, but Is it compulsion? Is a choice? Is it somewhere in between and how do you think about that?
CARL: Yeah. Thank you. I think that's a key starting point that I'll never get tired of reiterating, is that we have this tendency to create another essential binary between total choice and completely hijacked compulsion and that means total freedom on one end and total enslavement on the other, and I use that word intentionally. And That's harmful, too. That's a misleading binary, too. Because as anybody with addiction will attest to, it's not as if you just woke up one morning and you got zombified by the drug. There is a intimate relationship with choice and planning and thought and lots of ambivalence. People can feel one way and then act the other way. And to paint it as choice versus compulsion is just so oversimplified and misleading, I think it's really dangerous. It's not a matter of having no choice or being choiceless, it's a matter of misguided choice, or choice that's been misled or warped in some way. And that patient you mentioned, Susan, described this really well, but it's something I felt in myself, it's something I've seen countless times since, where somebody says, I'm very clear on what I want to do. I'm very clear on what I don't want to do. And yet I see myself doing the thing I don't want to do. And I can't get myself to do the thing I want to do. I know in my heart, sure, I might have like an urge or a craving or whatever, but I know in my heart that I want to stay abstinent from drinking. And yet I see myself walking down to the corner store and drinking, why is that? You know, this is the mystery. And I think it's a mystery at the, at the heart of human life, that's the thing that all those ancient philosophers were pointing toward. But it is the key mystery at the heart of addiction is that, that kind of misguided choice. Why do we do the things that we know not to be good, that we know not to be what our hearts truly want?
And in a way, that's sort of what the real the nuance and the useful and the thoughtful writers about sin are writing about like when we look at certain elements of St. Augustine and others that followed that's what sin is about. Sin is not about like doing a bad thing versus doing a good thing in the true philosophical theological sense, sin is about why do I do the bad even though I feel called toward the good? What is that about me that gets twisted up? And Listen, I studied neuroscience at Columbia, and I'm big on neuroscience, there's some neuroscience in the book, and I think neuroscience is useful, but one legacy of focusing only on neuroscience and reducing it only to the brain level, is that we miss out on all those human nuanced, rich psychological factors and people get painted as a cartoon of just, you know, automata disease, either you're choiceless or you're totally free.
ELISE: Yeah, I'm also very interested in sin, I wrote a whole book about it but this and St. Augustine too writes about Lust, someone who has a sexual compulsion, which is also very interesting. But yeah, it is human. I mean, as you're talking about Susan, who is this, I think, at times functional, sort of corporate business person, you write about her one time drinking like tons of vanilla extract.
CARL: That's right.
ELISE: Yeah, I mean the other day it's like the internal conversation I had with myself at like 11 a. m. over whether to eat an ice cream sandwich or not, right? Like this is alive and all of us, like I recognize like it's not a great choice But I really wanted it the more I denied myself and I ate the ice cream sandwich, I did it. Not to minimize Susan, but we all have it. This is human. This idea of some sort of ability to self regulate in the face of highly tempting, uh, sometimes dissociative, sedating, numbing, enlivening, substances and more than ever, it feels like we all need to understand and come to peace. Not to reduce what is a very complex issue to sort of, oh, if we could find peace in ourselves, we would never have any addictions, but part of it is like understanding these drives and appetites and not denying them, but to recognize that this is who we are, right?
CARL: Exactly. Yeah. I think there's a lot of low hanging fruit in addiction prevention. Like if we didn't horrifically traumatize people or expose them to abject poverty or fail to provide for their basic needs, that would be a very good addiction prevention program. And I know that's exactly what you're speaking to when you say that the self love and the recognition of the internal conflict is not the whole story. But that's one thing I write about toward the end of the book, is even if we did everything perfectly, even if we had all the right programs and we did all the supposedly right things, there would still be addiction. There's no cure for it. It's not like we cure it through the perfect social planning or we cure it through the perfect medicine, that there's something in us and it comes out in different ways for different people sometimes severely and sometimes in a really subtle and almost kind of funny way, you know, like I had ice cream. I had two servings of ice cream last night. I write about ice cream in the book. I finalized that edit, I guess two years ago now, more than two years ago. And, you know, probably there was a part of me that was like, Oh yeah, sure by 2023, I'll have cracked the ice cream nut and I haven't cracked it. But it's also not, it's not actively killing me today. So that's something, you know, but it's there it's in all of us.
ELISE: Yeah.
CARL: We need that compassion toward that essential human vulnerability. It's there.
ELISE: Yeah. So, you write about your own recovery throughout the book, which I thought those parts were quite fascinating and you locate what happened to you in the context of a family system, I don't know if they talk about themselves in this way, but both of your parents have alcohol substance use, but didn't work programs, etc. When you talk about going to an AA meeting as a med student and refusing, again, like you were refusing almost a binary, which is interesting and you write about how it was clear you weren't like those people or your parents. And that you thought your problem, to quote you, "was more sophisticated, something more complex and existential than a quote unquote disease like alcoholism or a psychiatric disorder like suicidal depression or debilitating OCD." you sort of talk about how those patients are the ones who are suffering. You're just medicating yourself through burnout but that, I think, also gets in the way, is Particularly in the U. S. where we're very alive and awake to Levels of oppression, privilege Who has access to what can be like, I'm fine, don't worry about me I don't know how much it seems like that was somewhat alive in you unless that was more of a defense mechanism. But can you talk a little bit about your own denial?
CARL: Yeah. Yeah, that's exactly right. I mean, if I'm hearing you right, you're talking about not just the core of the denial in terms of protecting the addictive behavior, but also the discomfort and fully owning whatever suffering I had, you know, I think those can be distinguished, you know, the latter is that if I have all the externals and have good friends. And I'm in a good med school, and things seem to be going well for me, and my parents had their problems, but I was never beat or horrifically abused, and how dare I claim some sort of suffering? Like, I should be able to just tough it out and go harder and solve my own problems. And that for sure was there. I had this feeling that I didn't deserve it. You know, I didn't deserve to consider myself somebody who had struggled. And the cause doesn't matter. It's not because of my parents or because of genetics or whatever. It's just whatever brought me to that point, there was a notion this can't be that bad. I don't deserve to call this like real suffering. So that was part of the denial too. And that's the thing that is not 100 percent within me. I think that kind of waxes and wanes across history, that's a legacy of some of our more recent messaging around addiction. It's one of those negative byproducts of really focusing too much on a broken brain sort of disease idea.
If it really is like a broken brain disease, then it doesn't make sense that somebody who's going to Columbia University Medical School and otherwise functioning reasonably well could have an addiction. But I certainly did. And I really had to work with that denial, not just to accept my identity that I identify with today of being a person with addiction and recovery. But to do the recovery part too. It's not just about like admitting to or not even admitting because admitting is sort of a loaded and stigmatized term, but it's not even about recognizing the addiction, but it's also continuing on the process of recovery that to to really own my suffering and say, you know, like I had it hard in significant enough ways, or that I continue to have it hard in significant enough ways, even while there's unimaginable pain and sorrow and devastation around us, certainly today, and also every day, the full catastrophe living that Jon Kabat Zinn wrote about, like there's an unimaginable suffering way worse than what I'm going through. And also I get to wake up to my own suffering, like I get to acknowledge my suffering as real suffering. That's a big one. And I think it's especially big for people with addiction because shame is such a big part of addiction. It's really one of those powerful universals that you know, I've never met somebody with a significant addiction who didn't have a powerful experience of shame as well.
ELISE: Yeah and I think it's so beautiful because what I do see, you know, high functioning addiction in our culture obviously is rampant, right? If 95 percent of people, A significant margin, I would imagine, of those people are still sort of moving through life functioning. But the way that, and I understand this instinct, and I have loved ones who are very much part of what you talk about, that refused to acknowledge that anything could possibly be wrong. You know, Gabor Mate talks about this a lot, like, tell me you had a good childhood. And let me ask you a few questions and sort of take it apart really quickly. And I probably live in this world of quote unquote self help, which is, you know, has its own stigma and of course we can laugh at it, but there's a lot of it that's really important. I just would like it to be rebranded toward like personal responsibility or something like this, which is particularly for those of us who want to work toward bettering or serving the world. There's a fair amount of emotional hygiene, mental hygiene that's required, right, to attend to your own suffering on the regular so you're not pushing it into some sort of shadow or suitcase and carrying it around and projecting it onto other people or asking them to carry it for you. And I don't know what the twist That's required is That allows how we move out of this like who's got a bad You know, I don't know how we move past that As not oppression Olympics, but this sort of like constant comparison or weighing our experiences against other people who we perceive to have it worse. But it seems like a big hurdle.
CARL: Yeah, and I want to say that it's not just some idea about suffering, it's also a function of social and economic systems that are deliberately weaponizing an individualized view of suffering as a technique, as a strategy. I found across eras and eras and eras in the book is that addiction supply industries, which is what one scholar calls them, like the alcohol industry, the tobacco industry, they constantly come back to this hyper individualization in saying, you know, like, the problem is not in the bottle, the problems in the person. If so many people can drink, quote unquote normally, that means the problem is really with these sick people over here. And that happened with tobacco. And then very directly and deliberately, things like the processed food industry and other modern addiction supply industries have used the same language.
And not to mention the fossil fuel industry has too, and that's not even a psychoactive chemical. It's just a way of conveniently putting all the responsibility and the onus on the individual. And so it's not just a matter of like, oh, if we get the right psychological messaging, society will wake up and we'll have an awakening. This is part of Holly Whitaker's work too, which is how you and I got connected, is just to wake up to the fact that there are extremely powerful forces that have a vested interest in making us feel like we are the problem, that I am the problem. And if only I toughened up a little bit, then I should be able to solve this.
ELISE: Yeah. No, certainly. I want to talk to you a bit now about the way that our recovery ecosystem is set up and I want to talk to you about you methadone and I know that there are a lot of prescriptions that I don't think people really even know about for Alcohol and to help with cravings and sort of functional nutritional programs, etc and maybe I'm just oblivious because I'm not in recovery, and this is certainly true that and Holly and I talked about this at length as well, but there's so much anxiety and or control in the world of recovery that it wants to insist that it has to be a certain way and if you deviate from that you'll die and if you explore other options or ask questions about it that you are going to cause someone else to die because you will implant in their head the idea that moderation or harm reduction or that there are other potential avenues to explore that would lead them back to the substance that they can't touch. So where do we start?
CARL: I mean, we could start with the sort of knee jerk stereotypical image that most people on the street probably have of entering recovery and getting help and getting treatment. You know that 95 percent statistic you mentioned earlier, that's a really important statistic. 95 percent of people with a substance use disorder don't think they have a problem and don't want treatment. And so there's a lot of denial baked into that, but also baked into that could be the totally appropriate Hopelessness about our existing treatment systems. Maybe people don't want treatment because they've been poorly served by our existing treatment systems. There are some real problems.
ELISE: Yeah, can't go to rehab for 30 days. I invested in this company called North Star, which is a different way of doing it where you can continue your life without going away.
CARL: That's great. Yeah. Because there are financial interests baked into that stereotypical idea too. It didn't necessarily start that way, but yeah, the stereotypical idea people have is exactly what you say. You go away for 30 days, you get cured, you come back. You have some sort of transformative experience, which enables you to come back to your home and, get a sponsor, get a home group, do a 90 90, you know, do all the traditional AA stuff. And then people rightly say it's just an extended introduction to a free program. So if that's all you're providing, then it's not a problem. There's not a good solution. So, you know, that stereotypical image is not the only solution out there. There are very good addiction psychiatrists and addiction medicine doctors who can provide an integrative and holistic assessment of other problems that people might be having, whether it's other mental health problems or other things that need addressing. There are different forms of therapy, there are intensive outpatient programs, but these are often not accessible to people because they're Either geographically limited or especially as we've seen since covid their massive waiting lists and just not a lot of availability providers. Or, of course, insurance coverage in our broken system.
The important thing about this is that sort of core of the 28 day rehab came about in history because there was a total vacuum because we were totally unprepared to provide for addiction problems for example, in like the 1920s, 1930s, 1940s, and we're basically in a similar situation today. It's sure as heck is better then 100 years ago. But it's not great. We still have massive shortages of physicians overall and of professionals. And when you do go to a treatment program, you don't get the kind of integrative holistic wraparound care that people really need. So we have a problem both of access period, and a problem of access to the proper sort of diversity and patient centered flexibility that the best science shows us we really do need in addiction medicine. And I mean, we could have like a whole, you know, eight hour seminar series on problems with the addiction treatment complex. But that's at least the starting point.
ELISE: I know that there are sort of disruptive forces within it. And that there are more options that have emerged, but it seems like it's hard to break through because there is such a stronghold on one path which again, probably contributes to denial, right? Like I'm putting myself into the position of if I needed help, I don't know that I could even acknowledge, I couldn't even functionally get to the place of saying like, Oh, okay, I'll just leave my work, leave my family. I have the privilege that I have insurance, right. But there's so many hurdles that feels so big, right, for so many people who are probably on the line. It's interesting in reading so many addiction memoirs and your work, Maya's work, that everyone has in their mind their own idea, right? Like you are in an inpatient treatment facility sort of convinced that you need to get out of there, for Maya, it was a moment where she was contemplating prostitution for drugs. That to her was the line that showed her she had an addiction. She couldn't grapple with that. Can you talk a bit about that? Like, what you think it is in people's minds that inhibits them from seeing themselves as needing some sort of intervention?
CARL: Yeah. I do think it's going to be different for different people, as just those examples between me and Maya, but we can think about some of the different forms that that inhibition can take, like what gets in the way of somebody seeing that they have a problem, you know, one thing might be that the diagnosis and the recommendations are being met with are not the good ones. They're not the right ones for them. So, as an example, when I went to treatment, I was ready to go. I wanted to go to outpatient treatment, but, you know, by and large, I was prepared to go and get treatment at the point that I kind of came out of my psychotic mania and recognized that I was an alcoholic and wanted help. I said, sign me up. Like I need help. Like, I'm ready to say that I need some sort of intervention. And then I got to an inpatient treatment facility that was much more old school than the NYU inpatient facility that I started off at. I mean, they were very hardcore. Not everyone. There are some people who are really compassionate, but there were also some people who were very old school, very confrontational, very much in the mindset, like you know, I'm board certified in addiction medicine, but my real specialty is trouble. And you boy, there are trouble, you know, people were telling me I was a liar and doing a hair test for drugs and saying, yeah, I know I'm going to find something else. What are we going to find? And I was sitting there saying, you know, I'm telling you the truth. Like I actually do want treatment right now. So somebody is operating with a hoyeristic based on an outmoded model of like needing to break people down. And building them back up again. And so that was the thing that was feeding my denial for sure. It wasn't all on me. It wasn't all that, like it was self generated.
There can be a mismatch between what someone actually needs and what's being offered out there. And that comes up a lot because we were just talking about the way that, you know, there are options out there, but most people don't get exposed to them. Most people think it's just rehab and that's the only thing. And once again, rehab worked for me, you know, once I got past that sort of like confrontational hardcore stuff and once I had a little time and just took what I needed from it and really connected with the other patients who were there, which was the thing that really worked for me. That was really helpful for me. But for me today as an addiction clinician, it's absolutely essential that I recognize that my own lived experience does not dictate what everybody else's should be. That other people will have different pathways, they'll have different pathways and different experiences, they will need different things. And it's that kind of humility that we sort of lost in the treatment.
ELISE: Well, I think it just speaks to the myriad versions of people with different variations of addiction and then the myriad paths to Health or moderation, we need a more individualistic system, and a little bit more grace maybe for people as they navigate through this. Can you talk a little bit, I thought this was so fascinating about the Rand study and then also the work of the Sobels, because this is wild to me?
CARL: Oh, yeah. I'll just say it briefly. I'd love to hear what you love about it, too. But by the 1970s, there was a lot of interest in medicalizing and professionalizing traditional recovery. And so there is a really powerful, what would one former senator called the treatment industrial complex, like the traditional rehabs. And that's basically the legacy of the system that we have today. This treatment industrial complex that was very invested in a sort of old school binary of you're an alcoholic or you're healthy, normal, that there's a quote unquote pickle line that you cross like past this point, you're not a cucumber anymore, you're a pickle. And that's the way people would actually talk about. I've heard that in. Recovery meetings and in the treatment centers, so I heard it at an addiction conference that I went to last week, by the way, by one of the speakers, I mean, it's just preposterous to me because it flies in the face of the science and some of that science was being done back in the 1970s, so the very early days of the National Institutes of Alcohol Abuse and alcoholism, which is a terrible name that they haven't renamed yet.
But back then the N. I. A. A. A. didn't just do research, they also did treatment. And so they collected a lot of data about the very early waves of addiction treatment in the United States. And one of the key questions they were looking at is what happens to people when they return to moderate drinking. And so it went to the Rand Corporation. The Rand Corporation, people might know, is a think tank that's very closely allied with the government in Santa Monica. And so they sent off all of these, like, punch cards and old school data. And they processed it. And what the researchers found is that there was a significant portion of people who, even when they were diagnosed with very severe alcoholism, seemed to be able to return to moderate drinking without major problems.
Now, of course, there are people out there who returned to moderate drinking and had terrible problems. And in my own personal recovery, that's not a gamble I'm willing to take. You know, I've been abstinent from alcohol for a very long time now. And You know, is there a percent chance that I could return to healthy moderation? Maybe. I don't know. I'm not interested in making that bet. The point is, some people will do that. And it's very good to know the science of what actually happens and what the risks are. And so when the RAND report Was in a preliminary stage word kind of leaked out to some of the nonprofits and advocacy groups and allegedly some of the governmental actors that were involved in the whole process.
And there was a really powerful effort to suppress the report. They said, this is dangerous. Exactly what you were talking about earlier. This is dangerous. We can't give people the message that they might be able to return to moderation because even if that's true, it's going to mislead a lot of people and cause a lot of deaths. And it became a huge public relations battle. There were sort of warring press conferences, one by the Rand Corporation, one by the opponents, and it got extremely vicious. And it sort of set the ground for the Sebel thing, which is basically just that some researchers found that if they trained people in behavioral approaches to try to moderate drinking that it was somewhat helpful on the margins for some of those people. This is not a profound. Discovery, but it flew in the face of the orthodoxy and the orthodoxy said once an alcoholic, always an alcoholic. It's irreversible. Not only is it permanent and necessarily progressive, it's irreversible, meaning there's nothing you can do to alter the course of this problem.
Well, the Sobel's found that that wasn't true, and they were subjected to a tremendous range of personal attacks and lawsuits and efforts to totally destroy their academic careers and you know, lucky for them, they had enough of an academic record that they went to Canada and they went to one of the best addiction research programs in the world affiliated with the University of Toronto. And if they were a little bit earlier in their careers, maybe they would have been successfully assassinated character wise, not literally though, who knows? And that's interesting because we still have those same fights today. You know, all that happened in the 1970s, it was interesting to me to put in the book, because we have the exact same battles today about, you know, the science doesn't count, or the science isn't true or even if the science is true, we can't say what it actually is because it might mislead people. And I think that's totally dehumanizing to people with substance use problems. You know, I think people want to know the truth. And by the way, the genie's out of the bottle. And there's plenty of books, much more skeptical than mine that are out there using this data and talking about it. So we might as well approach it head on. But I, even I have gotten some blowback about talking about those types of studies.
ELISE: yeah, but I think to your end and maybe this is accurate, but this idea of being close to many addicts, some who venerate AA and feel like it absolutely saved their lives and you know, myriad paths and others who feel like outsiders within their own recovery because they didn't do it in a traditional way. But there's so much pressure this like fear, this control over the whole experience and being open and speaking about your experience that it will somehow negate someone else's or give someone else in the quote unquote an idea that's dangerous feels quite supressive. And it limits, I think, the amount of people who are willing to be creative or explore what this could mean for them. I understand a tendency to be like, not for me. I don't have a problem. I'm not engaging with any of this because it feels like a life sentence, I guess, that you're in a guillotine and that at any minute the blade's coming down to take off your head. It just doesn't seem like it gives anyone any room or grace.
CARL: Right.
ELISE: and can you talk a little bit about methadone, suboxone, which is a life saving intervention for so many, and yet it's still very stigmatized, and I know it's also hard to access, right?
CARL: Yeah, I guess the thing I'd like to say, because there might be people listening who are wondering about the place of medications if they're struggling with control, that there are many FDA approved, perfectly safe medications that help people with cravings and urges and problems, not just for opioids, but also for alcohol. And some of those are things like ant abuse where you could take it with a partner it kind of helps by making alcohol cause a bad reaction. So it's unpleasant. Others, for some people, regularly craving and desire but not in a way that makes you into a totally desireless zombie. And we vastly underutilize those, and alcohol kills tons and tons of people as well, you know, so that's another failure. But when it comes to opioids you know, there are a lot of things that are really helpful. I think that 12 step is really useful for a lot of people with opioid use problems. I think that traditional therapy is really good. I think that There are many other alternative therapies such as therapeutic communities or whatever else. Whatever works fine. That's great. But scientifically speaking, the only things that have been proven to reduce death suboxone aka buprenorphine and methadone, period. Regardless of what your views are about Their effects on recovery or whether that counts as sober or not, blah, blah, blah, like, all that stuff is a downstream question, you know, so it gets me really annoyed when people start talking about, like, whether something qualifies as true sobriety, like, bottom line is we're in the middle of a massive overdose epidemic, it's only getting worse year on year on year, it's topped 100, 000 people this year, you know, there's no sign that it's getting any better despite all our best efforts. Like we need expansion from the top down, but we also need just a broader recognition that these drugs save lives, period, full stop. They can be hard to access methadone in particular. It's hard to access because of a legacy of racialized controls that arose in the 1970s and a lot of stigma attached to it that's gotten a little better during COVID. It needs to get a lot better, a lot faster. I'm sure Maya will talk about this as well. Maya Svalovitz, who talks a lot about harm reduction and democratizing care. But there's also, you know, there's hope for Suboxone as well. You know, I think the pandemic, even though it's drastically increased the rate of death from substance use problems has also democratized care for telehealth and there's more and more telehealth options for suboxone, which is a useful option.
Again, like some people might have like a stigma, like this is not real recovery or it's not the answer. What I just want to say is that these medications save lives and then a lot of people get the opportunity to recover. And then the opportunity to pursue other paths and find the version of recovery that works for them. In my clinical practice, I take people off Suboxone, you know, not cavalierly. It's a big decision. It has to be done super slowly, but it's not a life sentence. It's just a thing that you do for a period of time to regulate your risk and to save lives. And you know, it's heartbreaking that these tools are so underutilized.
ELISE: Yeah. No, I know people who have tapered very slowly with psychiatrists off of Suboxone. It's a hard, long process, but it's also, again, something you can also stay on, right? And you can get it as a shot. Is that accurate? For every six months or something?
CARL: Yeah, there are long acting formulations. There's a sort of surgical implantation and then there's also a shot. And those are more and more available. You know, I heard apparently in certain rural areas of Canada and Australia, like the rate of long term suboxone uptake is like in the 20, 30 percent, even 40 percent in some places where it's harder to do daily oral medications and so there's real promise there, you know, there's real opportunities to make that better and to expand access there.
ELISE: And for people who don't understand how that drug works, it doesn't make you high, it just keeps you out of, not out of withdrawal, but you can't really take opioids, right? Like they don't work?
CARL: Exactly. Yeah, that's it. And there are like subtleties that we probably don't need to get into of methadone versus buprenorphine, but the bottom line is these are very long acting medications. Methadone, for example, it takes like three to five days to build up to a steady state. And so it just exists in your body, and it's at a high enough concentration, just at a basic, steady, stable level that if you were to take other opioids on top of it, it barely nudges the needle. And that prevents people from the big highs and the low lows and the constant cycle of withdrawal and drug seeking and all the rest. And you know, people can use on top of these medications to get a little bit high. It happens, especially as we get these more potent drugs like, like fentanyl and carfentanil. So it's not a perfect magic bullet but it sure helps a lot. And the drugs themselves don't make you high. Some people, you know, I think we should be clear about what the actual downsides are, they're not, they're not without downsides. Some people feel a little bit of emotional numbing on the margins, and that's a big motivation to get off suboxone. Some people feel a reduction in sexual desire, and that's true for other psychiatric medications too. So let's not get too stuck into a binary of like drugs good, no drugs bad. But for somebody who's an active opioid addiction, it's just such a there's no debate whether it's worth it or not. And again, these things are not necessarily permanent.
ELISE: What do you think it is in our culture that's so ascetic in a way, that's so, again, this is the the podcast episode about binaries, but this like idea of being clean, right? being untainted being, sort of unmedicated or even though you know We're all constantly changed by our environment by like the the chemistry of our food for example, but what do you think that that comes from And that was the immediate backlash to methadone, right, like this isn't, again, I think you said it, this isn't real recovery, you're not really clean, it's that somehow this idea, and there's the same debate with, about psychiatric medicines, right, and SSRIs and, which are really helpful for some people, not helpful for other people, but there's this idea in our culture that like you should be completely Unmoderated, right? Like you should be a pure vehicle vessel container, which is kind of impossible. But what do you think that is?
CARL: Well, one of the big strands where that comes from is definitely from early, early American Christian evangelism. And that's why I spent a good portion of the book writing about the second great awakening and the first big temperance movement in the 19th century. I think there's a really clear through line to people once you look into that history of how it relates to today and some of those inherited ideas about purity and which are really ideas about like godliness and being free of sin.
ELISE: Yeah.
CARL: Yeah. And so Christian perfectionism was a name of a movement in that period of time. And, you know, I got to that not because I'm some sort of religious scholar. I mean, far from it. I actually was like pretty allergic to the Christian faith that I was raised in, in certain ways. But when I was researching the history of abstinence and the history of the temperance movement and the history of things like prohibition, it all led back to the first, there's a second temperance movement that preceded prohibition in like 1900s, 1910s. But there was a temperance movement before that in like the 1820s, 1830s, 1840s. And that was way bigger. Actually, and the reason that got so big as an anti alcohol movement was because it was linked to this broader Christian perfectionistic movement that basically said that you proved your godliness through your own individualized action, through your own personal effort is a bit like prosperity gospel is like a way of justifying post facto, like, Oh, this person's rich, then it must be godly and like, show the show your worth by going out and achieving, which we also see today in terms of like hustle culture, and a lot of, you know, the weird messaging we get about money and independence. But I think that, you know, out of that time period, and that kind of uniquely American individualistic perspective on spirituality and religion we got some ideas about cleanliness and about how to prove your worth. And a lot of people have written about this in interesting ways. You know, one framing that actually did not make it into the book that I really love is there's a bioethicist earlier on in the 20th century who called this the battle between psychotropic hedonism and pharmacological Calvinism, which is just a complicated way of saying that we swing between these poles of like free for all hedonism, use whatever drug who cares, like very Wild West cowboy esque, and then on the other end, pharmacological Calvinism is the idea that like, oh, through my suffering, I prove that I'm godly. If I manage to stay completely unsullied by any substances, then that proves that I'm sort of like a higher, more evolved individual. And we, yeah, we have trouble in the United States and in North American culture and Western culture in general finding that healthy middle ground between the two where like, You know, substances are always here. They'll always be a part of it. That's what I found through the historical research. We've had drug epidemics going back at least 500 years. We're never going to eradicate them or stamp them out. So we need to find a way of working with it in the same way we need to find a way of working with the addiction that we were talking about before.
ELISE: Do you have any thoughts about like Ibogaine and other psychedelics in Ayahuasca, et cetera, and like any role you think they might ultimately play in addiction? I know with Ibogaine, they're working to isolate hallucinogen from the drug that blocks cravings. And sort of helps people skip withdrawal, but do you have any thoughts about where you think that might lead us? Or are you concerned about it?
CARL: Well, you know, I'm always concerned when there's hype because there's going to be people who are misled or reify the substance. Addiction is really complex. You know, it always exists at the intersection of multiple causes and conditions. I've seen a lot of people benefit tremendously from psychedelics and from, you know, other more sort of novel, holistic plant based approaches. So I think there is a lot of promise there. We need research to validate that. I think that a lot of people in the psychedelic research community are a little disappointed in the more recent wave of trials on alcohol use disorder, for example. You know, the early phase of, say, like, Michael Pollan era work was very positive about existential distress in people with a terminal cancer diagnosis, for example.
Very, very big results, huge, huge results in terms of alleviating mental suffering. And then the substance use disorder studies are not quite as promising. And maybe that's because those folks are a little more severe. They're more adversely selected. You know, the people who are facing existential distress, they haven't necessarily lived for years in the mental health treatment system. They maybe don't have as heavy a load of trauma or adversity or otherwise. So I'm careful about the hype. I don't think that they're a one size fits all solution but for people who use it as part of a comprehensive, holistic, balanced, individualized, personalized program of care, by all means, you know, what's the problem?
ELISE: Yeah. And then finally, I mean, obviously your book, your work, but for those who are sort of sober curious or maybe feel like they need to engage, where do you where do you think people should start?
CARL: I should mention, you know, obligatory plug that I've got my own podcast and it's called flourishing after addiction. And it's in part to answer that question because I didn't see a ton of other very clear answers to that question. And it's called flourishing after addiction because, you know, there's a lot of people who identify as in recovery, but there are other people who don't even necessarily think of themselves as in recovery. You know, I talked, for example, with Zach Siegel, who's a journalist who focuses a lot on drugs, had a serious opioid problem, and he's gone the more medical route, you know, he takes medications and he goes to his psychiatrist and he says, I don't identify with recovery because for me, that feels like it's over here as part of this different community. Even though if he said he were in recovery, he for sure qualifies, you know, so that's one option. I think that it's really about finding your people. And it's easy to find your people if you fall in with traditional recovery and you like the 12 steps, and it's harder to find your people otherwise. But I would say to people that it comes to connecting with other human beings in the real world and or over Zoom, like there are other alternative mutual help support groups for people who are struggling with craving and control.
There are things like Smart Recovery, Life Ring, SOS, the Buddhist recovery network, which is not just one thing, but a whole range of things for people who are interested in meditation and mindfulness as relates to substance use problems. There's moderation management, you know, like the point of these things is not that any one program has the perfect answer, but I think by going out there and engaging with the diversity of offerings. You know, not to mention professional offerings, like therapists, coaches, whatever, then you find your people, you find the people for whom this resonates or with whom this resonates. And then I've seen a lot of people eventually when it clicks, they say, okay, now it makes sense. You know, it makes sense cause I saw it in somebody else or I heard it in somebody else's stories. And so I would just encourage anybody who's out there who's struggling and looking for engaging in sober curiosity or otherwise, you know, just go out there and try six different things because maybe the first five you think they're assholes or you don't like them, you know, just keep going.
ELISE: Well, thank you. And thank you for your book. And thank you for your work. And I'm excited to see, are you working on another book?
CARL: I haven't announced it yet, but I'm planning on developing a substack on different varieties and frameworks for recovery, for precisely this question, because I don't see a lot of really broad based spectra, like across the whole variety of recovery. I'm a very organized kind of obsessional guy. So I thought it would be useful to just have a serialized. Set of writings just going through different ideas about recovery, different frameworks for recovery. And in trying to break it down, not as if I have all the answers, but just to say here's a diversity of ways people have thought about this issue and ways that it might make sense for you.
ELISE: I think that's great. Someone needs to organize all of this so that there's on ramps for people.
CARL: Yeah, I think if you're a hammer, the world tends to look like a nail. That's a classic Abraham Maslow quote applied to psychology and psychotherapy. And when I was in early recovery, I wanted someone to break it down for me. Instead, I got people pushing their own pet theories. Which is all well and good. I'm glad that there are people out there who are champions for their own individual pet theories. Like, we need those people. But we also need synthesizers who kind of break it down. That's what I think a good doctor normally does, is they break it down and say, you know, here's what I think is going on. Here are the options available. Here's the whole span of things. And then maybe if I have a recommendation, here's the recommendation. But it's our job, to present the whole menu, usually.
ELISE: I agree.
Carl’s book, The Urge, is fascininating—I took 22 pages of notes—because he explores both his own story, the stories of patients, the long history of substances in our country, as well as policy and practical steps towards recovery. And what he is ultimately pushing is just to widen the aperture here, to expand the lens in terms of understanding ourself on this spectrum, recognizing that it’s really not a binary and that there are myriad creative solutions that have emerged, will emerge. And for anyone who is listening who feels not quite ready to commit to exploring what might be happening, this is the sort of book that creates space and context for how to move forward outside a traditional framework, which is wonderful for so many people, I don’t want this series to feel like it’s picking on the establishment, but it could certainly evolve and grow. I think we need more solutions and more access as well. Alright, see you next time.
